Beehive Retirement and Assisted Living Community.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written . N/A . Statement of Deficiencies License #: 2148 Compliance Determination # 65468 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date was asked to discuss the expectations of staff when a Resident-to-Resident altercation occurred in the facility. Staff A stated, “[Staff] should be separating residents and moving them away from other residents if they are agitated. Make sure they are safe. They should do a physical check-in with the resident if there are injuries. Make notifications to the nurse, [Administrator], family, and [the resident’s provider]. Collect witness statements, progress notes, and put [both of the residents] on alert. They should do a state [Department] report, and an Incident Report.” Staff A was asked within what time frame the Department should be notified per the facility policy. Staff A stated, “24 hours. We try to do it right away. My expectation is that it should be right away. But I think the policy says 24 hours. My expectation is that it should happen before the end of their shift.” Review of R1’s Face Sheet showed that the resident was admitted to the assisted living facility on /2024. Review of R1’s progress notes showed a note written by Staff B, the Resident Care Coordinator, dated 08/25/2025 at 12:30AM. The note stated, “Resident was sitting at the activity table with [their] back towards [the community]. When I heard [R2] yelling out. I rushed out of the nurse’s station and found [R2] pushing [their] right hand against [R1’s] neck and screaming in [R1’s] face. When I saw [R1] reach up and scratch at [R2’s] left side of [their] face. I immediately intervened and removed [R2’s] hands away from [R1’s] neck. [R2] then grabbed at [R1’s] arms holding them down. I asked [R2] to remove [their] hands and to stop. [R2] then struck me in the face twice, screaming at me to stop touching [them]. I explained [to R2 that they were] gripping my arms and I showed [them] that my palms were both open. [R2] continued to scream in my face telling me to go to hell. [R2] then attempted to shove me out of the way to reach around towards [R1]. I calmly asked [R2] to go to [their] room as [R1] continued sitting in the chair. [A caregiver] then came over to assist in redirecting [R2]. While [the caregiver] spoke with [R2], I redirected [R1] to another part of the living room to look over [them] for discolorations or marks. [R1] had red substance [blood] coming down [their] face and had visibly widened eyes that were tearful. [R1] stated [they were] upset and cried. I sat with [R1] on the [couch] while [the Medication Aide] attempted to clean red substance from [R1’s] hands and face. [R2] refused to leave the living area and redirect back to [their] room so we continued to stay and keep residents separated.” Further review of R1’s progress notes showed that there was no documentation of any notification to the R1’s provider, or R1’s family/representative. Review of R1’s medical record showed there was no Incident Report/Investigation completed by the facility for the incident. Review of R2’s Face Sheet showed that the resident was admitted to the assisted living facility on /2023. Review of R2’s progress notes showed a note written by Staff B, Resident Care Coordinator, dated 08/25/2025 at 12:33AM. The note was identical (copy and pasted) to the note entered into R1’s progress note dated 08/25/2025 at 12:30AM. Further review . Statement of Deficiencies License #: 2148 Compliance Determination # 65468 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date of R2’s progress notes showed that there was no documentation of any notification to the R2’s provider, or family/representative. Review of R1’s medical record showed there was no Incident Report/Investigation completed by the facility for the incident. Review of Department records showed a report made by the facility to notify the Department of the incident and report the Resident-to-Resident altercation on 08/28/2025. During an interview with Staff B on 09/11/2025 at 12:52PM, Staff B was asked to discuss the delay in reporting the altercation to the Department. Staff B stated, “I did not do the state report. I was under the impression that it was going to be done by the medication aide.” Staff B then stated, “It wasn’t until I sat down later to review notes that I noticed it was not reported, so I reported it.” During an interview with Collateral Contact 1 (CC1), R1 and R2’s medical provider, on 09/11/2025 at 12:48PM, CC1 was asked to verify that they were responsible for the medical care of R1 and R2. CC1 confirmed that they were. CC1 was asked if they were notified by the facility of a recent Resident-to-Resident altercation involving R1, and R2. CC1 stated that the facility just notified them earlier that day. CC1 was asked if the facility notified them at the time of the incident, on 08/25/2025. CC1 reviewed their records, which included scanned copies of faxes/notifications from the facility and stated that they received no notifications from the facility for the entire month of August 2025 for R1 or R2. This is a recurring deficiency previously cited on 12/14/2023, and previous consultation on 10/05/2022. .

Plan of Correction for Beehive Retirement Community 1. Kitchen HVAC unit: Replace current Mitsubishi HVAC system in the kitchen with a 18k Mini split using the existing lines and electrical. Remove ceiling mount unit, frame, sheetrock, mud, tape, texture and paint. Working around kitchen hours and needs. This work will be started by 5/10/25 and completed by 5/31/25. This work will be performed by Kelly Britz, Commercial Property Services 2. Walk-in Cooler repair: Replace damaged mdf in the cooler with FRP, only repairing walls and ceiling where needed to keep a cleanable food safe surface. The condenser is functional does not need to be removed. This work will be started by 5/10/25 and should be completed by 5/17/25. This work will be performed by Josh Tucker and Brian Willis, CPM Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Beehive Retirement We are hiring a general contractor to Project Manager, 3/29/2025 Estimates are in refurbish the existing structure of our Administrator and progress walk-in to meet compliance Maintenance Supervisor requirements. Kitchen overhead leaking pipe has Maintenance Supervisor, 3/29/2025 3/29/2025 been repaired and tankless water Administrator and heater closet has been scrubbed and Kitchen Staff sanitized. Overhead lights in kitchen no longer Maintenance Supervisor 3/29/2025 3/3/2025 have exposed wires. and Adminstrator ADA doors are operable. We replaced Project Manager, the hydraulic arms and air fittings. Maintenance Supervisor 3/29/2025 3/29/2025 and Administrator Overhead light in Activities Room will Maintenance Supervisor 3/29/2025 3/29/2025 have new cover installed and Administrator Memory Care Hallway has had the Maintenance Supervisor 3/29/2025 3/14/2025 hole in the ceiling and leaking pipe has and Administrator been repaired Shower chairs and shower benches for Assistant Administrator 3/29/2025 3/28/2025 Memory Care shower rooms have all and Administrator been replaced with new ones . Beehive Retirement We are currently working with Food Maintenance Supervisor 3/29/2025 Currently in Service Equipment (FSE) to let us know and Administrator progres if oven door can be replaced or if we need to replace the whole oven. R5’s bedroom door will have the Project Manager 3/29/2025 3/29/2025 inoperable magnetic door stop replaced Kitchen floor vinyl has been repaired Maintenance Supervisor 3/29/2025 3/14/2025 and new vinyl laid WAC 388-78A-2821 Design, We have submitted plans to DOH for Construction Review and Approval retroactive inspection and approval Maintenance Supervisor 3/29/2025 3/28/2025 Plan for roof repairs in Memory Care WAC 388-78A-2040 Other Carbon Monoxide detectors have been Project Manager and 3/29/2025 3/14/2025 Requirements placed in Memory Care per mandated Maintenance Supervisor locations All interior and exterior fire extinguishers have been inspected and Project Manager, 3/29/2025 3/29/2025 properly tagged Maintenance Supervisor and Administrator Cover plate for hot water heater in Assisted Living Laundry Room is currently on order . Beehive Retirement WAC 388-78A-2950 Water Supply Our water temperatures are now Project Manager and 3/29/2025 3/14/2025 within the safe range based on State Maintenance Manager requirements. We have added the policy with proper temperatures to the bottom of our temperature logs WAC 388-78A-2930 Our call lights and paging system are Project Manager, 3/29/2025 2/25/2025 Communications System all up and working properly. Corporate IT and Maintenance Supervisor WAC 388-78A 2730 Licensee’s We are currently obtaining estimates Project Manager and 3/29/2025 Currently receiving Responsibilities to replace HVAC system in kitchen Maintenance Supervisor estimates WAC 388-78A-2450 Staff Staff E has completed the application Assistant Administrator 3/29/2025 Waiting for DOH for her HCA credentials test to provide clearance for test date WAC 388-78A-2474 Training and We have changed our process for Assistant Administrator 3/29/2025 2/02/2025 Home Care Aide Certification employee schedules. Once the Requirements schedule is posted, it is printed and put in a binder. Any changes in the schedule will be kept in electronic form. . . Beehive Retirement WAC 388-110-220 Enhanced adult All health assessments are current and Oversight Nurse and RCC 3/29/2025 3/29/2025 residential care service standards being completed quarterly along with their negotiated service agreements. .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . I&] □ □ 01/02/2025 . ST ATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License#: 2148 Compliance Determination# 51938 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 12/17/2024, 12/17/2024 and 12/17/2024 of: Beehive Retirement and Assisted Living Community 401 W Maple St McCleary, WA 98557 This document references the following complaint number(s): 156137, 156731, 159020, 159210 The following sample was selected for review during the unannounced on-site visit: 3 of 47 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Phan Pham, Nurse Surveyor From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . From: 01/03/2025 16:07 #606 P.008/009 01.03.2025 14:28:24 State of llashington 417 or Statement Deficiencies License #: 2148 Compliance Determination# 51938 Pian of Correction Beehive Retirement and Assisted Living Community Completion Date Page2 of3 Lic.ensee: Carii1g Places Management, LLC 12/26/2024 WAC 388-78A-2210 Medication services. (2) The assisted living facility must ensure the following residents receive their medications as prescribed, except as provided for in WAC 388-78A-2230 and 388-78A-2250 : (a) Each resident who requires medication assistance and his or her negotiated service agreement indicates the assisted living facility will provide medication assistance; and This req!Jirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility failed to ensure 1 of 2 s.ampled staff (Staff C) administered pain medication as ordered for 1 of3 sampled residents (Resident 1[R1]) reviewed for medication services. This significant medication error placed R 1 and all residents at risk for experiencing health complications from being over medicated. Findings included ... On 12/16/2024 review of R 1' s admission record showed R 1 was admitted to the facility on /2024 with a diagnosis of . R1 was clischarged on /2024. Review of R1's service agreement dated 11/1812024 s.howed R1 had memory problems and Impaired cognition. R1 required assistance with medication services and staff members were responsible for ensuring R 1 received her medications as prescribed. Review of R1's physician order record showed on 12/11/2024 R1 had a physician order for Morphine Sulfate (pain medication) 20 milligrams (mg) per milliliter (ml) to be administered 0.5 ml every two hours. Review of R1's medication administration record (MAR) Showed from 12111/2024 at 10:00 PM to 12112/2024 at 4:00 AM Staff C, Facility Staff, administered four dosages of Morphine Sulfate. Review of the narcotic record showed R1 was given Morphine Sulfate 1.0 ml on 12/11/2024 at 10:20 PM, and on 12/12/2024 at 12:15 AM, 2:16 AM, and 4:30 AM. Staff C administered twice the amount of the Morphine Sulfate ordered, . Statement of Deficiencies License#: 2148 Compliance Determination# 51938 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date Administrator (or Representative) Date WAC 388-78A-2210 Medication services. (2) The assisted living facility must ensure the following residents receive their medications as prescribed, except as provided for in WAC 388-78A-2230 and 388-78A-2250 : (a) Each resident who requires medication assistance and his or her negotiated service agreement indicates the assisted living facility will provide medication assistance; and This requirement was not met as evidenced by: Based on interview and record review, the Assisted Living Facility failed to ensure 1 of 2 sampled staff (Staff C) administered pain medication as ordered for 1 of 3 sampled residents (Resident 1[ R 1]) reviewed for medication services. This significant medication error placed R 1 and all residents at risk for experiencing health complications from being over medicated. Findings included ... On 12/16/2024 review of R 1' s admission record showed R 1 was admitted to the facility on /2024 with a diagnosis of . R1 was discharged on /2024. Review of R 1' s service agreement dated 11/18/2024 showed R 1 had memory problems and impaired cognition. R 1 required assistance with medication services and staff members were responsible for ensuring R1 received her medications as prescribed. Review of R1's physician order record showed on 12/11/2024 R1 had a physician order for Morphine Sulfate (pain medication) 20 milligrams (mg) per milliliter (ml) to be administered 0.5 ml every two hours. Review of R1's medication administration record (MAR) showed from 12/11/2024 at 10:00 PM to 12/12/2024 at 4:00 AM Staff C, Facility Staff, administered four dosages of Morphine Sulfate. Review of the narcotic record showed R 1 was given Morphine Sulfate 1.O ml on 12/11/2024 at 10:20 PM, and on 12/12/2024 at 12:15 AM, 2:16 AM, and 4:30 AM. Staff C administered twice the amount of the Morphine Sulfate ordered. . From: 01/03/2025 16:07 #606 P.009/009 01.03.2025 14:28:24 State of Washington 517 Statement of Deficiencies License#: 2148 Compliance Determination # 51938 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date Page 3 of3 Lic.ensee: Caring Places Management, LLC 12/26/2024 In an interview on 12/16/2024 at 10:34 AM. Staff A, Resident Care Coordinator (RCC) stated staff mernbers had been delegated and trained on medicatioolnarcotic administration. The RCC said staff members were mentored and had been observed for safely administered medications prior to being permitted to assist residents with medication administration independently. Staff A stated staff members had been instructed to call the Licensed Nurse, the RCC or the .Administrato.r when they had questions with an order and/or medication. In an interview on 12/16/2024 at 10:54 AM, Staff B. Medication Tech, said she had been trained by the facility's Licensed Nurse and approved to perform medication administration independently, Staff B stated she had been trained to check for the right resident. right medication, right dosage, right route and right time when she administered a medication. Staff B said she would contact the Licensed Nurse When she had questions related to a medical and/or order. This is a recurring citation, previously cited or, 03/0812023 and 09/27/2023. Plan/Attestation Statement I .hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Beehive Retirement and Assisted L'ving omn1unily is or will be in compliance with this law and / or regulation on (Date)O 3 Z In addition, I will implement a system to monitor and ensure continued compliance with this requirement. . ,i,d;/:t,lffte-.,., .. ,,;,, /~f!'--z.:s- 01 . Statement of Deficiencies License#: 2148 Compliance Determination# 51938 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date In an interview on 12/16/2024 at 10:34 AM, Staff A, Resident Care Coordinator (RCC) stated staff members had been delegated and trained on medication/narcotic administration. The RCC said staff members were mentored and had been observed for safely administered medications prior to being permitted to assist residents with medication administration independently. Staff A stated staff members had been instructed to call the Licensed Nurse, the RCC or the Administrator when they had questions with an order and/or medication. In an interview on 12/16/2024 at 10:54 AM, Staff B, Medication Tech, said she had been trained by the facility's Licensed Nurse and approved to perform medication administration independently. Staff B stated she had been trained to check for the right resident, right medication, right dosage, right route and right time when she administered a medication. Staff B said she would contact the Licensed Nurse when she had questions related to a medical and/or order. This is a recurring citation, previously cited on 03/08/2023 and 09/27/2023. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency.

finding another resident in their bed at bedtime. Investigation Methods: Sample: Total residents: 48 Resident sample size: 3 Closed records sample size: 1 Observations: Identified resident Residents Activities Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Nursing staff Residents Business office manager Record Reviews: State reporting log Incident investigation Facility policies Care Plans Progress Notes/Alert Charting Investigation Summary: Facility failed investigate for one of two residents involved in the incident. Failed practice identified. Facility failed to follow policy and procedure by not notifying the residents physician timely and failed to monitor the resident for adverse affects after the incident occurred. Failed practice identified. Conclusion / Action: . Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION 800 NE 136th Ave Ste 200, Vancouver, WA 98684 Statement of Deficiencies License #: 2148 Compliance Determination # 44066 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date You are required to be in compliance at all times with all licensing laws and regulations to maintain your Assisted Living Facility license. The department completed data collection for an unannounced on-site complaint investigation on 07/12/2024 and 07/23/2024 of: Beehive Retirement and Assisted Living Community 401 W Maple St McCleary, WA 98557 This document references the following complaint number(s): 134767 The following sample was selected for review during the unannounced on-site visit: 3 of 48 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Pamela Horlick, NCI RN Complaint Investigator From: DSHS, Aging and Long-Term Support Administration 800 NE 136th Ave Ste 200 Vancouver, WA 98684 As a result of the on-site visit(s), the department found that you are not in compliance with the licensing laws and regulations as stated in the cited deficiencies in the enclosed report. I understand that to maintain an Assisted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. . Statement of Deficiencies License #: 2148 Compliance Determination # 44066 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date Administrator (or Representative) Date WAC 388-78A-2600 Policies and procedures. (2) The assisted living facility must develop, implement and train staff persons on policies and procedures to address what staff persons must do: (a) Related to suspected abandonment, abuse, neglect, exploitation, or financial exploitation of any resident; (i) To supervise and monitor residents, including accounting for residents who leave the premises; This requirement was not met as evidenced by: Based on interview and record review, the facility failed to implement their policy and procedure for physician notifications after an incident and the facility failed to implement their policy and procedure for alert charting for 1 of 3 (Resident 1 [R1]) sampled residents. This failure placed R1 at risk for their physician being unaware of their condition and placed them at risk for decreased quality of life. Findings included… <Notification to Provider> Record review of a facility policy, titled, “Resident Incidents and Investigation”, undated, showed under section 2, “Critical components of the Quality Assurance Investigation include:”, documented, “Prompt reporting to: • Supervisor • Nurse • Administrator • Emergency contact(s) • Medical professional(s) • Abuse hotline (if abuse is even a remote consideration) • Police (if required)” Record review of R1’s face sheet, undated, showed that R1 admitted to the facility on /2024. Review of Department Records showed that a report was made on 06/14/2024 at 11:20 AM notifying the Department that R1 found a man in their bed 06/14/2024 at 12:00AM. . Statement of Deficiencies License #: 2148 Compliance Determination # 44066 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date In an interview on 07/12/2024 at 1:28 PM, Staff B, Medication Aide (Med Aide), was asked what the process was when a resident finds another resident in their bed, Staff B stated, they would make sure they are safe and notify the residents Primary Care Physician (PCP) and Power of Attorney (POA). Staff B was asked when those notifications would be made, they stated, immediately. In an interview on 07/12/2024 at 11:02 AM, Staff C, Medication Aide, was asked what the process was if they found a resident in another residents room or bed, they stated we will remove them, make sure both residents are safe. Staff C stated that they will make the proper notifications to the residents PCP and POA. During a record request on 07/12/2024 at 10:55 AM, an investigation to show who was notified of the incident was not provided for R1. Record review of R1’s investigation, dated 07/14/2024 at 3:16AM, showed R1 came out of their room claiming there was a man in their bed. Upon the caregiver going into R1’s room, another resident was found laying in R1’s bed with their eyes closed. The caregiver removed the other resident. The other resident was “already on alert for behaviors towards the ladies.” Under the section, “Notifications Made,” showed R1’s PCP was notified on 07/15/2024 at 10:15 AM, one month after the incident occurred. In an interview on 07/18/2024 at 10:35 AM, Staff A, Executive Director, was asked what their expectation of staff was when a resident was found in another residents room, they stated they would remove them and notify the doctor. Staff A was asked when the notification would be made, they stated, immediately after making sure the residents were safe. Staff A was asked why the notification was made a month late, Staff A stated, it was a failure on the RCC (Resident Care Coordinator.) <Alert charting> Review of the facility policy, titled, “Resident Alerts”, undated, stated, “All incidents, changes of condition in medication; etc. require an enhanced monitoring of the resident and potential changes in care…The Med Aide on shift when the Alert Protocol is triggered will create the Medical Alert in CommuniCare beginning the Alert Charting Process…The Med Aide will notify the Resident Care Coordinator and the Resident Representative when the Resident is placed on Alert Charting…Resident Care Coordinator will review resident vitals and the Alert Charting, documenting this review by digital signature, during the Alert process…Documentation of the observed status of the Resident will be done once daily unless otherwise specified in the protocol.” During a record request on 07/12/2024 at 10:55 AM, alert charting for the incident for R1 was not provided for R1. In an interview on 07/12/2024 at 11:02 AM, Staff C, Medication Aide, was asked what . Statement of Deficiencies License #: 2148 Compliance Determination # 44066 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date kind of documentation was done when staff find a resident in another residents bed, they stated they do a progress note and the resident was put on alert to monitor for behaviors. Staff C was asked how long would the resident be on alert for, they stated usually a week. In an interview on 07/12/2024 t 1:28 PM, Staff B, Medication Aide, was asked what the process was when staff find a resident in another residents room or bed, Staff B stated, they would assess them and make sure they were safe. They stated they would document behaviors in case it escalates. Record review of an email dated 07/15/2024 at 11:38 AM from Staff D, Business Office Manager, showed that there was no alert charting available and no progress notes available for R1. In an interview on 07/18/2024 at 10:35 AM, Staff A, was asked what was your expectation of staff when a resident was found in another residents room or bed, they stated, staff should remove the resident that was in the wrong room. They stated both residents should be put on alert and progress notes should be done on both residents. Staff A was asked what alert charting was, they stated, every shift documents for 7 days to ensure the resident has not had any negative reactions to the incident. Staff A stated for R1, we want to make sure she is safe and comfortable. Staff A was asked why R1 was not placed on alert, they stated the RCC forgot. This is a recurring deficiency previously cited on 01/18/2024 and was a previous consultation on 10/05/2022.

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written . Failed Provider Practice Not Identified / No Citation Written N/A . . .

Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A . sampled residents observed and reviewed had their own clothing on and no concerns reported. no failed practice. 2) after interview and record review, the facility failed to have 2 caregivers implement their training and safety when they found a resident on the ground, complaining of pain to their head and had a head injury. The caregivers moved the resident without any directive from a trained medical professional and without knowing the extent of the injuries to the resident. The injuries resulted a displaced fracture to the back of their neck that resulted in the residents hospitalization and death 2 days later. facility failed to have caregivers training on to review resident service plans to know what care and services the residents need. the facility failed to have the service plans updated for the care staff to provide the most accurate care and services for the resident. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A .

Findings included… Review of R1’s face sheet showed that R1 was admitted to the facility on /2022. Review of R1’s Negotiated Service Agreement (NSA), last reviewed on 07/16/2023, showed the facility was to provide bathing/showering for R1, and R1 required stand by assistance from the caregivers with bathing and hygiene. Review of R2’s face sheet showed that R2 was admitted to the facility on /2022. Review of R2’s Negotiated Service Agreement, last reviewed on 04/30/2023, showed the facility was to provide bathing/showering for R2, and R2 required staff assistance with bathing and hygiene. Review of R3’s face sheet showed that R3 was admitted to the facility on /2022. Review of R3’s Negotiated Service Agreement, last reviewed on 06/12/2023, showed the facility was to provide cueing and set up for bathing/showering for R3. It showed that R3 was often resistant to showers and stated that staff in the event of resident refusals, would provide cueing, and reminders for R3. Staff were also instructed to notify R3’s Power of Attorney (POA) to assist with showers in the event of consecutive refusals. Review of R4’s face sheet showed that R4 was admitted to the facility on /2018. Review of R4’s Negotiated Service Agreement, last reviewed on 06/25/2023, showed the facility was to provide bathing/showering for R4, and R4 required full staff assistance with bathing and hygiene. During an interview with Staff A, Business Manager, on 06/02/2023 at 11:32AM, when asked why the bathing schedule for the residents was not located in the negotiated service agreement, Staff A stated that their process was to keep the shower schedule in the . Statement of Deficiencies License #: 2148 Compliance Determination # 26831 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date “Shower Binder.” During an interview with Staff B, Nurse, on 06/07/2023 at 10:58AM, when asked the reasoning for not including the resident’s bathing schedule in the resident’s negotiated service agreement, Staff B stated, “To my knowledge we have never put the shower days in the care plan due to changes in schedule. We have a shower sheet that we use as the shower schedule. The shower schedule is placed in the 24-hour caregiver book [Shower Binder] that they all have access to and are reviewing prior to the shift.” During an interview with Staff C, Medication Technician, on 07/18/2023 at 12:54PM, when asked how caregivers knew when a resident’s shower days was, Staff C stated, “We have a shower book that caregivers review, and it says when residents are to have showers.” When asked what the process was for situations when caregivers were unable to complete resident showers, Staff C stated, “Whoever is on shift will try and do it. If they are not able to do it, like an incident etc, or if they are refusing, then it is passed on to the next shift that it was not completed. We also try and reapproach the resident to get them to agree.” When asked if any documentation was required for missed showers, Staff C stated, “there is a shower log that staff are to initial when they complete it.” During an interview with Staff D, Caregiver, on 07/18/2023 at 1:09PM, when asked the process for residents getting their showers, Staff D stated that residents bath schedules were listed in the book [Shower Binder]. Staff D stated, “Normally we have 3 residents scheduled during our shift. If they refused, we would try and ask a couple of more times that day.” Staff D stated that there must be 3 attempts made to try convincing residents who were refusing to shower, and all of the attempts, refusals, and reasons for missed showers must be documented on the back of the shower sheet. When asked what it indicated if a resident shower was not initialed by staff on the shower sheet, Staff D stated “If there is no initial it means they did not get their shower.” During an interview with Staff B, on 07/18/2023 at 2:06PM, when asked what was done for their Plan of Correction regarding the previous citation for not providing showering/bathing per the NSA, Staff B stated that staff were educated on the procedure, and it was discussed during the all-staff meeting. “Caregivers are to review the shower schedule before shift. If the resident refuses, 3 attempts must be made. It is required to document for every shower.” When asked what it indicated if a resident shower was not initialed by staff on the shower sheet, Staff B stated, “If it was not documented, it was not done.” Review of the shower sheets in the Shower Binder/Log on 07/18/2023 showed the following: R1 was scheduled for two showers per week, Wednesday and Saturday. Review of the shower sheets for R1 from 06/28/2023 to 07/15/2023 showed that there was no signature/initial from staff for the following dates: Wednesday, 06/28/2023, and Saturday, 07/08/2023. There was no “make-up” shower given for the missed day, or documentation as to why the shower was not completed. R2 was scheduled for two showers per week, Wednesday and Saturday. Review of the shower sheets for R2 from 06/28/2023 to 07/15/2023 showed that there was no signature/initial from staff for the following dates: Wednesday, 06/28/2023, and Saturday, 07/08/2023. There was no “make-up” shower given for the missed day, or documentation as to why the shower was not completed. . Statement of Deficiencies License #: 2148 Compliance Determination # 26831 Plan of Correction Beehive Retirement and Assisted Living Community Completion Date R3 was scheduled for two showers per week, Tuesday and Friday. Review of the shower sheets for R3 from 06/28/2023 to 07/15/2023 showed that there was no signature/initial from staff for the following dates: Friday, 06/30/2023, and Friday, 07/07/2023. There was no “make-up” shower given for the missed day, or documentation as to why the shower was not completed. R4 was scheduled for two showers per week, Tuesday and Friday. Review of the shower sheets for R4 from 06/28/2023 to 07/15/2023 showed that there was no signature/initial from staff for the following dates: Wednesday, 07/07/2023, and Tuesday, 07/11/2023. There was no “make-up” shower given for the missed day, or documentation as to why the shower was not completed. This is an uncorrected deficiency previously cited on 06/08/2023, and a recurring deficiency previously cited on 10/19/2020. Plan/Attestation Statement I hereby certify that I have reviewed this report and have taken or will take active measures to correct this deficiency. By taking this action, Beehive Retirement and Assisted Living Community is or will be in compliance with this law and / or regulation on (Date)________________ . In addition, I will implement a system to monitor and ensure continued compliance with this requirement. Administrator (or Representative) Date . Investigation Summary Report Provider/Facility: Beehive Retirement and Provider Type: Assisted Living Facility Assisted Living Community License/Cert.#: 2148 Intake ID: 83327 Compliance Determination #: 24823 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 06/02/2023 through 06/08/2023 Complainant Contact Date(s): Allegation(s): Quality of Care/Treatment: Facility report of an allegation of neglect of a resident in the community. Investigation Methods: Sample: Total residents: 48 Resident sample size: 5 Closed records sample size: 1 Observations: Identified resident Residents Dining Resident rooms Staff to resident interactions Resident to resident interactions Interviews: Identified resident Nursing staff Family members Management Record Reviews: Incident investigation Facility policies Staff Schedules Disclosure of Services Negotiated Service Agreements Admission Agreements Progress Notes Investigation Summary: Quality of Care/Treatment: Facility failed to provide bathing services as determined in the resident's negotiated service agreements. Failed practice identified. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written . Failed Provider Practice Not Identified / No Citation Written N/A . Investigation Summary Report Provider/Facility: Beehive Retirement and Provider Type: Assisted Living Facility Assisted Living Community License/Cert.#: 2148 Intake ID: 83100 Compliance Determination #: 24823 Region/Unit #: RCS Region 3 / Unit E Investigator: Paul Aube Investigation Date(s): 06/02/2023 through 06/08/2023 Complainant Contact Date(s): Allegation(s): 1. Quality of Care/Treatment: Public report of neglect of residents in the facility. 2. Misappropriation of Property: Public report of clothing going missing.