Legacy House of Mesa

Based on documentation review, record review, and interview, after the manager had a reasonable basis, according to A.R.S. § 46-454, to believe abuse, neglect, or exploitation had occurred on the premises, the manager failed to report the suspected abuse, neglect, or exploitation of the resident according to A.R.S. § 46-454. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: 1. A review of department documentation revealed that an intake on July 3, 2025, reported that “the care staff hit R1 and stated that the care staff needed to defend themselves against R1.” 2. A review of R1’s medical record revealed a charting note dated June 26, 2025. The documentation indicated that the resident was hitting the caregiver, and the resident got a skin tear.” However, no reports indicate whether the facility checked on R1 skin, reported the incident, or conducted an investigation. 3. In an interview, E1 stated that there was no incident report of R1's skin tear or an investigation conducted to find out how R1 got the skin tear. 4. In an interview, E1 acknowledged that E1 failed to comply with requirements of R9-10-803. J by not completing an incident report or investigation.

Based on documentation review and interview, after having a reasonable basis to believe abuse occurred on the premises, the manager failed to report the suspected abuse of a resident according to Arizona Revised Statutes (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. A review of facility documentation revealed an investigation report of an incident which occurred at approximately 10:30 PM on April 9, 2025. The report revealed the manager had a reasonable basis to believe abuse occurred on the premises. The review further revealed a report made to Adult Protective Services (APS) and a printout of a confirmation email from APS demonstrating facility personnel reported the suspected abuse. However, the email indicated the suspected abuse was not reported to APS until 4:39 PM on April 10, 2025, more than 18 hours after facility personnel were made aware of the incident. 4. In an interview regarding the report to APS, E1 stated, “I know we sent this on Thursday the next day.” After reviewing the email confirmation, E1 confirmed the suspected abuse was not reported to APS until 4:39 PM on April 10, 2025.