Inspection Reports for Bonaventure of Puyallup
14503 Meridian E, Puyallup, WA 98375, WA, 14503
Back to Facility ProfileDeficiencies per Year
4
3
2
1
0
Unclassified
Census Over Time
Inspection Report
Follow-Up
Deficiencies: 2
May 29, 2025
Visit Reason
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.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to resident supervision and notification of death were corrected.
Complaint Details
Complaint investigation regarding an unexpected death. The facility failed to implement policies addressing resident safety and failed to notify representatives of the death. Citation(s) were written.
Deficiencies (2)
| Description |
|---|
| Failure to implement policies and procedures to supervise and monitor residents, including accounting for residents who leave the premises, resulting in a resident not receiving timely care and passing away. |
| Failure to notify representatives of the death of residents, causing emotional distress and complicating the grieving process. |
Report Facts
Compliance Determination Completion Date: May 29, 2025
Compliance Determination Completion Date: Oct 31, 2024
Closed records sample size: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Conducted on-site verification and complaint investigation |
| Manfay Chan | Allied Health Field Manager | Signed follow-up inspection letter |
| Staff A | Administrator | Interviewed regarding resident supervision and notification procedures |
| Staff B | Registered Nurse | Interviewed regarding resident safety checks |
| Staff C | Health and Wellness Director | Interviewed regarding meal rosters and resident safety procedures |
Inspection Report
Follow-Up
Deficiencies: 1
Jan 16, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to discharge notice requirements.
Findings
The follow-up inspection found no deficiencies, confirming that the previously cited deficiencies regarding written discharge notices were corrected.
Complaint Details
The complaint investigation found that a resident was discharged without a written notice as required by licensing laws. Interviews with the resident's representative and facility administrator confirmed no written discharge notice was provided. The investigation concluded with a failed provider practice and citation issued.
Deficiencies (1)
| Description |
|---|
| Failure to provide a written discharge notice including reason, effective date, location, and ombudsman contact information for 1 of 1 residents, resulting in mental stress to the resident. |
Report Facts
Complaint number: 147350
Compliance Determination number: 48615
Number of residents in sample: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Mason | NCI ALF Licensor | Conducted the follow-up inspection and complaint investigation |
| Jody Just | Field Manager | Signed the follow-up inspection letter and statement of deficiencies |
Inspection Report
Follow-Up
Census: 87
Deficiencies: 0
May 13, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 05/13/2024 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previous deficiencies related to tuberculosis skin testing were corrected.
Report Facts
Residents sampled: 6
Residents sampled: 9
Deficiencies cited: 3
Staff sampled for TB testing: 6
Staff with missing fingerprint background checks: 4
Staff with incomplete TB testing: 3
Staff without initial TB test within 3 days: 3
Staff without current food worker cards: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Moran | Assisted Living Facility Nursing Consultant Institutional | Department staff who conducted the on-site verification |
| Shirley Grew | LTC Surveyor | Department staff who conducted the on-site verification |
| Manfay Chan | Field Manager | Signed enforcement and follow-up letters |
| Staff B | Home Care Aide | Cited for missing initial and second TB tests |
| Staff C | Home Care Aide | Cited for missing initial and second TB tests and missing fingerprint background check |
| Staff D | Caregiver | Cited for missing fingerprint background check |
| Staff E | Caregiver | Cited for missing fingerprint background check |
| Staff F | Home Care Aide | Cited for missing initial and second TB tests and missing fingerprint background check |
| Staff G | Server | Initially lacked current food worker card |
| Staff H | Server | Initially lacked current food worker card |
| Staff A | Executive Director | Provided interviews regarding TB testing and personnel records |
| Staff J | Dining Services Manager | Received consultation on food temperature control |
Inspection Report
Enforcement
Deficiencies: 1
Mar 28, 2024
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to Bonaventure of Puyallup to address previously cited deficiencies and to impose a civil fine related to tuberculosis skin testing violations.
Findings
The facility failed to ensure that four staff members received the required two-step tuberculosis skin testing within the mandated timeframe, placing residents, staff, and visitors at risk. This deficiency was previously cited and remains uncorrected, resulting in a $300 civil fine.
Deficiencies (1)
| Description |
|---|
| Failure to ensure four staff had an initial tuberculosis skin test within three days of employment and a second skin test one to three weeks after the first. |
Report Facts
Civil fine amount: 300
Number of staff with missing TB tests: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manfay Chan | Field Manager | Contact person for plan of correction and appeals |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 1
Jan 5, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding unqualified personnel at the Assisted Living Facility Bonaventure of Puyallup.
Findings
The investigation found that Staff B, a dishwasher, had a disqualifying background condition making them ineligible for employment. The facility failed to ensure a timely fingerprint background check for Staff B, resulting in care and services being provided by an unqualified staff member. Staff B was subsequently terminated.
Complaint Details
The complaint investigation found substantiated allegations of unqualified personnel due to a disqualifying background check condition for Staff B. The facility failed to complete the background check timely, resulting in Staff B working while unqualified.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a timely fingerprint background check for Staff B, who had a disqualifying condition making them unqualified for employment. |
Report Facts
Total residents: 87
Resident sample size: 0
Closed records sample size: 0
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 2
Jan 5, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding a named resident who experienced a delay in care and Cardiopulmonary Resuscitation (CPR) performed despite being identified as Do Not Resuscitate (DNR).
Findings
The facility failed to provide timely and appropriate care during an emergency for one resident, resulting in a delay in care and a less than pleasant death with dignity. Additionally, the facility failed to provide care and services related to toileting as stated in the negotiated service agreement. Failed provider practices were identified and citations were written.
Complaint Details
The complaint alleged that a named resident had a delay in care and CPR was performed despite the resident being identified as Do Not Resuscitate (DNR). The investigation found failed provider practices related to delayed emergency care and failure to provide agreed-upon services.
Deficiencies (2)
| Description |
|---|
| Failed to coordinate care with an external health care provider and respond timely and appropriately during an emergency, causing delay in care to Resident 1. |
| Failed to provide care and services to Resident 1 as stated in the negotiated service agreement related to toileting. |
Report Facts
Total residents: 87
Resident sample size: 1
Closed records sample size: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Melisa Moran | Assisted Living Facility Nursing Consultant Institutional | Investigator who conducted the complaint investigation and on-site verification |
| Manfay Chan | Field Manager | Signed follow-up inspection letter confirming no deficiencies on 07/18/2024 |
Inspection Report
Complaint Investigation
Census: 4
Deficiencies: 4
Oct 12, 2023
Visit Reason
The inspection was a follow-up and complaint investigation related to allegations including resident falls during transfer, medication administration issues, wound care, personal hygiene, and care plan compliance at Bonaventure of Puyallup Assisted Living Facility.
Findings
The facility was found to have multiple deficiencies including failure to properly train staff on Hoyer lift use leading to resident injury, failure to provide showers as agreed in service plans, and failure to ensure staff were qualified to perform delegated nursing tasks such as medication administration and blood sugar checks. Some deficiencies were recurring and uncorrected from prior inspections.
Complaint Details
The complaint investigation addressed allegations including a resident dropped during transfer, missed pain medications, wound care concerns, lack of showers and personal hygiene, room odor, and missed meals. The investigation substantiated failures in staff training, medication administration, and shower provision, with some allegations not supported.
Deficiencies (4)
| Description |
|---|
| Failure to ensure staff were properly trained on Hoyer lift use, resulting in resident fall and injury. |
| Failure to provide showers as agreed upon in negotiated service agreements for residents. |
| Failure to ensure staff received appropriate training and orientation to perform job duties. |
| Failure to ensure staff were qualified and trained to perform delegated nursing tasks including medication administration and blood sugar checks. |
Report Facts
Resident sample size: 3
Current residents reviewed during follow-up: 4
Staff training failures: 9
Residents at risk due to lack of showers: 3
Residents at risk due to unqualified staff: 6
Diabetic residents at risk: 8
Inspection Report
Follow-Up
Deficiencies: 1
Oct 10, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection on 10/10/2023 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. Previously cited deficiencies related to cooperation and provision of requested records were corrected.
Complaint Details
The complaint investigation was triggered by the facility's failure to provide requested documents during an investigation. The complaint was substantiated with a failed provider practice identified and citation(s) written.
Deficiencies (1)
| Description |
|---|
| Failure to cooperate with the department by not providing requested records during an investigation, resulting in incomplete investigation and risk to residents. |
Report Facts
Resident sample size: 4
Complaint number: 86168
Compliance Determination Completion Dates: 10/10/2023 and 06/20/2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Investigator who conducted complaint investigation |
| Cathleen Davis | ALF Licensor | Department staff who did on-site verification |
| Shirley Grew | LTC Surveyor | Department staff who did on-site verification |
| Lisa Mason | NCI ALF Licensor | Department staff who did on-site verification |
| Melisa Moran | Assisted Living Facility Nursing Consultant Institutional | Department staff who did on-site verification |
Inspection Report
Follow-Up
Deficiencies: 1
Oct 10, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies related to medication administration and coordination of health care services.
Findings
The follow-up inspection on 10/10/2023 found no deficiencies and confirmed that the facility meets Assisted Living Facility licensing requirements. The prior deficiencies related to failure to coordinate medication services and failure to notify the doctor and family about missed critical medications were corrected.
Complaint Details
Complaint investigation conducted from 06/28/2023 through 07/26/2023 regarding allegations that a resident did not receive her medications and received an incorrect insulin dose. The investigation found failed provider practice related to medication administration and coordination, but no additional citations were written as the facility was out of compliance. The second allegation was not substantiated.
Deficiencies (1)
| Description |
|---|
| Failed to notify the doctor and coordinate alternative medication treatment for 1 of 4 sampled residents when critical medication was not delivered for a week, placing the resident at risk for malnutrition, weight loss, abdominal pain, and failure to thrive. |
Report Facts
Resident sample size: 4
Compliance Determination Completion Date: Oct 10, 2023
Compliance Determination Completion Date: Jul 26, 2023
Days medication not received: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Investigator who conducted the complaint investigation |
| Shirley Grew | LTC Surveyor | Department staff who conducted the follow-up inspection |
| Cathleen Davis | ALF Licensor | Department staff who conducted the follow-up inspection |
| Lisa Mason | NCI ALF Licensor | Department staff who conducted the follow-up inspection |
| Melisa Moran | Assisted Living Facility Nursing Consultant Institutional | Department staff who conducted the follow-up inspection |
| Staff A | Administrator | Interviewed regarding medication coordination and notification failures |
| Staff B | Assisted Living Director | Interviewed regarding pharmacy communication and medication coordination |
| Staff C | Registered Nurse | Interviewed regarding medication concerns and communication |
| Staff D | Medication Technician | Interviewed regarding notification procedures for missed medications |
| CC1 | Primary Care Physician’s Registered Nurse | Interviewed regarding notification of missed medication |
Inspection Report
Follow-Up
Deficiencies: 2
Oct 10, 2023
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 10/10/2023 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, indicating the facility meets the Assisted Living Facility licensing requirements. Previously cited deficiencies related to medication administration and nonavailability of medications were corrected.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents received medications as prescribed, resulting in potential negative health outcomes and decline in quality of life. |
| Failure to ensure availability of medications for residents, placing residents at risk for potential decline in health. |
Report Facts
Sample residents reviewed: 4
Residents affected: 2
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cathleen Davis | ALF Licensor | Department staff who did on-site verification |
| Shirley Grew | LTC Surveyor | Department staff who did on-site verification |
| Lisa Mason | NCI ALF Licensor | Department staff who did on-site verification |
| Melisa Moran | Assisted Living Facility Nursing Consultant Institutional | Department staff who did on-site verification |
Inspection Report
Follow-Up
Census: 81
Deficiencies: 3
Jul 18, 2023
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to the assisted living facility to verify correction of previously cited deficiencies.
Findings
The facility was found to have multiple uncorrected deficiencies related to staff training, failure to provide agreed-upon showers to residents, and lack of proper nurse delegation training, placing residents at risk for inadequate care and decreased quality of life.
Deficiencies (3)
| Description |
|---|
| Failure to ensure staff were trained and oriented to perform their job responsibilities for nine staff. |
| Failure to provide showers as agreed upon for three residents. |
| Failure to ensure staff were delegated for five staff before checking residents’ blood sugars or administering insulin for six residents. |
Report Facts
Civil fine amount: 300
Civil fine amount: 600
Civil fine amount: 300
Total civil fines: 1200
Resident census: 81
Number of staff not trained: 9
Number of residents affected by shower deficiency: 3
Number of staff lacking nurse delegation: 5
Number of residents affected by nurse delegation deficiency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter regarding civil fines |
| Manfay Chan | Field Manager | Contact person for the enforcement and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 20, 2023
Visit Reason
The Department of Social and Health Services completed a complaint investigation at the assisted living facility Bonaventure of Puyallup on June 20, 2023, due to concerns about compliance with licensing requirements.
Findings
The licensee failed to cooperate with the department by not providing requested records during the investigation, which hindered a thorough and timely investigation and placed residents at risk of receiving non-compliant services. This deficiency was recurring from a previous citation on July 1, 2022.
Complaint Details
The complaint investigation found that the licensee did not cooperate by withholding requested records, resulting in an incomplete investigation and risk to residents. This deficiency was substantiated and is a recurring issue.
Deficiencies (1)
| Description |
|---|
| Failure to cooperate with the department in providing requested records during an investigation. |
Report Facts
Civil fine amount: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manfay Chan | Field Manager | Contact person for plan of correction and appeals |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
Inspection Report
Enforcement
Deficiencies: 2
Jun 13, 2023
Visit Reason
The Department of Social and Health Services completed a follow-up visit to the assisted living facility to assess compliance and enforce civil fines based on previously cited deficiencies.
Findings
The facility failed to ensure that two residents received their medications as prescribed and failed to ensure availability of medications for these residents, resulting in civil fines for uncorrected deficiencies previously cited in November 2022.
Deficiencies (2)
| Description |
|---|
| Failure to ensure two residents received their medications as prescribed. |
| Failure to ensure availability of medications for two residents. |
Report Facts
Civil fine amount: 300
Civil fine amount: 300
Total civil fines: 600
Previously cited date: Nov 2, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Manfay Chan | Field Manager | Contact for submission of Statement of Deficiencies and follow-up |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
Inspection Report
Enforcement
Deficiencies: 1
Dec 6, 2022
Visit Reason
The Department of Social and Health Services conducted an investigation at the assisted living facility which resulted in the imposition of a civil fine due to violations of regulatory requirements.
Findings
The licensee failed to provide showers as agreed upon in the Negotiated Service Agreement for one resident, placing the resident at risk for skin-related infections and a decrease in quality of life. This was a recurring deficiency previously cited in 2021 and 2022.
Deficiencies (1)
| Description |
|---|
| Failure to provide showers as agreed upon in the Negotiated Service Agreement for one resident. |
Report Facts
Civil fine amount: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the enforcement letter. |
| Manfay Chan | Field Manager | Contact person for plan of correction and inquiries. |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 2, 2022
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies, and the facility meets the Assisted Living Facility licensing requirements.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Gijima | Community Complaint Investigator (NCI) | Department staff who did the on-site verification. |
| Manfay Chan | Field Manager | Signed the follow-up inspection letter. |
Loading inspection reports...



