Bridgeport Place.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. Statement of Deficiencies License #: 2427 Compliance Determination # 58763 Plan of Correction Bridgeport Place Completion Date Page 4 of 6 Licensee: C.F. Bridgeport, LLC 05/02/2025 Review of R5's “Washington Health and Service Evaluation Results and Service Plan” showed their last assessment was completed on 11/07/2023. At the time of inspection, more than one year had passed since R5's last assessment. Review of R6's “Washington Health and Service Evaluation Results and Service Plan” showed their last assessment was completed on 11/28/2023. At the time of inspection, more than one year had passed since R6's last assessment. Review of Resident 8's (R8) “Washington Health and Service Evaluation Results and Service Plan,” showed their last assessment was completed on 11/27/2023. At the time of inspection, more than one year had passed since R8's last assessment. Review of R9's “Washington Health and Service Evaluation Results and Service Plan” showed their last assessment was completed on 11/07/2023. At the time of inspection, more than one year had passed since R9's last assessment. During the exit interview on 05/02/2025 at 3:42 PM, Staff A, Executive Director, acknowledged that the assessments for R1, R5, R6, R8, and R9 were late. Staff A stated that the facility is working on updating the residents' assessments. 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, Bridgeport Place 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 WAC 388-78A-2150 Signing negotiated service agreement. The assisted living facility must ensure that the negotiated service agreement is agreed to and signed at least annually by: (1) The resident, or the resident's representative if the resident has one and is unable to sign or chooses not to sign; (2) A representative of the assisted living facility duly authorized by the assisted living facility to sign on its behalf; and This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. TThhiiss ddooccuummeenntt wwaass pprreeppaarreedd bbyy RReessiiddeennttiiaall CCaarree SSeerrvviicceess ffoorr tthhee LLooccaattoorr wweebbssiittee.. Residential Care Services Investigation Summary Report Provider/Facility: Bridgeport Place Provider Type: Assisted Living Facility License/Cert.#: 2427 Compliance Determination #: 22317 Intake ID: 73766 Investigator: Woodetta Maulana Region/Unit #: RCS Region 3 / Unit D Investigation Date(s): 04/10/2023 through 06/07/2023 Complainant Contact Date(s): Allegation(s): 1) developed diverticulitis 2) did not sign a care plan 3) Given bill for $900 4)Xarelto stopped for 5 days instead of 2 5) Fish oil stopped for 4 days instead of 7 6) Pills found on floor Investigation Methods: Sample: Total residents: 66 Resident sample size: 2 Closed records sample size: 0 Observations: staff to resident interaction residents general observation of the facility Interviews: staff residents others not associated with the facility Record Reviews: Resident records Investigation Summary: 1) Diagnosed prior to admitting to the facility 2) care plan signed after POA agreed with lower level of care. During an interview, the Executive Director stated the POA will be reimbursed for previous month 3) Interviewed business office manager who stated the resident was billed for two months, not one, and the bill was paid without issue 4) Consultation: Xarelto held 4 days instead of 2 as ordered 5) According to the medication administration record (MAR), the fish oil was held for seven days as ordered 6) Observed resident's room and pills not found on floor during this investigation Conclusion / Action: TThhiiss ddooccuummeenntt wwaass pprreeppaarreedd bbyy RReessiiddeennttiiaall CCaarree SSeerrvviicceess ffoorr tthhee LLooccaattoorr wweebbssiittee.. Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A TThhiiss ddooccuummeenntt wwaass pprreeppaarreedd bbyy RReessiiddeennttiiaall CCaarree SSeerrvviicceess ffoorr tthhee LLooccaattoorr wweebbssiittee..

This document was prepared by Residential Care Services for the Locator website. STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALT H SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION PO Box 99250, Lakewood, WA 98496 C.F. Bridgeport, LLC Bridgeport Place 5250 Bridgeport Way W University Place, WA 98467 RE: Bridgeport Place License# 2427 Dear Administrator: This letter addresses Compliance Determination(s) 31196 (Completion Date 12/18/2023) and 24978 (Completion Date 06/23/2023). The Department completed a follow-up inspection of your Assisted Living Facility on 12/18/2023 and found no deficiencies. Your facility meets the Assisted Living Facility licensing requirements. The Department found that deficiencies for the following licensing laws and regulations were corrected: WAC 388-78A-2371-1, WAC 388-78A-2371-3 The Department staff who did the off-site verification: Woodetta Maula-na, If you have any questions, please contact me at (253)442-3013. Sincerely, Manfay Chan, Field Manager Region 3, Unit D Residential Care Services Residential Care Services Investigation Summary Report Provider/Facility: Bridgeport Place Provider Type: Assisted Living Facility License/Cert.#: 2427 Compliance Determination #: 24978 Intake ID: 77730 Investigator: Woodetta Maulana Region/Unit #: RCS Region 3 / Unit D Investigation Date(s): 06/07/2023 through 06/23/2023 Complainant Contact Date(s): Allegation(s): Named resident fell over a bucket of water and the facility received the resident back from the hospital when they should have had the resident return to the hospital. Investigation Methods: Sample: Total residents: 62 Resident sample size: 7 Closed records sample size: 1 Observations: staff to resident interaction residents general observation of the facility Interviews: staff residents Record Reviews: resident records facility investigation report Investigation Summary: The Assisted Living Facility (ALF) failed to document findings of their investigation and failed to institute appropriate measures to prevent similar future incidents in relation to identified contributing environmental factors when resident one had a fall with injury. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Bridgeport Place Provider Type: Assisted Living Facility License/Cert.#: 2427 Compliance Determination #: 24978 Intake ID: 77739 Investigator: Woodetta Maulana Region/Unit #: RCS Region 3 / Unit D Investigation Date(s): 06/07/2023 through 06/23/2023 Complainant Contact Date(s): Allegation(s): Named resident fell over a bucket of water and the facility received the resident back from the hospital when they should have had the resident return to the hospital. Investigation Methods: Sample: Total residents: 62 Resident sample size: 7 Closed records sample size: 1 Observations: staff to resident interaction residents general observation of the facility Interviews: staff residents Record Reviews: resident records facility investigation report Investigation Summary: The Assisted Living Facility (ALF) failed to document findings of their investigation and failed to institute appropriate measures to prevent similar future incidents in relation to identified contributing environmental factors when resident one had a fall with injury. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. 07-06-'23 14:38 FR0M- T-438 P0005/0008 F-663 u,.tfU,Lv,~ IL,11.~~ •J d ~ ~l?.t •. ~'3"-; J~t. ' STATE OP WASHINGTON DEPARTMENT OF SOCIAL AND HEAL TH SERVICES AGING AND LONG-TERM SUPPORT ADMINISTRATION PO Box 99250, Lakewood, WA 98496 sfafori-i"ei,·1·0foe·iiderides······························•·········ticerise·#:·24it··················co,ip1iifricetfoie"rrnir,aHori·#·24tiiil° Plan of Correction Bridgeport Place Completion Date Page 1 of~ Licensee: C.F. 81idgeport, LLC 06/23/2023 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 06/07/2023 and 06/07/2023 of: Bridgeport Place 5250 Bridgeport Way W University Plaee, WA 98467 This document references the following complaint number(s): 77730, 77739, 80383 The following sample was selected for review during the unannounced on-site visit: 7 of 62 current residents and 1 former residents. The department staff that investigated the Assisted Living Facility: Woodetta Maulana. From: DSHS, Aging and Long-Term Support Administration Residential Care Services, Region 3 , Unit D PO Box 99250 Lakewood, WA 98496 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. 06/26/2023 Residential Care Services Date I understand "that to maintain an Assis.ted Living Facility license, the facility must be in compliance with all the licensing laws and regulations at all times. This document was prepared by Residential Care Services for the Locator website. 07-06-'23 14:39 FROM- T-438 P0006/0008 F-663 Stateroeot of Deficiencies License#: 2427 Compliance Determination# 24978 Plan of Correction Bridgeport Place Completion Date Page 2 of 3 licensee: C.F. Bridgeport, LLC 06/23/2023 ···-----·····-·····-------··"bate···············. .... ········ WAC 388-78A-2371 Investigations. The assisted living facility must: {1) Investigate and document investigative actior'ls and findings for any alleged or suspected abuse, neglect, or financial exploitation; or accident or incident jeopardizing or affecting a resident health or life; (3) When necessary, institute and document appropriate me.asures to prevent similar future situations if the alleged incident is substantiated; and This requirement was not met as evidenced by: Based on interview and record review the Assisted Living Facility (ALF) failed to document findings of their investigation and failed to institute appropriate measures to prevent similar future incidents in relation to identified cMtributing environmental factors when 1 of 7 sample residents (Resident 1) had a fall with injury. This failure placed all residents at risk for harm. Finc,lings included ... Review of the facility's "Resident Incident Report'' dated 04/07/2023 documented, Resident 1 (R1) was facing the floor with a bleeding nose and injuries that included a fracture, bump on the head with fresh blood and a bruise. Further review showed ''resident was walking back to her room and lost balance and fell on her face. R1's right eye was bruise and had bleeding nose," The "Resident Incident Report" dated 04/07/2023, under the heading "Contributing Factors: Environment~! Factors'' documented, "Fell while ambulating independently, improper use of two~ wheel walker, independently completing AOL's, Resident lost balance and fell while ambulating." Review of the "Resident Incident Report" dated 04/07/2023 under the heading "Resident Follow up and Prevention: Fall Reduction Interventions Implemented" documented. "alert charting, appropriate footwear, area checked for trip hazards, asked resident when feeling ligl1theaded or dizzy to call for assistance before transfers, encourage resident to call for staff assistance if feeling weak/unsteady, encourage resident to \.1S8 walker in room." On 06/07/2023 at 12:30 p.m .. Housekeeper (Staff 8,) stated she was inside a resident's room cleaning when she heard a noise. Staff B stated she came out and saw R1 on the floor in the haltway. Staff 8 stated the mop bucket that was filled with water was dumped over and R1 was on the floor next to the bucket. This document was prepared by Residential Care Services for the Locator website. 07-06-'23 14:38 FROM- T-438 P0007/0008 F-663 Statemeni°of Deficiencies License#: 2427 Compliance Determination# 24978 Plan of Correction Bridgeport Place Completion Date Page 3 of 3 Licensee: C.F. Bridgeport, LLC 06/23/2023 On 06/07/2023 at 1 :00 p.m., Director of Wellness (Staff A) stated she did not incll1de: the knocked over bucket that wa's filled wfth water as a contributing environme1Jtal factor in the facility's incident report and investigation because the bucket was completely empty of water, and there should have _been some wate_r left inside of the bucket. V\ihen asked, Staff A confirmed the floor was wet and stated she thought the resident had an episode of incontinence. 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 7 , B /: f l- i . d .': g J. e ~ p!'~ 3 lace . i s or will be in compliance with this law and/ or regulation on (Date) l'lk.rf Alt-sk-11--- '1;, .C ,p"~< &1 ~N- In addition, I will lm~ment a system to monitor and ensure contiifueYc~~pliance with this requirement. ·~~··,~~~-idd-•··-···········--·· -----7/~l!-2··········- 1 ~