Beehive Retirement and Assisted Living Community.

—: Facility failed to notify the resident's provider and family/representative of a resident-to-resident altercation involving physical violence and injury. The incident occurred on 08/25/2025, but the provider was not notified until 09/11/2025 (17 days later), and there is no documentation of family notification. —: Facility failed to complete an Incident Report/Investigation for a resident-to-resident altercation involving physical violence and injury to both residents. No formal investigation documentation was created despite the severity of the incident. —: Facility failed to report the resident-to-resident altercation to the Department within the required 24-hour timeframe. The incident occurred on 08/25/2025, but the Department was not notified until 08/28/2025 (3 days later).

WAC 388-78A-2821: Roof repairs in Memory Care required design, construction review and approval from DOH. Facility submitted plans for retroactive inspection and approval. WAC 388-78A-2040: Carbon monoxide detectors were not installed in mandated locations in Memory Care. Detectors have been placed per state requirements. WAC 388-78A-2950: Water temperatures were not within the safe range based on State requirements. Water temperatures are now compliant and facility added policy with proper temperatures to temperature logs. WAC 388-78A-2930: Call lights and paging system were not operational. System has been repaired and is now fully functional. WAC 388-78A-2730: Kitchen HVAC system requires replacement to meet compliance standards. Facility is obtaining estimates for replacement of the existing system. WAC 388-78A-2450: Staff member did not have HCA credentials. Employee has completed application for HCA credentials test and is awaiting DOH clearance for test date. WAC 388-78A-2474: Employee schedule posting process was not compliant with training and Home Care Aide Certification requirements. Facility changed process to print and binder schedules with electronic tracking of changes. WAC 388-110-220: Health assessments and negotiated service agreements for enhanced adult residential care service were not current. All assessments are now current and being completed quarterly.

WAC 388-78A-2210: Staff member administered twice the ordered dose of Morphine Sulfate pain medication to a resident with memory problems and impaired cognition. The resident was ordered 0.5 ml every two hours but received 1.0 ml per dose, placing the resident and all residents at risk for health complications from overmedication.

WAC 388-78A-2600: The facility failed to implement their policy and procedure for physician notifications after an incident and failed to implement their policy and procedure for alert charting for one sampled resident. The resident's physician was not notified until one month after the incident occurred, and the resident was not placed on alert charting despite policy requirements. WAC 388-78A-2371: The facility failed to investigate and document investigative actions and findings for an incident involving one sampled resident. The investigation documentation was incomplete and the facility failed to investigate for one of the two residents involved in the incident.

WAC 388-78A-2930: The facility failed to provide residents with the means to summon on-duty staff assistance when the call light system became nonoperational. The facility also failed to develop and utilize a policy and procedure describing mitigating measures for system disruption, including for maintenance and loss of power.

—: Facility failed to notify the resident's physician after the resident sustained an injury from a fall and was sent to the hospital for evaluation.

—: Two caregivers failed to implement proper training and safety protocols when they found a resident on the ground with head pain and injury. They moved the resident without medical professional directive and without assessing injury extent, resulting in a displaced neck fracture, hospitalization, and the resident's death two days later. —: The facility failed to ensure caregivers received training to review resident service plans and understand what care and services each resident requires. —: The facility failed to maintain updated service plans that would enable care staff to provide accurate and appropriate care and services to residents.

WAC 388-78A-2160: The facility failed to provide care and services as agreed upon in the negotiated service agreement for 4 of 4 residents reviewed. Residents did not receive scheduled bathing/showering services, with missed showers on multiple dates (R1: 06/28/2023, 07/08/2023; R2: 06/28/2023, 07/08/2023; R3: 06/30/2023, 07/07/2023; R4: 07/07/2023, 07/11/2023) and no makeup showers or documentation provided for why showers were not completed.