Bridgewater Assisted Living

Based on record review and interview, a manager failed to ensure that a resident had a service plan that included the correct level of medication services the resident received for one of seven residents sampled. The deficient practice posed a risk if a resident's service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R3's service plan dated October 9, 2025, revealed R3 received personal care services and stated "Trained Wellness Med Tech will provide resident with assistance in managing and taking medications as prescribed. Trained Wellness Associates will administer medications/treatments according to providers orders." 2. A review of R3's medical record revealed a document titled "Referral" dated October 9, 2025. This document was signed by a medical practitioner and stated: "the facility is to administer pt's medications as of October of 2025 due to [R3's] extreme noncompliance with self medication administration." 3. A review of R3's March 2026 medication administration record (MAR) revealed the following medications were self-administered by R3 March 1st - 31st: Aspirin EC 81 mg once a day Bupropion HCL SR 150 mg twice a day Duloxetine HCL DR 30 mg once a day Furosemide 20 mg every other day Pioglitazone HCL 45 mg once a day Sertraline HCL 50 mg once a day 4. In an interview, E1 reported that R3 was incorrectly self-administering medication, and the facility obtained a doctor's order for the facility to administer R3's medication. E1 reported that R3 used other physicians and pharmacies to obtain medications to self-administer. 5. In an exit interview, findings were reviewed with E1 and no additional information was provided.

Based on record review, observation, and interview, the manager failed to ensure medications were administered in compliance with medication orders and documented in the medical record for one of seven residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Finding include: 1. A review of R3's service plan dated October 9, 2025, revealed R3 received personal care services and stated "Trained Wellness Med Tech will provide resident with assistance in managing and taking medications as prescribed. Trained Wellness Associates will administer medications/treatments according to providers orders." 2. A review of R3's medical record revealed a March 2026 medication administration record (MAR). This MAR revealed that Oxycodone HCL (IR) 15 MG tab was administered three times a day, March 1 through March 31, 2026. 3. A review of R3's medical record revealed no signed or verbal order for Oxycodone HCL (IR) 15 MG tab, take one tablet three times a day. 4. The Compliance Officer observed E7 administer R3 Oxycodone HCL (IR) 15 MG tab. A review of the medication label revealed Oxycodone HCL (IR) 15 MG tab, take one tablet three times a day, and stated that it was filled on March 9, 2026. 5. In an interview, E1 reported that there was no medication order available for R3's Oxycodone HCL (IR) 15 MG tab, take one tablet three times a day. 6. A review of R3's medical record revealed signed medication orders dated February 12, 2026. These orders stated the following: Isosorbide Mononitrate ER 30 mg Tab ER 24hr sig: Take 1 tablet by mouth every day Jardiance 25 mg Tab Lantus SoloStar 100 Unit/ml solution Pen-injector Subcutaneous sig: 45u sq daily Lisinopril 20 mg Tab sig: Take 1 tablet by mouth every day *Hold for systolic blood pressure less than 100 or heart rate less than 60 7. A review of R3's March 2026 medication administration record (MAR) revealed no documentation that Isosorbide Mononitrate ER 30 mg, Jardiance 25 mg, Lantus SoloStar 100 Unit/ml solution 45 units, and Lisinopril 20 mg were administered. 8. During an observation of R3's medications, Isosorbide Mononitrate ER 30 mg, Jardiance 25 mg, and Lisinopril 20 mg were available. 9. A review of R3's medical record revealed a document titled "Referral" dated October 9, 2025. This document was signed by a medical practitioner and stated: "the facility is to administer pt's medications as of October of 2025 due to [R3's] extreme noncompliance with self medication administration." 10. A review of R3's medical record revealed signed medication orders dated February 12, 2026. These orders stated the following: Aspirin 325 mg Tab delayed rel sig: 1 tablet orally daily Pioglitazone 45 mg Tab sig: Take 1 tablet by mouth every day Furosemide 20 mg Tab sig: 1 tablet orally every 48 hours Additionally, signed medication orders dated December 12, 2025, stated: Bupropion HCL SR 150 mg Tab tack 1 tablet by mouth twice daily

Based on documentation review, interview, and record review, the manager failed to immediately report suspected abuse according to A.R.S. § 46-454. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A.R.S. § 46-454(A) states: "A health professional... or other person who has responsibility for the care of a vulnerable adult and who has a reasonable basis to believe that abuse, neglect or exploitation of the vulnerable adult has occurred shall immediately report or cause reports to be made of such reasonable basis to a peace officer or to the adult protective services central intake unit...The reports required by this subsection shall be made immediately by telephone or online." 2. Arizona Administrative Code R9-10-101(111) states, "'Immediate' means without delay." 3. Documentation review revealed the facility's policy and procedure title, "GP03 - Abuse, Neglect and Exploitation," that stated "...Procedure 4. Upon the notice of reported, observed suspected, or at imminent risk of any form of abuse: a. Immediate steps will be taken to ensure the resident is protected from potential future abuse and neglect while the investigation is conducted. b. The alleged perpetrator will have NO CONTACT with any residents during the investigation. c. A thorough investigation will be conducted by the Wellness Director or Executive Director." 4. In an interview, E1 reported that E1 was aware of the altercation between R3 and E3 and that R3 reported E3 assaulted R3 during the altercation. 5. Documentation review revealed a copy of the facility's Internal Incident Report dated December 11, 2025 at 3:17 pm. The report provided a summary of an incident involving R3 and E3 in which E3 was listed as being assaulted. The case manager for R3 was notified on December 11, 2025 at 2:05 pm. 6. Record review of R3's Medication Administration Record revealed Bridgewater Deer Valley Observations form that included progress notes. The December 11, 2025, 3 pm notes stated, "It was reported to this nurse that the resident was observed attempting to collect mop water from the housekeeping mop bucket using a pickle jar. Maintenance staff intervened and retrieved the jar due to the resident stating [R3] was alleger to the chemicals in the mop water. During the retrieval, the resident attempted to snatch the jar back from staff, resulting in maintenance staff sustaining a scratch. Following the incident, the resident reported that [R3] called the police, claiming that staff had assaulted [R3]. No assault was observed by any other staff member present at the time, staff intervened out of concern for the resident's safety related to potential allergic reaction. Resident was monitored and no further issues were observed at this time." 7. Documentation review revealed a letter received from R3's case manager dated December 17, 2025 "(RE: Reported Assault by ALF Staff and Request of No Contact - R3, DOB (XX/XX/XXXX)." The letter read:

Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities that included initial training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. A review of the Centers for Disease Control and Prevention (CDC) website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "All health-care workers (HCWs) should receive training on the prevention, transmission, and symptoms of TB disease that is appropriate to their work responsibilities and setting. Initial training should be provided to all new employees, with annual refresher training thereafter." 2. Review of E2’s, E3’s, E4’s, E5’s, E6’s, E7’s, E8’s, and E9’s personnel records revealed no current documentation of training and education related to recognizing the signs and symptoms of TB. Based on the hire dates, this documentation was required. 3. In an interview, the finding was reviewed with E1 and no additional information was provided. 4. This is a repeat deficiency from the inspection conducted on December 2, 2024.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. § 36-411(C)(1), for four of ten personnel sampled. The deficient practice posed a risk to the health and safety of residents, as there was no evidence to show the employees were fit to work at the assisted living facility. Findings include: 1. A.R.S. § 36-411(C)(1) states: "C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. A review of E7’s, E8’s, E9’s, and E10’s personnel records revealed no documentation of evidence to indicate a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver’s or assistant caregiver's skills and knowledge were verified and documented before the caregiver or assistant caregiver provided physical health services, for three of eight caregivers and assistant caregivers reviewed. The deficient practice posed a risk if a caregiver or assistant caregiver did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled, “Orientation and training Policy & Procedure" which stated, “4. Caregivers will be given a Skills Checklist to be completed by the Supervisor and/or team member who is working with the new caregiver... will be kept in the caregiver’s personnel record.” 2. A review of E3’s personnel records revealed a hire date of September 23, 2025. E3's record revealed a skills checklist signed and dated October 16, 2025. 3. A review of E8’s personnel records revealed a hire date of September 16, 2025. E8's record revealed a skills checklist signed and dated September 25, 2025. 4. A review of the personnel schedules revealed the following employees were not scheduled with a supervisor or team member on the following days before the skills checklist was completed: - E3 worked October 5th, 9th, and 11th of 2025, and - E8 worked September 24th of 2025. 5. A review of E10’s personnel record revealed E10 was hired as an assistant caregiver. However, the review revealed no documentation of E10’s skills checklist. Based on E10’s hire date, this documentation was required. 6. In an interview, the finding was reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the assisted living center that contacted an emergency responder (EMS) on behalf of a resident failed to provide to the emergency responder a written document that included all of the information required in A.R.S. § 36-420.04.A.1-9, for two of three residents reviewed. The deficient practice posed a risk if the emergency responder was not aware of critical health information for the resident. Findings include: 1. A review of R1's medical records revealed that the facility contacted emergency services on October 17, 2025. The EMS documentation did not include the following: The name, address and telephone number of the resident's current pharmacy. 2. A review of R1's medical records revealed that the facility contacted emergency services on October 21, 2025. The EMS documentation did not include the following: The name, address and telephone number of the resident's current pharmacy. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. 3. A review of R3's medical record revealed that the facility contacted emergency services on October 17, 22, and 23, 2025. The EMS documentation did not include the following: The name, address and telephone number of the resident's current pharmacy. 4. In an interview, findings were discussed with E1, and no additional information was provided.

Based on Record review, documentation review, and interview, the manager failed to ensure that a resident was treated with dignity, respect, and consideration. The deficient practice posed a risk as a resident's rights were violated. Findings include: 1. A record review of an incident report dated June 30, 2025 revealed, R4 went to the hospital on June 2, 2025. On June 12, 2025, E4 went in to the resident's room and removed some of the resident's personal property and took it to the employee's home. On June 12th and June 14, 2025, E4 was seen on camera exiting the facility with the resident's belongings. E4 was on vacation until August 8, 2025 while the investigation was taking place. E4 was terminated on July 8, 2025, and told to return the property immediately. E4 met with the facility's security staff and returned all of R4's property. 2. A documentation review of the facility's Policies and Procedures titled, "Personal Rights" stated, "2. Community Management ensures: a. Residents are treated with dignity, respect, and consideration; b. Residents are not subject to: xi. Misappropriation of personal and private property by Community Staff." 3. In an interview, E1 acknowledged the manager failed to ensure, R4 was treated with dignity, respect, or consideration.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident was not subjected to misappropriation of personal and private property by the assisted living facility's manager, caregivers, assistance caregivers, employees, or volunteers. The deficient practice posed a risk as a resident's rights were violated. Findings include: 1. A record review of an incident report dated June 30, 2025 revealed, R4 went to the hospital on June 2, 2025. On June 12, 2025, E4 went in to the resident's room and removed some of the resident's personal property and took it to the employee's home. On June 12th and June 14, 2025, E4 was seen on camera exiting the facility with the resident's belongings. E4 was on vacation until August 8, 2025 while the investigation was taking place. E4 was terminated on July 8, 2025, and told to return the property immediately. E4 met with the facility's security staff and returned all of R4's property. 2. A documentation review of the facility's Policies and Procedures titled, "Personal Rights" stated, "2. Community Management ensures: a. Residents are treated with dignity, respect, and consideration; b. Residents are not subject to: xi. Misappropriation of personal and private property by Community Staff." 3. In an interview, E1 acknowledged the manager failed to ensure, R4 was not subjected to misappropriation of personal and private property by the assisted living facility's manager, caregivers, assistance caregivers, employees, or volunteers.