Leisure Gardens

Based on observation, documentation review, and interview, the manager failed to ensure a designated caregiver was present on the assisted living facility's premises and accountable for the assisted living facility when the manager was not present on the assisted living facility premises. The deficient practice posed a risk as no individual was designated to act on behalf of the governing authority in the on-site management of the assisted living facility. Findings include: 1. The Compliance Officer observed E5, E6, and E7 were the only employees on the premises when the Compliance Officer arrived at the facility; E2, E3, and E4 arrived at the facility late during the survey. 2. A review of facility documentation revealed there was no documentation to reflect E5, E6, or E7 were designated in writing, to be accountable for the assisted living facility when the manager was not present. 3. In an interview, E2 reported E5, E6, and E7 were "substitutes" and acknowledged there was no documentation to reflect E5, E6, or E7 were designated in writing, to be accountable for the assisted living facility when the manager was not present. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on observation and interview, the manager failed to ensure that at least the manager or a caregiver was present at an assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. While on-site for the compliance inspection, the Compliance Officer observed E5, E6, and E7 were the only individuals at the facility, providing services to residents. 2. In an interview, E5 reported E5, E6, and E7 were not certified caregivers. 3. In an interview, E2 reported E5, E6, and E7 were substitutes and did not work at the facility on a daily basis. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a personnel record was established and maintained, for 4 of 8 personnel records reviewed. The deficient practice posed a risk to resident health and safety if the facility did not obtain documentation showing an employee met the requirements to provide services for the residents. Findings include: 1. The Compliance Officer requested E5's, E6's, E7's, and O1's personnel record. However, the records were not available for review. 2. In an interview, E2 reported E5, E6, and E7 were substituting at the facility and did not work there permanently. 3. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident had a written service plan that was reviewed and updated at least once every six months for one of three residents reviewed receiving personal care services, The deficient practice posed a risk if a resident's service plan was not updated as required to reinforce and clarify services, and a caregiver was not aware of the services to be provided for a resident. Findings include: 1. A review of R3's medical record revealed a service plan for personal care services dated March 22, 2025. However, documentation of a service plan after March 22, 2025 was not available for review. 2. In an exit interview, the findings were reviewed with E2, 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 was signed and dated by the resident or resident's representative, the manager, and if a review was required, by the nurse or medical practitioner who reviewed the service plan for one of four records reviewed. This posed a health and safety risk if the resident or the resident's representative, the manager, and the nurse or medical practitioner did not acknowledge the services that were to be provided. Findings include: 1. A review of R1's medical record revealed a service plan dated November 15, 2025. The service plan stated the resident received personal care and medication administration services. The service plan contained no dated signature by the nurse or medical practitioner who reviewed the service plan. 2. In an interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1, for two out of six residents sampled. The deficient practice posed a risk as required information could not be verified for the sampled resident. Findings include: 1. A.R.S. § 12, Chapter 13, Article 7.1 states, "Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: 1. If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider." 2. The surveyor requested R5's and R6's medical records for review. However, R5's and R6's medical records were unavailable for review at the time of the survey. 3.In an interview, E2 reported R5 and R6 no longer resided at the facility. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, record review, and interview, the assisted living home failed to provide the required documentation to an emergency responder, for one of one reviewed residents for whom an emergency responder had been contacted. Findings include: 1. A review of R2's medical record revealed progress notes which contained an incident report dated March 9, 2024. The incident report indicated R2 had been transported to the hospital. 2. A review of R2's medical record revealed a copy of documentation given to the emergency responder was not available for review. 3. In an interview, E1 acknowledged the documentation of what was given to the emergency responder for R2 was not provided for review.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented to protect the health and safety of a resident covering how a caregiver would respond to a resident's sudden, intense, or out of control behavior to prevent harm to the resident or another individual. Findings include: 1. Review of the facility's policies and procedures revealed no policy and procedure covering how a caregiver would respond to a resident's sudden, intense, or out of control behavior to prevent harm to the resident or another individual. 2. In an interview, E1 acknowledged a policy and procedure was not available covering how a caregiver would respond to a resident's sudden, intense, or out of control behavior to prevent harm to the resident or another individual.

Based on interview and documentation review, the manager failed to document the suspected abuse and any action taken to immediately stop the suspected abuse when the manager had a reasonable basis to believe abuse had occurred on the premises or while a resident was receiving services from an assisted living facility. The deficient practice posed a risk as the facility failed to properly document the report of suspected abuse. Findings include: 1. In an interview, E1 reported that Adult Protective Services had been to the facility to investigate an abuse allegation of a caregiver slapping R1 one day before the Department complaint investigation. 2. A review of facility incident report documentation revealed no documentation of the suspected abuse or actions taken to immediately stop the suspected abuse. 3. In an interview, E1 reported that the facility took the allegations of a caregiver slapping R1 seriously, and fired the caregiver, however, no documentation was available. E1 acknowledged that the suspected abuse or actions taken to immediately stop the suspected abuse had not been documented.