Inspection Reports for
Bonaventure of Lacey

The visit was a complaint investigation conducted on July 22, 2026, which found a recurring medication services deficiency that resulted in a civil fine.

The licensee failed to ensure medications were available and administered as prescribed for one resident, placing the resident at risk of health complications. This deficiency is recurring, having been previously cited twice in 2025, and resulted in a $1,000 civil fine.

No inspection findings are reported in this document as it is a scheduling letter for a document review only, with no meeting planned.

No inspection findings are reported as this is a notice of withdrawal of an IDR request.

This report is based on a complaint investigation conducted on November 4, 2025, which substantiated violations related to resident rights and monitoring of residents' well-being. The deficiencies were recurring and previously cited in 2023 and 2025.

The investigation found recurring deficiencies involving failure to protect residents from harm and physical altercations, and failure to ensure appropriate care during changes in residents' conditions. These violations resulted in psychological harm, injuries, and decreased quality of life for residents, leading to civil fines totaling $2,100.

The complaint investigation involved multiple allegations including unwitnessed falls causing injury, delayed hospital care for a hip fracture, failure to protect residents from abuse by an aggressive resident, and failure to notify law enforcement of physical abuse. All allegations were substantiated with citations written.

The facility was found to have multiple failed provider practices including failure to ensure resident safety after falls, failure to protect residents from abuse and harm by other residents, and failure to notify law enforcement of physical abuse incidents. Citations were written for these deficiencies.

This was a complaint investigation conducted on July 9, 2025. The deficiencies cited were recurring and substantiated, resulting in civil fines.

The investigation found recurring deficiencies related to medication services and failure to properly investigate and document incidents resulting in significant injury. Civil fines totaling $1,800 were imposed based on these violations.

The complaint investigation dated 04/23/2025 through 05/01/2025 involved allegations of staff not using gloves during personal care, not answering call lights timely, insufficient staff, and residents' medications being forgotten. The investigation found no failed practice regarding care and call lights but identified a failed practice due to an unlocked and unattended medication cart. The complaint number referenced is 173046. The conclusion was that a failed provider practice was identified and citations were written.

The follow-up inspection on 06/23/2025 found no deficiencies; the previously cited medication storage and security issues were corrected.

Complaint #177002 involved a sprinkler system malfunction. The investigation found the dry sprinkler system was not working properly due to a leak and malfunctioning accelerator and air compressor. No fire or injuries occurred. Violations were corrected on re-inspection.

The dry sprinkler system was found to have a leak and was not working as installed, with issues involving the air compressor tripping the electrical panel multiple times. No fire, evacuations, injuries, or fire department response occurred. All violations were corrected by the re-inspection on 06/16/2025.

The complaint investigation involved multiple allegations: unsafe staffing assignments, unqualified personnel, falsification of medication logs, lack of nursing services, resident neglect including failure to provide showers, and failure to administer prescribed medications. The investigation substantiated failed provider practices related to medication administration, resident monitoring, and incident investigation, but did not substantiate allegations of unqualified personnel or falsification of records.

The investigation identified failed provider practices related to medication administration, resident monitoring, and incident investigation. Several allegations were unsubstantiated, but deficiencies were cited for failure to monitor residents' well-being, medication errors including overdosing acetaminophen, untrained medication aides, inaccurate narcotic counts, and failure to investigate and document a significant injury. The facility was found noncompliant in these areas.

The complaint investigation involved allegations of residents being left soiled for hours, food and drinks out of reach, and a resident found on the floor. The investigation found failed practices including failure to use a fall mat and failure to administer medication with prescriber notification. Citations were written for these failed practices.

The follow-up inspection found no deficiencies; previously cited medication service deficiencies were corrected. The facility demonstrated compliance with medication administration and negotiated service agreement requirements.

This visit was a complaint investigation completed on May 1, 2025, which resulted in a civil fine due to medication security violations. The deficiency was recurring from prior citations in 2022 and 2023.

The facility failed to ensure medication carts were locked, placing 64 residents at risk of unauthorized access to medications. This recurring deficiency led to a $400 civil fine.

The visit was a complaint investigation completed on April 29, 2025, which found a recurring deficiency related to maintenance and housekeeping resulting in a civil fine.

The licensee failed to provide a safe and well-maintained environment, exposing 89 residents, staff, and visitors to gas fumes and risk of harm due to a gas leak. This deficiency is recurring and resulted in a $700 civil fine.

Complaint #173999 alleged a gas leak and evacuation on 4/3/2025; no odor of gas was found and repairs were made. Complaint #174187 alleged a leak in the dry sprinkler system on 4/7/2025; the sprinkler system was operating normally and activated during a fire watch. No injuries or fire occurred in either complaint.

The investigation found no odor of gas and confirmed repairs were made after a gas leak evacuation. The sprinkler system was operating normally with no fire or injuries, and the fire department responded appropriately. No violations were cited.

The inspection identified multiple fire safety violations including electrical hazards, improper use of extension cords, missing ceiling tiles, debris on fire sprinkler heads, failure to maintain emergency lighting and fire extinguisher inspection records, and malfunctioning fire door latches. The facility was disapproved due to these unresolved deficiencies.

The complaint investigation (Complaint #173999) was triggered by reports of a strong gas smell in the laundry rooms, especially on the fourth floor. Multiple caregivers and staff reported the smell over several months, with some experiencing headaches and dizziness. Maintenance staff initially denied the presence of gas leaks, attributing the smell to urine or musty clothes. Puget Sound Energy confirmed a gas leak with two pin holes in the gas line. The facility evacuated residents and shut off the gas. The investigation concluded with citations written for failed provider practice.

The investigation found that the facility failed to provide a safe and well-maintained environment due to a gas leak, placing 89 residents, staff, and visitors at risk of exposure to gas fumes and harm. Multiple staff and caregivers reported smelling gas over several months, and Puget Sound Energy confirmed a gas leak with two pin holes in a gas line. The facility evacuated residents and shut off the gas during the incident. This is a recurring deficiency previously cited.

The complaint investigation focused on a fall during a power outage. The facility did not report the outage to the Complaint Resolution Unit as required. Multiple staff interviews and record reviews confirmed the failure to report. The allegation was substantiated with citations written.

The facility followed policy and procedure when the resident had a fall and sustained injury, but failed to report the power outage to the Complaint Resolution Unit, which was identified as a failed practice with citations written.

The visit was a complaint investigation conducted on March 4, 2025, resulting in a civil fine for medication service deficiencies. The deficiency was recurring from prior citations on May 31, 2023, and December 13, 2022.

The facility was fined $400 for failing to implement systems that promote safe medication services for one resident when medication was refused or unavailable. This deficiency was recurring from previous citations in 2022 and 2023.

The complaint investigation involved allegations about quality of care related to a resident's injury after a fall. The investigation confirmed the facility failed to monitor the resident properly after returning from the hospital, substantiating the complaint with citations issued.

The investigation found that the facility failed to monitor a resident after they returned to the community following a fall and hip fracture, identifying a failed practice and resulting in citations.

The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.

The licensee failed to ensure two staff had required Nurse Delegation training and supervision, resulting in one resident receiving medications outside parameters and placing residents at risk. This violation is uncorrected and recurring, leading to a $1,000 civil fine.

The complaint investigation (Compliance Determination #29671) found that the facility was not back in compliance with their plan of correction by the attestation date, resulting in a citation. The follow-up inspection verified correction of this deficiency.

The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected as verified on-site.

The conditions on the license have been lifted following verbal notice to the administrator on January 10, 2024.

The complaint investigation involved allegations of neglect and quality of care related to failure to provide care per residents' Negotiated Service Agreements, including failure to provide showers and proper hygiene. The investigation found multiple failures including lack of hand hygiene supplies, incomplete respiratory fit-testing, failure to provide requested documentation, and failure to provide adequate resident care. One resident reported going up to three weeks without a shower, causing psychosocial harm. The facility withheld requested documentation during the investigation, impeding regulatory oversight.

The facility failed to provide necessary handwashing supplies and gloves in resident rooms, failed to maintain proper respiratory protection fit-testing records for staff, and failed to provide adequate documentation of resident care including shower refusals. These failures placed residents at risk for infection, skin breakdown, and decreased quality of life. The facility also withheld requested documentation during the investigation, impeding regulatory oversight. One resident reported going up to three weeks without a shower, causing psychosocial harm.

The visit was complaint-related, triggered by an allegation of abuse. The deficiency was substantiated as the facility failed to properly investigate and document the allegation.

The facility failed to investigate and document investigative actions after becoming aware of an allegation of abuse for one resident, placing the resident at risk for ongoing abuse. This deficiency is recurring and resulted in a $1,000 civil fine.

The IDR process reviewed materials and statements from the facility and regional staff and concluded that no changes would be made to the prior Statement of Deficiencies report. The facility is instructed to begin correcting the disputed deficiencies immediately and submit a Plan/Attestation Statement within 10 calendar days.

After review, the IDR Program Manager decided not to make any changes to the prior Statement of Deficiencies report. The facility is instructed to begin correcting the disputed deficiencies immediately and submit a Plan/Attestation Statement within 10 calendar days.

The IDR resulted in edits and clarifications to several cited deficiencies, including medication availability, nursing services, and resident rights. No changes were made to the previously imposed enforcement action dated October 4, 2023.

The licensee must continue employing a registered nurse consultant to assist with staff training on hand washing protocols, ensure availability of hand washing supplies, and maintain documentation. Weekly updates to the Department and posting of this notice are required until conditions are lifted.

The licensee failed to provide necessary handwashing supplies in one memory care unit and failed to implement proper infection control measures and hand hygiene during mealtime services in two areas. These deficiencies placed all 66 residents, staff, and visitors at risk for the spread of infectious disease. The deficiencies remain uncorrected despite previous citations.

The letter does not contain inspection findings but addresses the scheduling of the IDR meeting and the citations being disputed.

The letter does not contain inspection findings but lists the citations under dispute and the scheduled date and time for the IDR meeting.

The report details multiple uncorrected deficiencies related to medication availability, food sanitation, maintenance, nursing services oversight, safe storage of supplies, and resident rights. These deficiencies placed residents at risk and resulted in civil fines totaling $2,400. All cited deficiencies were previously noted and remain uncorrected.

The document does not contain inspection findings but serves as a notification for the IDR meeting to discuss disputed citations.

The stop placement order prohibiting admissions at Bonaventure of Lacey was lifted verbally on August 25, 2023, indicating the facility is no longer under admission restrictions.

The complaint investigation (Complaint #91115) substantiated allegations of lack of staffing and dietary service deficiencies. The facility failed to maintain staffing schedules and was out of compliance with food service requirements, causing resident dissatisfaction and unmet needs.

The investigation found the facility failed to keep actual worked staff schedules on-site, preventing evaluation of staffing, and was out of compliance with dietary services due to insufficient food amounts causing residents to run out of main entrée and desserts. Citations were written for these failed practices.

Several citations from the May 31, 2023 Statement of Deficiencies were deleted or edited following the IDR process, while some citations were upheld. The enforcement action dated June 13, 2023 remains unchanged.

The document outlines specific requirements for the licensee to hire a registered nurse consultant to ensure staff fit testing for N95 respirators, proper hand washing protocols, and documentation. It mandates weekly progress updates and posting of this notice in a visible location.

The licensee failed to maintain a respiratory protection program ensuring fit testing for N95 respirators for five staff and failed to provide necessary handwashing supplies in one memory care unit. These uncorrected and recurring deficiencies placed all 64 residents, staff, and visitors at risk for infectious disease spread, resulting in a stop placement order prohibiting admissions.

The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies regarding heating and temperature were corrected.

The document does not contain inspection findings but lists multiple disputed citations under Washington Administrative Code (WAC) sections related to the facility's deficiencies and civil fine.

The visit was a Full and Complaint Investigation conducted on May 31, 2023, resulting in multiple cited deficiencies and civil fines.

The report details multiple recurring deficiencies related to water temperature, fire marshal compliance, medication availability, qualified assessments, nursing services, investigations, coordination of health care, record accuracy, and resident rights. Civil fines totaling $5,900 were imposed due to these violations.

This was a complaint investigation resulting in a substantiated violation that led to a civil fine for failure to monitor a resident's well-being adequately.

The licensee failed to take appropriate actions and obtain labs as needed to address one resident’s changing needs, which contributed to a delay in treatment and resulted in the resident being hospitalized for 10 days. A civil fine of $500 was imposed based on this violation.

The Department of Social and Health Services requires the facility to hire a registered nurse consultant to ensure staff fit testing for N95 respirators, proper hand washing protocols, and documentation. The notice outlines specific infection control and training requirements to be met by specified deadlines.

The facility failed to provide necessary handwashing supplies in one memory care unit and failed to document and maintain employee N95 respirator fit testing records for twelve employees. These uncorrected deficiencies placed residents, staff, and visitors at risk for the spread of infectious disease, resulting in a $2,000 civil fine and conditions imposed on the license.

Complaint number 49450 alleged the facility did not initiate fire watch while the dry sprinkler system malfunctioned. The investigation confirmed failure to implement fire watch as required, resulting in citations.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies regarding failure to implement fire watch were corrected.

The investigation involved allegations that a resident with dementia on hospice was not obtaining adequate food and fluid intake, and that a medication cart was left unlocked in the memory care unit unattended. Both allegations were substantiated with citations written.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.

The complaint investigation was triggered by an allegation of a non-injury fall where the facility failed to conduct occurrence reports and investigations as required. The investigation found that occurrence reports were missing for two residents who had unwitnessed falls with injury, and no documented interventions to prevent recurrence were in place. This was a recurring deficiency.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies were corrected.

The complaint investigation involved allegations of fraud/false billing and financial exploitation related to failure to provide 30-day written notice of care cost increases, and failure to provide negotiated care and services. The investigation substantiated these allegations with citations written for failed provider practices.

The investigation found that the facility failed to provide required 30-day written notice to residents or their representatives regarding care cost increases, resulting in citations. Additionally, the facility failed to collect urinalysis samples and notify physicians, leading to resident decline and hospitalization. Citations were written for these deficiencies.

The complaint investigation identified recurring deficiencies related to infection control, failure to provide requested documents, and failure to maintain resident dignity and hygiene. These deficiencies were previously cited multiple times in prior years.

The investigation found multiple recurring deficiencies including failure to provide necessary infection control supplies, failure to provide requested documents during the investigation, and failure to ensure residents maintained dignity and hygiene. Civil fines totaling $1,600 were imposed based on these violations.

The complaint investigation (Complaint #44479 and others) was triggered by allegations that the facility failed to correct fire safety deficiencies from prior Fire Marshal visits. The investigation confirmed noncompliance with multiple fire safety requirements and lack of staff fire drill participation.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous fire safety deficiencies were corrected.

The licensee failed to investigate occurrences (accidents/injury reports) for two residents, placing them at risk for further injury and unmet care needs. This deficiency is recurring and resulted in a $500 civil fine.