Bridgewater La Cholla Operations, LLC

Based on documentation review, record review, and interview, the manager failed to maintain a personnel record which included all items required by this rule for three of five sampled employees. The deficient practice posed a risk as the required information could not be verified. Findings include: 1. A review of facility documentation revealed a series of personnel schedules which indicated E3, E4, and E5 worked numerous shifts in November and December of 2025. 2. A review of E3’s, E4’s, and E5’s personnel records revealed evidence of documentation of each employee’s orientation, verification of skills and knowledge, and documentation demonstrating compliance with A.R.S. 36-411(C), was unavailable for review. Furthermore, evidence of documentation indicating E4 was compliant with A.R.S. 36-411(A) was unavailable for review. Lastly, evidence of documentation indicating E5 was a certified caregiver was unavailable for review. 3. Research conducted through the Arizona Department of Public Safety, https://psp.azdps.gov/services/cardStatusRequest, revealed E4 did have a valid fingerprint clearance card. 4. Research conducted through https://azcg.tmutest.com/ revealed E5 was a certified caregiver. 5. In an exit interview, the findings were reviewed with E1, who indicated E3, E4, and E5 were hired through a staffing agency. E1 provided no additional information.

Based on record review and interview, for three of eight residents sampled, the manager failed to ensure a resident had a written service plan, when initially developed and when updated, was signed and dated by the resident or resident’s representative, the manager and a nurse or medical practitioner. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1’s medical record revealed a service plan dated December 8, 2024, indicating R1 received personal care services. The service plan included a signature page with a line for the “Resident or Resident Representative” to sign. However, the signature line was blank. Furthermore, as R1 was identified as receiving personal care services, R1 was required to have an updated service plan no less than six months from December 8, 2024. However, evidence of a current service plan dated within six months of December 8, 2024, was unavailable for review. 2. A review of R4’s medical record revealed a service plan dated October 20, 2025, indicating R4 received personal care services. The service plan was signed by the manager and nurse, and R5’s representative's name was listed on the plan. However, the signature line for the “Resident or Resident Representative” was blank. 3. A review of R5’s medical record revealed a service plan dated September 15, 2025, indicating R5 received directed care services. The service plan was signed by the manager and nurse, and R5’s representative's name was identified on the service plan; however, the signature line for R5’s representative was blank. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat citation from a compliance and complaint survey conducted on October 21, 2025, a complaint investigation conducted on October 3, 2025, and a complaint investigation conducted on July 29, 2025.

Based on observation and interview, the manager failed to ensure the premises and equipment used at the assisted living facility was cleaned according to policies and procedures designed to prevent, minimize, and control illness or infection. The deficient practice posed a potential risk to infection control. Findings include: 1. During a tour of the facility, the Compliance Officer observed a dark stain in the carpeting of a hallway of a residential unit. The stain appeared to be dry, continued down the hallway for several feet, and at its widest point measured approximately eight inches in diameter. 2. In an interview, E1 denied any knowledge as to what liquid may have caused the stain. 3. During the environmental tour, the Compliance Officer observed kitchen areas in Villa 2 and Villa 3, used for staging areas to serve food and store snacks for residents. Inside several cabinets in each kitchen area, the Compliance Officer observed what appeared to be rodent droppings. 4. In an interview, E8 advised the kitchen cabinets in Villa 2 were cleaned nightly. When the Compliance Officer showed E8 the rodent droppings in the cabinets, E8 advised the cabinets were cleaned “almost every night,” or as needed. 5. In an interview, E1 advised the facility did not have a current contract with a pest control company. E1 affirmed meals were not prepared in the kitchen areas of each Villa, but were rather prepared in the facility’s main kitchen. E1 said the Villa kitchen areas were only used to serve meals from and to store snacks for residents. 6. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation, document review and interview, the manager failed to ensure a pest control program, compliant with A.A.C. R3-8201(C)(4) was implemented and documented. 1. During a tour of the facility, the Compliance Officer observed kitchen areas in Villa 2 and Villa 3, used for staging areas to serve food and store snacks for residents. Inside several cabinets in each kitchen area, the Compliance Officer observed what appeared to be rodent droppings. 2. A review of facility documentation revealed an invoice from a pest control company for services rendered on April 21, 2025. Evidence of documentation of pest control services provided since April 21, 2025, was unavailable for review. 3. In an interview, E1 advised they were not aware of any pest control services at the facility since April 21, 2025. E1 stated the facility did not have a current contract with a pest control company. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications, and were inaccessible to residents. Findings include: 1. During a tour of the facility, the Compliance Officer observed a caregiver work area which was open and unoccupied. The Compliance Officer observed multiple cabinets in the work area, each affixed with locking mechanisms which required a magnetic key to secure and open. Several of the cabinets were left unsecured, and the Compliance Officer was able to open them with little effort. Inside one of the cabinets, the Compliance Officer observed a plastic spray bottle of “Ecolab Grease Express” degreaser, a can of “Comet” scouring powder, and a spray bottle of “Waxie-Green Glass & Surface Cleaner.” Each of the containers was marked “CAUTION KEEP OUT OF REACH OF CHILDREN.” An unlabeled, clear plastic bottle containing a yellow liquid, similar in color to the Waxie glass and surface cleaner, was also observed. 2. In an interview, E1 acknowledged the cleaners were not kept in a secure area, inaccessible to residents. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for two of seven employees sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E1’s (date of hire August 25, 2025) personnel record revealed evidence of documentation of two negative skin tests for TB, administered seven days apart, in January 2024. However, evidence of documentation of any additional negative skin tests for TB conducted within twelve months of E1’s date of hire was unavailable for review. Furthermore, evidence of documentation of a baseline assessment of signs and symptoms, or risk of exposure to active TB, signed by a registered nurse, medical provider, or local health authority, within twelve months of E1’s date of hire, was unavailable for review. 2. A review of E9’s personnel record revealed evidence of documentation of a negative T-Spot test for TB. However, documentation of a baseline assessment of signs and symptoms, or risk of exposure to active TB, signed by a registered nurse, medical provider, or local health authority, within twelve months of E9’s date of hire, was unavailable for review. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, for one of six caregivers sampled, the manager failed to ensure a personnel record for each employee included documentation of cardiopulmonary resuscitation training (CPR), and first aid training. Findings include: 1. A review of E5’s personnel record revealed evidence of documentation of current (CPR) or first aid training was not available for review. 2. A request was made to review E5's current CPR and first aid training card(s), and E1 was able to produce an image of E5's current CPR and first aid training card. 3. In an interview, E1 acknowledged E5's personnel record did not include documentation of E5's current CPR and first aid training.

Based on record review and interview, for three of seven residents sampled, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) within seven calendar days after the resident’s date of occupancy. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(A)(2)(a)(i-ii) states: “a. For each individual who is…admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious [TB], ii. Determining if the individual has signs or symptoms of [TB].” 2. A review of R2’s and R7’s medical records revealed evidence of documentation of a negative skin test for TB. However, evidence of baseline screening for signs and symptoms of, and risk assessment for exposure to TB, was unavailable for review. 3 A review of R4’s medical record revealed evidence of documentation of a negative test for TB, and a baseline screening for signs and symptoms of, and risk assessment for exposure to TB, was unavailable for review. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a written notice of termination of residency included the date of the notice, the policy for refunding fees, charges, or deposits, the deposition of a resident’s fees, charges, and deposits, and contact information for the State Long-term Care Ombudsman. Findings include: 1. A review of R4’s medical record revealed a letter regarding R4’s “30-day notice to vacate due to non-compliance.” The letter included the reason for the termination of R4’s residency. However, the letter did not include the date of the notice, the policy for refunding fees, charges, or deposits, the deposition of a resident’s fees, charges, and deposits, and contact information for the State Long-term Care Ombudsman as required. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on record review and interview, for two of seven residents sampled, the manager failed to ensure, when initially developed and when updated, a resident's service plan was signed and dated by the resident or the resident’s representative, and the manager. The deficient practice posed a risk if a resident was unable to exercise the right to participate or have the resident's representative participate in the development of, or decisions concerning, the resident's service plan. Findings include: 1. A review of R3’s medical record revealed a service plan for Directed care services, dated August 26, 2025. The service plan included a section for signatures of parties involved in the development of the plan; however, the service plan was not signed by R3’s representative, a nurse or medical practitioner, or the manager. 2. A review of R7’s medical record revealed a service plan for Directed care services, dated September 15, 2025. The service plan included a section for signatures of parties involved in the development of the plan; however, the service plan was not signed by R7’s representative or the manager. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat citation from a complaint investigation conducted on July 29, 2025, and a monitoring inspection conducted on October 3, 2025.

Based on documentation review, record review, and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for pneumonia, according to A.R.S. § 36-406(1)(d), for four of seven residents sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. § 36-406(1)(d) states, "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a license for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. A review of R1’s, R4’s, R5’s, and R6’s medical records revealed evidence of documentation indicating the flu and pneumonia vaccines were made available to each resident in February 2024. However, evidence of documentation indicating the flu and pneumonia vaccines were made available to each resident since February 2024 was unavailable for review. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. This is a repeat deficiency from a complaint inspection conducted on November 15, 2025.

Based on document review and interview, the manager failed to ensure the disaster plan required in R9-10-819(A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed a disaster plan compliant with R9-10-819(A)(1). However, evidence of documentation the disaster plan had been reviewed within the previous twelve months was unavailable for review. 2. In an interview, E4 advised they did not know when the disaster plan had last been reviewed. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on document review and interview, the manager failed to ensure an evacuation drill was conducted at least every six months. Findings include: 1. A review of facility documentation revealed evidence of documentation of an evacuation drill conducted on April 18, 2025. However, evidence of documentation of an evacuation drill conducted in the 6 months following April 18, 2025, was unavailable for review. 2. In an interview, E4 advised they were unable to locate documentation of any evacuation drill conducted after April 18, 2025. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which, when initially developed and when updated, was signed and dated by the resident or resident's representative, for three of seven resident records reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R3's medical record revealed an updated service plan, for personal care level of services, dated June 15, 2025. The service plan did not include the required signature of the resident or the resident's representative. 2. A review of R5's medical record revealed an initial service plan, for personal care level of services, dated July 7, 2025. The service plan did not include the required signature of the resident or the resident's representative, and the manager. 3. A review of R7's medical record revealed an initial service plan, for personal care level of services, dated April 9, 2025. The service plan did not include the required signature of the resident or the resident's representative. 4. In an interview, E1 and E2 acknowledged the service plans for R3, R5, and R7 were not signed as required by the resident or resident's representative. E2 took the unsigned service plans and met with each of the three resident’s and obtained resident signatures during the inspection.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record for seven of seven resident records reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed R1 received personal care level services. Further review of R1's medical record revealed a document titled "Care Tracking Sheet" for September 2025. The document recorded the service provided and initials of the person who provided the service. 2. A review of R1's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025; - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; and - “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025. 3. A review of R2's medical record revealed R2 received personal care level services. A review of R2's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “AM/PM Assistance”, on September 29, 2025, and October 1, 2025; - “Bathing: Full Assistance”, on September 29, 2025; - “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025; - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; - “Dining Limited Assistance”, on September 29, 2025, and October 1, 2025; - “Dressing: Full Assistance”, on September 29, 2025, and October 1, 2025; - “Full Mobility Assistance (Every 3-6 Hours)”, on September 29, 2025, and October 1, 2025; - “Grooming Moderate Assistance”, on September 29, 2025, and October 1, 2025; - “Resident Laundry+Put Away”, on September 29, 2025; - “Skin Evaluation”, on September 29, 2025; and - “Toileting Assistance”, on September 29, 2025, and October 1, 2025. 4. A review of R3's medical record revealed R3 received personal care level services. A review of R3's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025; - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; and - “Resident Laundry”, on September 29, 2025. 5. A review of R4's medical record revealed R4 received personal care level services. A review of R4's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Trash Removal and Bed Making”, on September 29, 2025, and October 1, 2025; - “Daily Wellness Checks”, on September 29, 2025, and October 1, 2025; - “Resident Laundry+Put Away”, on October 1, 2025; and - “Status Checks: 2 Hours”,

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every six months, for one of seven resident records reviewed. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R6's medical record revealed a service plan update, signed and dated November 1, 2024, for personal care services. A reviewed and updated service plan was required on or before May 31, 2025. However, no updated service plan was available for review. 2. In an interview, E1 acknowledged R6's service plan was not reviewed and updated at least once every six months. E2 further reported the system, that let them know when a service plan was due, in process, or completed, was not functioning properly and the facility was unaware it was unsigned.

Based on record review and interview, the manager failed to ensure a resident had a written service plan which, when initially developed and when updated, was signed and dated by the resident or resident's representative, and the manager, for five of seven resident records reviewed. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements. Findings include: 1. A review of R1's medical record revealed an updated service plan, for personal care level of services, dated July 7, 2025. The service plan did not include the required signature of the resident or the resident's representative. 2. A review of R3's medical record revealed an updated service plan, for personal care level of services, dated June 15, 2025. The service plan did not include the required signature of the resident or the resident's representative. 3. A review of R4's medical record revealed an initial service plan, for personal care level of services, dated July 6, 2025. The service plan did not include the required signature of the resident or the resident's representative, and the manager. 4. A review of R5's medical record revealed an initial service plan, for personal care level of services, dated July 7, 2025. The service plan did not include the required signature of the resident or the resident's representative, and the manager. 5. A review of R7's medical record revealed an initial service plan, for personal care level of services, dated April 9, 2025. The service plan did not include the required signature of the resident or the resident's representative. 6. In an interview, E1 and E2 acknowledged the service plans for R1, R3, R4, R5, and R7 were not signed as required by the resident or resident's representative and the manager.

Based on record review, document review, and interview, the manager failed to ensure a caregiver documented the services provided to a resident in the resident's medical record, for seven of seven resident records reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. A review of R1's medical record revealed R1 received personal care level services. Further review of R1's medical record revealed a document titled "Care Tracking Sheet" for July 2025. The document recorded the service provided and initials of the person who provided the service. 2. A review of R1's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Bathing Limited Assistance”, on July 2 and 9, 2025; - “Daily Trash Removal and Bed Making”, on July 1, 2, 8, 9, 10, 11, 19, 22, and 24, 2025; - “Daily Wellness Checks”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, 23, 24, and 25, 2025; - “Dining Moderate Assistance”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, 24, and 25, 2025; - “Dressing: Limited Assistance”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, and 24, 2025; - “Grooming Limited Assistance”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, and 24, 2025; - “Resident Laundry+Put Away”, on July 2 and 9, 2025; - “Skin: Evaluation Assistance”, on July 9 and 19, 2025; and - “Status Checks: 2 Hours”, on July 1, 2, 8, 9, 10, 11, 19, 20, 22, 23, 24, and 25, 2025. 3. A review of R2's medical record revealed R2 received personal care level services. A review of R2's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “AM/PM Assistance”, on July 19, 20, 26, and 27, 2025; - “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025; - “Dining Limited Assistance”, on July 19, 20, 26, and 27, 2025; - “Dressing: Full Assistance”, on July 19, 20, 26, and 27, 2025; - “Full Mobility Assistance (Every 3-6 Hours)”, on July 19, 20, 26, and 27, 2025; - “Grooming Moderate Assistance”, on July 19, 20, 26, and 27, 2025; and - “Toileting Assistance”, on July 18, 19, 20, 23, 24, 25, 26, 27, and 28, 2025. 4. A review of R3's medical record revealed R3 received personal care level services. A review of R3's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Trash Removal and Bed Making”, on July 18, 19, 20, 23, 25, 26, and 27, 2025; and - “Daily Wellness Checks”, on July 18, 19, 20, 23, 25, 26, and 27, 2025. 5. A review of R4's medical record revealed R4 received personal care level services. A review of R4's Care Tracking Sheet revealed services were scheduled according to shift. The following blank spots were not marked to indicate the service was provided: - “Daily Trash Removal and Bed Making”, on July 18, 19, 20, 23, 25,