Inspection Reports for
Leisure Garden Senior Assisted Living Facility

The complaint investigation was unsubstantiated. Allegations included staff withholding resident's personal funds, hitting a resident with a trash can, not safeguarding personal items, and disrespectful treatment. Interviews and record reviews did not verify any of these allegations.

The investigation found insufficient evidence to substantiate any of the allegations, including withholding resident funds, staff hitting a resident with a trash can, failure to safeguard resident personal items, and disrespectful treatment of residents. No immediate health or safety issues were observed during the visit.

The complaint alleged that staff could not adequately communicate with residents, did not ensure residents received medications as prescribed, and did not allow private visits in residents' rooms. All allegations were investigated and found unsubstantiated.

All allegations were found to be unsubstantiated based on interviews with residents, staff, family members, record reviews, and observations. No immediate health or safety issues were observed during the visit.

The complaint alleged that staff failed to seek medical attention for a resident resulting in hospital admission. Interviews with staff and the resident, along with record reviews, showed the resident refused medical attention multiple times and staff documented these refusals. The allegation was unsubstantiated.

Based on interviews and record review, there was insufficient evidence to verify the allegation. The resident had refused medical attention on multiple occasions, and staff documented and monitored the resident's condition. The allegation was unsubstantiated.

The facility was found to be in compliance with all applicable regulations. No deficiencies were observed during the visit, and all areas including kitchen, bedrooms, bathrooms, common areas, and medication management were properly maintained.

The complaint alleged that the Administrator signed a resident's POLST and hospice consent forms without the resident's consent. The investigation included interviews and record reviews, which revealed signature discrepancies and hospital designation of decision-making authority. The allegations were determined to be unsubstantiated.

The investigation found insufficient evidence to verify the allegations. Interviews and record reviews showed discrepancies in signatures and that the hospital was the designated decision maker for the resident's medical treatments. The allegations were unsubstantiated.

The complaint alleged that facility staff did not allow a resident to choose their own healthcare provider. The allegation was unsubstantiated based on interviews with staff, residents, and review of records including visitation logs and incident reports.

The investigation found no evidence that the facility staff denied services to the resident or restricted choice of healthcare provider. Interviews and record reviews confirmed the resident was able to choose and receive services from their home health agency. The allegation was unsubstantiated.

The complaint involved two allegations: mishandling of a resident's personal belongings and mishandling of a resident's medications. Both allegations were found to be unsubstantiated after interviews, record reviews, and observations.

The investigation found insufficient evidence to substantiate the allegations. The resident's belongings were infested prior to relocation, and the facility took precautions. Medication records were incomplete at relocation, but the facility sought updated prescriptions and provided medical treatment.

The facility accepted three relocated residents, all of whom were at their day program during the visit. The physical plant tour found residents' bedrooms to be neat, clean, and well-equipped with no immediate health or safety issues observed.

The complaint alleged improper disposal of hazardous items. After interviews with four staff members, observations, and record review, the allegation was found to be unsubstantiated.

The investigation found that all hazardous materials were properly disposed of in sealed trash bags inside trash barrels with lids. No unsecured hazardous materials were observed, and the allegation was unsubstantiated.

The complaint alleged that Resident 1 was sexually assaulted by three staff members. The investigation included interviews with residents and staff, review of police and medical records, and internal facility investigations. The allegation was unsubstantiated due to lack of evidence and contradictory statements.

The investigation found no substantiated evidence of sexual assault by staff members. Interviews, record reviews, and police reports indicated inconsistent allegations and no witnesses to abuse. The allegation was determined to be unsubstantiated.

The complaint involved allegations that staff did not provide a resident with an appraisal, did not provide the responsible party with an admissions agreement, failed to communicate with the responsible party regarding resident's care, and did not assist the resident with obtaining medical care. The investigation found these allegations unsubstantiated.

The investigation found all allegations unsubstantiated after reviewing resident files, interviewing staff and residents, and confirming no evidence of the alleged deficiencies.

The complaint investigation was unsubstantiated. Allegations included failure to assist with catheter care and failure to dispense medications as prescribed. Interviews with residents and staff and record reviews did not support the allegations.

The investigation found that staff promptly called 911 when a resident's catheter was clogged and residents confirmed timely medication administration. Based on record reviews and interviews, the allegations were unsubstantiated.

The complaint alleged that staff refused to release medical documents after receiving a medical consent form. The allegation was investigated and found to be unsubstantiated based on review of records and interviews.

The Licensing Program Analyst reviewed all records and email correspondence and confirmed that all requested records were sent to the requester in a timely manner. The allegation was found to be unsubstantiated.

The complaint alleged that staff failed to provide adequate care or supervision, causing a resident to be stuck in the toilet for an extended period. The investigation found the allegation unsubstantiated after interviews with staff and residents and review of records.

The allegation that a resident was stuck in the toilet for four hours and required hospital admission was unsubstantiated based on interviews and record review. Staff and resident interviews confirmed the resident independently uses the bathroom and takes a long time, but no neglect was found.

The complaint investigation was unsubstantiated. Allegations included facility disrepair due to elevator issues, unsafe environment due to lack of window screens and stranger entry, and failure to adhere to residents' dietary needs. Observations, interviews, and record reviews did not support these claims.

The investigation found that the facility elevators were operational and maintained, residents and staff reported feeling safe, and dietary needs were being met with appropriate accommodations. All allegations were deemed unsubstantiated.

The facility was found to be in compliance with no deficiencies observed. The physical plant, kitchen, bedrooms, bathrooms, common areas, and medication management were all inspected and found to be properly maintained and functional.

The complaint investigation addressed allegations that staff were withholding resident funds, not keeping the facility free from bed bugs, and not maintaining cleanliness. The allegations were found to be unsubstantiated after interviews with 15 residents, review of exterminator reports, and facility inspection.

The investigation found all allegations to be unsubstantiated based on resident interviews, record reviews, and facility observations. Residents confirmed receipt of funds, no bed bugs were found, and the facility was observed to be clean.

The complaint alleged that staff were not releasing a resident's medical records despite a signed medical release form. The resident confirmed during interview that all medical records could be released and to whom. The facility administrator was aware of the consent but could not confirm it with the resident. The allegation was found unsubstantiated.

The investigation found that although the resident had signed a medical release form authorizing release of records, the facility administrator was unable to confirm the resident's current consent. Based on interviews and records reviewed, the allegation was unsubstantiated.

The complaint investigation addressed allegations of resident rape by another resident, failure to meet hygiene needs, failure to provide laundry services, forced haircuts, pest infestation, facility disrepair, and failure to provide clean eating utensils. All allegations were found to be unsubstantiated after interviews with residents, staff, and administrator, facility tours, and review of documentation.

All allegations including resident rape, failure to meet hygiene needs, failure to provide laundry services, forced haircuts, pest infestation, facility disrepair, and failure to provide clean eating utensils were investigated and found to be unsubstantiated based on interviews, observations, and documentation review.

The complaint investigation addressed three allegations: staff did not refill resident's medication in a timely manner, staff did not dispense medication as prescribed, and staff did not prevent residents from smoking in non-smoking areas. All allegations were found to be unsubstantiated based on interviews with staff and residents, document reviews, and physical plant observations.

Based on interviews, record reviews, and observations, there was insufficient evidence to verify any of the allegations. All allegations were determined to be unsubstantiated at the time of the investigation. No health and safety hazards were noted during the visit.

The complaint involved two allegations: 1) Facility did not notify responsible party of resident's death, and 2) Facility refused to provide resident's personal belongings to responsible party. Both allegations were investigated and deemed unsubstantiated based on interviews and record reviews.

Both allegations were found to be unsubstantiated. The facility notified the responsible party about the resident's death, although with some delay, and the resident's belongings were securely stored and available for pick up, but the family failed to arrange for delivery or pick up.

The complaint involved two allegations: 1) Staff did not seek medical care for a resident needing surgery for a brain-related diagnosis. The investigation found the resident received appropriate medical care and follow-up. 2) Licensee refused to release medical documents after receiving a medical consent form. The investigation found the resident did not consent to release medical information and the facility did not release documents without valid consent. Both allegations were unsubstantiated.

The investigation found that the facility staff assisted the resident with medical care and appointments, and the resident sometimes declined appointments. The allegation regarding refusal to release medical documents was unsubstantiated as the resident did not consent to release and the facility did not release documents without proper consent.

The complaint investigation was unsubstantiated. Allegations included mismanagement of residents' money, failure to refill or provide medication as prescribed, failure to prevent smoking in non-smoking areas, elevator disrepair, lack of cleanliness, and uncomfortable room temperatures. All were found unsubstantiated after thorough investigation.

All allegations were investigated through interviews, record reviews, and facility tours. No discrepancies or violations were found, and all allegations were deemed unsubstantiated based on observations and evidence.

The facility was found to be in compliance with all applicable regulations. No deficiencies were observed during the visit.

The complaint alleged that staff did not respond timely to communications from a resident's representative regarding changing the primary payee. Interviews revealed the representative called twice and concerns were resolved. The administrator was unaware of any communication issues. The allegation was unsubstantiated.

The investigation included interviews and record reviews. The allegation was found to be unsubstantiated due to insufficient evidence to verify the claim.

Allegation: Staff inappropriately touched resident in care. The allegation was investigated through interviews with residents, staff, and the administrator, and review of relevant records. The allegation was found to be unsubstantiated due to lack of evidence.

The investigation found no evidence to substantiate the allegation. Interviews with residents, staff, and the administrator, as well as a review of records, did not corroborate the claim. The allegation was determined to be unsubstantiated.

The Licensing Program Analyst conducted an unannounced visit, reviewed a resident's file, interviewed a resident and a staff member, and planned additional staff interviews. The visit was related to a resident's death reported on 2024-04-09.

The complaint alleged that resident #1 was hit on the head repeatedly by resident #2. Interviews and record reviews did not confirm the incident. Resident #2 had moved out prior to the investigation. The allegation was unsubstantiated due to lack of evidence.

The investigation found no corroborating witnesses or sufficient evidence to substantiate the allegation. The allegation was determined to be unsubstantiated at this time, and no deficiencies were cited.

The Licensing Program Analyst received a copy of the resident's Admissions Agreement. The Administrator stated that the requested documentation would be sent via email by January 5, 2023.

The Licensing Program Analyst confirmed the facility maintained records of fire alarm testing and observed removal of mid hallway doors and display of the inspection/license sign. There were no deficiencies reported at this time.

The complaint involved allegations that staff restricted visitors for a resident and listened in on the resident's private phone calls. After interviews with the resident, staff, and other residents, and observation, the allegations were found to be unsubstantiated.

The investigation found that residents are allowed visitors and the facility has not denied visitors. Residents reported feeling privacy when using community telephones and did not feel staff were eavesdropping. Both allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included missing resident belongings, withholding of personal and incidental funds, and unsafe environment due to bullying. Interviews and document reviews did not support these claims.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews with clients, staff, and the administrator, as well as document reviews, indicated that residents are responsible for their belongings, personal and incidental funds were properly distributed, and no bullying or unsafe environment was reported.

The complaint investigation addressed allegations that facility staff did not allow a resident to leave without escort, failed to refill a resident’s prescription timely, did not seek medical attention promptly for an injured resident, and failed to deliver mail to a resident. After interviews and record reviews, all allegations were found unsubstantiated.

The investigation found all allegations unsubstantiated based on interviews with residents and staff, review of medical and medication records, and observations. Residents were allowed to leave the facility, prescriptions were refilled timely, medical attention was sought promptly, and residents received their mail.

The complaint investigation was unsubstantiated. Allegations included a resident not receiving prescribed medications, falsified medication logs, and inadequate care. Interviews with staff, residents, and review of medication logs did not support these allegations.

The investigation found that the allegations regarding medications not being provided as prescribed, falsified resident logs, and inadequate service were unsubstantiated after interviews, record reviews, and observations.

The complaint investigation was unsubstantiated. The resident was able to leave the facility unassisted but signed out as required. Staff met hygiene needs by encouraging the resident daily, but the resident refused care multiple times per week.

Both allegations were found to be unsubstantiated. The resident was confirmed to have signed out when leaving the facility and was able to bathe and dress themselves. Caregivers encouraged hygiene daily, but the resident often refused to shower or change clothing.

The complaint involved a resident refusing assistance with showering, medications, and medical care. The administrator notified the family and physician. No deficiencies were found.

The licensing evaluator toured the facility and reviewed the resident file. No health or safety issues were observed during the visit.

The interview with Resident #1 revealed that the resident is doing fine at the facility. No health and safety concerns were observed during the visit.

The complaint investigation was unsubstantiated. Allegations included failure to seek timely medical attention, presence of lice on a resident, and unmet hygiene needs. Staff and family interviews indicated the resident refused hygiene assistance and staff called 911 promptly when needed.

The investigation found no health or safety issues and staff interviews confirmed timely medical attention was provided. The allegations regarding lice and unmet hygiene needs were unsubstantiated as the resident refused hygiene assistance and did not complain of health issues.

The complaint was unsubstantiated after investigation. Allegations included staff not providing a safe environment and withholding PNI funds, both found unsubstantiated based on observations and interviews.

The investigation found no health or safety issues during the facility tour. Interviews with staff and administrators confirmed that residents were reminded to keep doors locked, and the allegations regarding unsafe environment and withholding PNI funds were unsubstantiated.

The complaint alleged that the facility had residents sign up for services they do not need. The allegation was found to be unsubstantiated after review of the resident's informed consent form for hospice services.

The investigation found that the resident did consent to hospice services as evidenced by the signed informed consent form. Therefore, the allegation was unsubstantiated.

The complaint alleged staff were not cleaning resident #1's bed sore daily. The allegation was deemed unsubstantiated based on interviews and documentation.

The investigation found no substantiation for the allegation. Interviews and record reviews showed the resident did not have a staged wound on the left thigh and was receiving appropriate hospice care with nursing visits as needed.

The complaint involved allegations that staff were preventing a resident from contacting their physician and refusing to allow the resident to take medication. Both allegations were found to be unsubstantiated based on interviews and medication record reviews.

The investigation found no immediate health and safety issues. Interviews and record reviews determined that the allegations were unsubstantiated as the resident had not requested assistance to contact their physician and did receive their medication as documented.

The complaint alleged that staff was withholding resident #1's mail. After interviews with the resident and staff, it was determined that the resident received mail on time and the allegation was unsubstantiated.

The investigation found that the resident received their mail and packages in a timely manner, and staff were unaware of any issues. The allegation was deemed unsubstantiated.

The complaint involved an incident where resident #1 slammed a door on resident #2's hand resulting in injury. Law enforcement was involved and a report number was obtained. The complaint is under follow-up by the case carrying Licensing Program Analyst.

The Licensing Program Analyst interviewed the administrator and involved residents, reviewed the incident report and witness statement, and obtained a law enforcement report number. The information will be forwarded for follow-up action.

The complaint alleged that Resident #1 sustained severe pressure injuries and multiple bruises while in care. The investigation was unsubstantiated based on facility documentation, caregiver interviews, and hospital medical records.

The investigation found insufficient evidence to substantiate the allegations. The resident had redness and wounds documented prior to hospitalization, but no open wounds or multiple bruises were confirmed while in care. The allegations were deemed unsubstantiated.

The complaint alleged the facility did not notify the resident’s authorized representative of the resident’s move. The allegation was found unsubstantiated after review of records, interviews with the Licensee, Administrator, previous Administrator, hospice agency, and documentation from physicians and the Conservator.

The investigation found no health or safety issues and confirmed the facility did notify the resident’s authorized representative. The allegation was unsubstantiated based on interviews and documentation including a letter from the Conservator approving the move.

The complaint alleged that a resident sustained wounds while in care and that staff did not seek medical attention for the resident. The investigation included interviews with the resident and staff, a facility tour, and review of medical records. The allegations were found to be unsubstantiated.

The investigation found no evidence of open wounds on the resident and confirmed that medical care was sought promptly for a past infection. Both allegations were determined to be unsubstantiated.

The complaint alleged over-medication of a resident with over-the-counter medication and disrespectful behavior by a medical technician. Both allegations were investigated and found to be unsubstantiated.

The investigation found no evidence to support the allegations. Medication administration was accurate and followed facility policies, and the medical technician was not disrespectful to the resident. Therefore, the allegations were unsubstantiated.

The visit was triggered by an incident report and phone call regarding a resident incident at another location. No substantiation status is provided.

The licensing evaluator conducted a tour and review of resident records and found no immediate health and safety issues at the time of the visit. Further investigation is needed.

The complaint was unsubstantiated after interviews with staff and ten residents who receive incontinent care. No evidence was found to support claims that staff refused to change a resident's diaper or that residents were malodorous.

The investigation found no substantiation for the allegations. Staff reported checking incontinent residents every one to two hours, and residents interviewed reported no complaints about toileting care or odors.

The complaint alleged that a resident was being illegally evicted and threatened. The investigation included interviews with the resident, licensee, and administrator, review of resident files, and a physical plant tour. The allegations were found to be unsubstantiated.

The investigation found that the resident was advised to find a skilled nursing facility due to care needs, but no eviction notice or threats were issued. The allegations of illegal eviction and threats were unsubstantiated.

The complaint investigation was unsubstantiated. The allegation that a resident sustained scabies while in care was not confirmed by medical diagnosis or medication records. The allegation that the facility had bed bugs was not supported by inspection or resident reports.

The investigation found no evidence of bed bugs after inspection and resident interviews. The allegation of scabies was unsubstantiated as no diagnosis or medication for scabies was confirmed for the resident.

The complaint alleged that caregivers did not provide proper care to a resident, including failure to change soiled bedding and missed medication doses. The investigation found these allegations unsubstantiated.

The investigation found no substantiated evidence that caregivers failed to provide proper care. Allegations regarding unclean bedding and missed medication were unsubstantiated based on interviews and medication records.

The complaint investigation was unsubstantiated for all allegations including over medication, dignity issues, room odor, resident freedom to leave, and access to personal items.

All allegations including staff over medicating a resident, lack of dignity in staff-resident relationships, failure to clean a resident's room from odor, restricting resident's freedom to leave, and denying access to personal items were investigated and found to be unsubstantiated.

The complaint alleged that a resident was prevented from getting medical treatment while in care. The investigation included interviews with the resident, caregivers, administrator designee, and weekend manager. The complaint was found unsubstantiated.

The investigation found that the resident did not notify staff or leave a note requesting assistance, and staff members interviewed denied knowledge of such a note. Based on interviews with four staff members, the complaint was determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included staff not notifying authorized representative of resident's death, resident not having toilet paper, and staff not returning resident's personal property. All were found unsubstantiated after review and interviews.

All allegations were found to be unsubstantiated after interviews with residents, staff, and administrators. The facility was confirmed to provide toilet paper timely, notify family members regarding resident death attempts, and securely store residents' possessions for family pickup.

The complaint alleged that two residents were arguing and threatened each other with chairs. After interviews with ten residents and four staff members, the complaint was found unsubstantiated.

The investigation included interviews with residents and staff. No witnesses confirmed the alleged altercation, and the complaint was determined to be unsubstantiated.

The complaint alleged that staff did not assist a resident with transporting from the hospital to the facility and failed to provide a wheelchair at the front entrance upon arrival. The allegation was unsubstantiated after investigation.

The investigation found that the caregiver did provide a wheelchair within a timely manner on July 2, 2021, and the allegation was deemed unsubstantiated based on interviews with the Administrator Designee and Caregiver.

The complaint alleged that a resident sustained injury with multiple large bruises. The investigation included interviews with facility staff, caregivers, the licensee, and the resident's treating physician. The bruising was attributed to medical conditions including leukemia, blood thinners, and IV placement. The complaint was unsubstantiated.

The investigation found that the bruising on the resident was likely caused by the resident's illness, IV attempts, and blood thinner medications. The findings were unsubstantiated as no evidence of staff abuse or neglect was found.

The complaint involved a female resident reporting she had been raped three times. Emergency services responded, a police report was filed, and the resident was sent to the hospital and returned the same day.

The licensing evaluator interviewed the resident involved, reviewed medication records, obtained a police report, and toured the facility observing staff and residents. The facility was found to have appropriate infection control measures such as mask usage and hand hygiene signage.

The investigation involved three incident reports, including two residents who were AWOL and one resident found with a metal hanger around their neck. The resident with the hanger was conscious, 911 was called, and the resident is being treated in a hospital. The clinician will check on the resident twice weekly upon return, and the resident will be relocated closer to staff for frequent monitoring.

The facility staff follow specific room check procedures to monitor residents, especially those who have previously eloped. One resident was found with a metal hanger around their neck and was immediately taken to the hospital. The facility has implemented additional checks and plans to frequently monitor the affected resident upon return.

The complaint alleged that staff did not seek timely medical care for a resident and did not supply the resident with a bed after the hospice agency removed the hospital bed without notice. The investigation found these allegations unsubstantiated.

The investigation found no health and safety issues during the facility tour. Interviews revealed that the resident was removed from hospice services without proper notice and that the facility staff provided an alternative bed the same day. The allegations were deemed unsubstantiated based on the information obtained.

The complaint alleged that a resident sustained injury with multiple large bruises. The investigation included interviews with facility staff, the complainant, and the resident's treating physician. The bruising was attributed to medical causes including leukemia, blood thinners, and IV placement. The complaint was unsubstantiated.

The investigation found that the bruising on the resident was likely caused by the resident's illness, IV attempts, and blood thinner medications. The findings were unsubstantiated as no evidence of abuse or neglect was found.