Inspection Reports for Bonaventure of Lacey

The Department of Social and Health Services completed a complaint investigation at the assisted living facility Bonaventure of Lacey due to allegations of resident harm and failure to protect residents from abuse and inadequate care.

The investigation found recurring deficiencies including failure to protect residents from harm and physical altercations resulting in psychological harm, and failure to provide appropriate care during changes in residents' conditions, leading to pain, discomfort, falls, and decline in health.

The visit was complaint-related, triggered by allegations of resident abuse and inadequate care. The deficiencies were substantiated and are recurring issues previously cited in 2023 and 2025.

The Department of Social and Health Services completed a Complaint Investigation at the assisted living facility Bonaventure of Lacey on July 9, 2025, due to allegations related to medication services and investigation failures.

The investigation found recurring deficiencies including failure to follow prescribed medication orders, unsafe medication administration practices, unaccounted narcotic medications, and failure to investigate and document incidents resulting in significant injury to a resident. These deficiencies placed residents at risk of injury, hospitalization, and adverse medication effects.

Complaint investigation conducted on July 9, 2025. The deficiencies were recurring and substantiated, resulting in civil fines.

The inspection was a complaint investigation triggered by multiple allegations including quality of care/treatment, unqualified personnel, falsification of records, nursing services, resident neglect, and medication administration issues at Bonaventure of Lacey Assisted Living Facility.

The investigation found multiple failed provider practices including failure to monitor residents' well-being, failure to follow prescribed medication orders, unsafe medication administration by untrained staff, narcotic medication discrepancies, and failure to investigate and document significant resident injuries. Some allegations were not substantiated, but several deficiencies were cited.

The complaint investigation included allegations of unsafe staff assignments, unqualified personnel, falsification of medication logs, lack of nursing services, resident neglect including failure to provide showers, and failure to administer prescribed medications. Some allegations were substantiated with citations issued for failed provider practices, while others were not substantiated.

A complaint investigation was conducted on 05/19/2025 at Bonaventure of Lacey regarding issues with the sprinkler system.

The investigation found that the dry sprinkler system had a leak and was not working as installed. The accelerator was not working as intended, and the air compressor was tripping the electrical panel multiple times. There was no fire, no activation of the sprinkler system, no evacuations, no injuries, and the fire department did not respond.

Complaint #177002 regarding the sprinkler system. The complaint was investigated and violations were identified related to the sprinkler system not working as installed. No fire or injuries occurred. Re-inspection scheduled for 06/16/2025 to verify correction.

The Department of Social and Health Services completed a complaint investigation at the assisted living facility Bonaventure of Lacey on May 1, 2025, resulting in a civil fine due to medication security violations.

The licensee failed to ensure that medication carts for one cart were locked, placing 64 residents at risk for ingestion of potentially harmful medications and unauthorized access to the medication cart. This was a recurring deficiency previously cited in 2022 and 2023.

Complaint investigation completed on May 1, 2025, resulting in a civil fine for medication security violations.

The Department of Social and Health Services completed a complaint investigation at the Bonaventure of Lacey assisted living facility due to concerns about maintenance and housekeeping.

The licensee failed to provide a safe and well-maintained environment, resulting in a gas leak that placed 89 residents, staff, and visitors at risk of exposure to gas fumes and potential harm. This deficiency was recurring, having been previously cited in 2023.

The visit was complaint-related and substantiated, resulting in a civil fine of $700 for maintenance and housekeeping violations related to a gas leak.

The investigation was conducted due to complaints regarding staff not using gloves during personal care, not answering call lights, insufficient staffing, and residents' medications being forgotten.

The investigation found no failed practice related to quality of care or call light response. However, a failed practice was identified regarding pharmaceutical services, specifically an unlocked and unattended medication cart, placing all 64 residents at risk.

Complaint investigation regarding quality of care/treatment and pharmaceutical services. The medication cart was found unlocked and unattended, constituting a failed practice. The complaint about staff not using gloves and call light response was not substantiated.

The inspection was conducted in response to complaints #173999 and #174187 regarding a possible gas leak and dry sprinkler system issues at Bonaventure of Lacey.

The investigation found no odor of gas and confirmed repairs were made after a gas leak on 4/3/2025. The sprinkler system was operating normally with activation during a fire watch on 4/7/2025. No fire occurred, no injuries were reported, and the fire department did not respond.

Complaint #173999 involved a reported gas leak and evacuation on 4/3/2025; repairs were completed. Complaint #174187 involved a leak in the dry sprinkler system and activation of the sprinkler system on 4/7/2025 during a fire watch. Both complaints found no fire, no injuries, and no fire department response.

The Office of the State Fire Marshal conducted an inspection at the Bonaventure of Lacey facility to assess compliance with fire safety and electrical codes.

Multiple violations were found including electrical hazards such as a broken ground outlet and improper use of extension cords, missing ceiling tiles, fire sprinkler heads loaded with debris, failure to maintain emergency lighting and fire extinguisher inspection reports, and fire door latching hardware failures.

The inspection was conducted as an unannounced on-site complaint investigation due to a report of a strong smell of gas coming from a laundry room.

The facility placed residents, staff, and visitors at risk of exposure to gas fumes and at risk of harm and injury due to a gas leak. The investigation found a failure to provide a safe and well-maintained environment, with a gas leak identified in the laundry room area.

The complaint involved a physical environment issue with a strong smell of gas reported in the laundry room. Multiple staff and caregivers reported smelling gas over several months, with maintenance initially denying the issue. 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 complaint was substantiated with citations written.

The investigation was conducted due to a complaint regarding quality of care/treatment related to a report of a fall in the community when the power was out.

The facility followed policy and procedure when a resident had a fall and sustained injury, with notifications made to proper parties and monitoring of the resident's condition. However, the facility failed to report the power outage to the Complaint Resolution Unit, which was identified as a failed practice.

Complaint investigation regarding a fall during a power outage. Failed provider practice was identified and citations were written.

The inspection was conducted as an unannounced on-site complaint investigation due to allegations of a resident being left soiled for hours, food and drinks out of reach, and a resident being found on the floor.

The investigation found failed practices including the facility not using a fall mat as ordered for a resident who slid off the bed and failure to provide medication to a resident with no notification to the prescriber. The facility was cited for these deficiencies.

Complaint investigation regarding quality of care/treatment including resident being left soiled for hours, food and drinks out of reach, and resident found on the floor. The complaint was not substantiated for some allegations but failed practices were identified related to fall mat use and medication administration.

The Department of Social and Health Services completed a Complaint Investigation at the assisted living facility Bonaventure of Lacey on March 4, 2025, due to concerns related to medication services.

The licensee failed to implement systems that promote safe medication services for one resident when the resident refused medication or the medication was unavailable, placing the resident at risk for unmet care needs. This was a recurring deficiency previously cited in 2022 and 2023.

Complaint Investigation conducted on March 4, 2025. The deficiency was substantiated as it resulted in a civil fine.

The inspection was conducted as an unannounced on-site complaint investigation regarding a facility report of a resident sustaining an injury after falling in the community.

The facility failed to monitor a resident after they returned to the community following a fall and hip fracture, resulting in a failed practice being identified and citation written.

The complaint involved a resident sustaining an injury after falling in the community. The investigation found the facility failed to monitor the resident properly after the fall and hip fracture, confirming a failed provider practice and citation.

The Department of Social and Health Services conducted a follow-up visit to Bonaventure of Lacey to verify correction of previously cited deficiencies related to nurse delegation training and supervision.

The facility failed to ensure two staff had required Nurse Delegation training, supervision, and documentation by the RN Delegator for two residents receiving nurse delegated services. This resulted in one resident receiving medications outside of parameters and placed residents at risk due to untrained and unsupervised care staff. The citation is uncorrected and recurring from prior inspections.

This document serves as formal notice that the conditions placed on the assisted living facility license on March 21, 2023, and subsequently amended on July 26, 2023, and October 13, 2023, are lifted effective January 9, 2024.

The letter informs that all previously imposed license conditions have been lifted as of January 9, 2024, following verbal notification on January 10, 2024.

Follow-up inspection to verify correction of previously cited deficiencies related to infection control and respiratory protection.

The facility was found to have corrected prior deficiencies and met licensing requirements on the follow-up visit. Previous issues included failure to provide necessary handwashing supplies, improper infection control practices, and incomplete respiratory protection fit testing for staff.

Complaint investigation regarding neglect and quality of care related to failure to provide care per resident's Negotiated Service Agreement, including failure to provide showers and documentation. Facility withheld requested documentation needed for investigation.

The Department of Social and Health Services completed a complaint investigation at the assisted living facility Bonaventure of Lacey on December 6, 2023, due to an allegation of abuse.

The facility failed to investigate and document investigative actions after becoming aware of an allegation of abuse for one resident, resulting in an inability to demonstrate investigative actions and findings, which placed the resident at risk for ongoing abuse. This deficiency is recurring.

The complaint investigation found that the licensee failed to investigate and document investigative actions after becoming aware of an allegation of abuse for one resident. This is a recurring deficiency previously cited on May 31, 2023, November 14, 2022, and January 05, 2022.

The investigation was conducted due to a public allegation of sexual abuse from a staff member to a resident in the community.

The facility failed to follow policy and complete an Occurrence Report when they became aware of the allegation. They also failed to document the investigation and investigative actions, resulting in a failed provider practice with citations written.

The complaint involved a public allegation of sexual abuse from a staff member to a resident in the community. The facility failed to complete required documentation and investigation. The allegation was not substantiated due to lack of documentation and investigative actions.

This document communicates the results of the Informal Dispute Resolution (IDR) process regarding disputed deficiencies from the Statement of Deficiencies report dated August 25, 2023.

After review of all materials, oral statements, and records, the decision was made not to change the original Statement of Deficiencies report dated August 25, 2023.

This document is a follow-up letter regarding the Informal Dispute Resolution (IDR) process conducted on October 31, 2023, addressing citations from the Statement of Deficiencies report dated September 21, 2023.

The letter details edits and clarifications made to specific citations in the Statement of Deficiencies, including medication availability, nursing services, and resident rights, but confirms no change to the previously imposed enforcement action dated October 4, 2023.

This notice imposes continued and amended conditions on the license of Bonaventure of Lacey based on a prior Statement of Deficiencies dated October 2, 2023, requiring employment of a registered nurse consultant to assist with infection control compliance.

The facility must employ a registered nurse consultant to train staff on hand washing protocols, ensure availability of hand washing supplies, revise policies, and document training efforts. Weekly updates to the Department are required until compliance is achieved.

The Department of Social and Health Services completed a follow-up visit to impose a civil fine and continued and amended conditions on the license of Bonaventure of Lacey assisted living facility due to infection control violations.

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, placing 66 residents, staff, and visitors at risk for infectious disease spread.

The letter confirms the rescheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility to dispute citations from a Statement of Deficiencies dated August 25, 2023.

The document does not contain inspection findings but addresses the scheduling details and participants for the IDR meeting related to disputed citations.

The Department of Social and Health Services conducted a follow-up visit to Bonaventure of Lacey to assess correction of previously cited deficiencies and to impose civil fines based on violations found.

Multiple uncorrected deficiencies were identified including nonavailability of medications, improper food storage and labeling, unsafe and unsanitary maintenance conditions, lack of required nurse delegation oversight, unsecured hazardous supplies, and failure to address resident grievances, all placing residents at risk.

This document is the result of an Informal Dispute Resolution (IDR) process regarding disputed deficiencies identified in the Statement of Deficiencies (SOD) report dated September 21, 2023, for an Assisted Living Facility.

After review of all materials, oral statements, and records, the decision was made not to change the original SOD report dated September 21, 2023. The facility is instructed to begin correcting the disputed deficiencies immediately and submit a Plan/Attestation Statement within 10 calendar days.

The document confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility to dispute specific citations from a prior Statement of Deficiencies.

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

The inspection was conducted as an unannounced complaint investigation due to concerns that the facility was not back in compliance with their plan of correction by the attestation date.

The investigation found failed provider practice related to the facility not completing their plan of correction by the attestation date, placing all 66 residents at risk. The facility was cited for WAC 388 78A 3152 (1)(6)(a)(b).

The complaint alleged the facility was not back in compliance with their plan of correction by the attestation date. The complaint was substantiated with failed provider practice identified and citation written.

This letter serves as formal notice that the stop placement order prohibiting admissions placed on the facility's license on July 26, 2023, was verbally lifted effective August 25, 2023.

The stop placement order prohibiting admissions was lifted verbally on August 25, 2023, following the initial order dated July 26, 2023.

The inspection was conducted as an unannounced complaint investigation based on public reports alleging lack of staffing resulting in unmet care needs and issues with dietary services including long wait times and running out of main entrée and desserts during dinner.

The facility failed to keep actual worked staff schedules on-site, preventing evaluation of staffing, and was out of compliance with dietary service requirements due to insufficient staff during meal times and running out of main entrée and desserts. These failures were substantiated through interviews and record reviews, resulting in failed provider practices and citations.

Complaint investigation was based on public reports of lack of staffing leading to unmet care needs and dietary service issues including long wait times and insufficient staff assistance during meals. The allegations were substantiated through interviews and record reviews.

The document is a follow-up letter communicating the results of the Informal Dispute Resolution (IDR) process held on July 27, 2023, addressing citations from the Statement of Deficiencies report dated May 31, 2023.

After review and consideration, several citations from the May 31, 2023 Statement of Deficiencies report were deleted or edited, while some citations were upheld as written. The enforcement action dated June 13, 2023 remains unchanged.

This notice was issued to impose continued and amended conditions on the license of Bonaventure of Lacey based on a prior Statement of Deficiencies dated July 12, 2023, requiring the hiring of a registered nurse consultant to assist with infection control compliance and staff training.

The document outlines specific requirements for the facility to ensure staff are fit tested for N95 respirators, trained on hand washing protocols, and that proper documentation and supplies are maintained to meet infection control standards.

The document serves as a Stop Placement Order based on a Statement of Deficiencies dated July 12, 2023, imposing restrictions on the facility's license.

The Department of Social and Health Services has imposed a Stop Placement Order on the facility's license effective July 26, 2023, which remains in effect until formally lifted.

The Department of Social and Health Services completed a follow-up visit to Bonaventure of Lacey to assess compliance with previously cited deficiencies related to infection control and to impose continued and amended conditions on the facility's license, including a stop placement order prohibiting admissions.

The facility failed to maintain a respiratory protection program ensuring all staff were fit tested for N95 respirators and failed to provide necessary handwashing supplies in one memory care unit, placing all 64 residents, staff, and visitors at risk for infectious disease spread. These deficiencies were uncorrected and recurring from prior citations.

The letter confirms the scheduling of an Informal Dispute Resolution (IDR) meeting requested by the facility to dispute citations listed in a Statement of Deficiencies and a civil fine.

The document does not contain inspection findings but lists the citations being disputed and the scheduled date and format of the IDR meeting.

The Department of Social and Health Services completed a Full and Complaint Investigation at the assisted living facility to assess compliance with regulations and address complaints.

Multiple deficiencies were found including unsafe water temperature, noncompliance with fire safety regulations, medication availability issues, unqualified pre-admission assessments, inadequate nursing services, failure to investigate incidents, poor coordination of health care services, inaccurate records, and failure to address resident grievances. Many deficiencies were recurring.

The visit was a Full and Complaint Investigation triggered by complaints. The report notes recurring deficiencies and multiple violations placing residents at risk.

The inspection was conducted as an unannounced on-site complaint investigation regarding a public report that the dining room was too cold during breakfast hours.

The investigation found that the dining room temperature was 63°F, below the required minimum of 68°F during waking hours, placing residents, staff, and visitors at risk of a cold and uncomfortable environment. A failed provider practice was identified and citations were written.

Complaint related to the physical environment: the dining room being too cold during breakfast hours. The complaint was substantiated with failed provider practice identified and citations written.

The Department of Social and Health Services conducted a complaint investigation at Bonaventure of Lacey to address concerns related to monitoring residents' well-being.

The licensee failed to take appropriate actions and obtain labs as needed to address one resident’s changing needs, resulting in a delay in treatment and a subsequent 10-day hospitalization. A civil fine of $500 was imposed based on this violation.

Complaint investigation completed on March 27, 2023, resulting in substantiated violation and imposition of a civil fine.

This notice was issued to impose conditions on the license of Bonaventure of Lacey following a Statement of Deficiencies dated March 13, 2023, requiring the licensee to hire a registered nurse consultant and implement infection control measures.

The Department requires the facility to ensure all staff are fit tested for N95 respirators, provide necessary PPE, train staff on hand washing protocols, and maintain documentation of these activities. The notice also mandates posting the conditions publicly and making the consultant available to the Department.

The Department of Social and Health Services completed a follow-up visit to the assisted living facility to assess correction of previously cited deficiencies related to infection control.

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 deficiencies placed residents, staff, and visitors at risk for the spread of infectious disease and were recurring and uncorrected from prior citations.

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to licensing laws and regulations.

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 Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication storage and administration.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to medication storage and administration were corrected.

The complaint investigation was triggered by allegations that a resident with dementia on hospice was not obtaining adequate food and fluid intake, and that the medication cart was left unlocked and unattended in the memory care unit. The investigation found failed practices in medication administration and storage.

The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.

The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to WAC 388-78A-2371-1, -2, and -3 were corrected.

The investigation was conducted due to multiple complaints including fraud/false billing, financial exploitation, quality of care/treatment, and admission, transfer & discharge rights related to Bonaventure of Lacey Assisted Living Facility.

The facility failed to provide 30-day written notice to residents or their representatives prior to increasing care costs, resulting in citations for fraud/false billing and financial exploitation. Additionally, the facility failed to collect urinalysis samples and notify physicians, leading to resident decline and hospitalization, resulting in citations for quality of care and admission rights violations.

Complaints included fraud/false billing and financial exploitation related to failure to notify residents of care cost increases, and quality of care/treatment and admission rights violations related to failure to collect urinalysis and notify physicians, resulting in resident hospitalization.

The Department of Social and Health Services completed a complaint investigation at the assisted living facility Bonaventure of Lacey on January 12, 2023, due to allegations related to infection control, documentation, and resident care.

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, resulting in civil fines totaling $1,600.

The visit was complaint-related and resulted in substantiated findings leading to civil fines for infection control failures, failure to provide requested documents, and failure to maintain resident dignity and hygiene.

The Department of Social and Health Services conducted an investigation at Bonaventure of Lacey assisted living facility which resulted in the imposition of a civil fine due to violations found during the investigation.

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 was recurring, having been previously cited in January 2022 and June 2020.

The inspection was conducted as a complaint investigation triggered by an allegation that the facility failed to fix deficiencies from a Fire Marshal follow-up visit.

The facility was found noncompliant with Washington State Patrol Fire Protection Bureau requirements, failing to correct multiple fire safety deficiencies including lack of fire drills for all shifts, maintenance of fire safety equipment, and staff awareness of fire procedures. The facility placed all 85 residents at risk in the event of a fire.

The complaint investigation found that the facility failed to correct fire safety deficiencies identified in prior inspections conducted on 04/26/2022 and 07/06/2022. Staff interviews revealed that some employees had not participated in fire drills and were unaware of fire procedures. The facility was cited for multiple violations placing all 85 residents at risk.

The letter confirms the facility's request for an Informal Dispute Resolution (IDR) to review and dispute specific citations from a Statement of Deficiencies dated 09/21/2023.

The document outlines the scheduled date and time for the IDR review meeting and lists the specific citations under dispute related to plan of correction, medication availability, nursing services, safe storage, and resident rights.

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