Inspection Reports for Leisure Vale Assisted Living

An unannounced Case Management - Deficiencies visit was conducted in conjunction with Complaint Control #31-AS-20251003161950 to investigate reported issues at the facility.

The inspection found that bedroom 50 had a broken window covered with a wooden board that had been unrepaired for several months, and bedroom 68 had multiple maintenance issues including only one functioning light bulb in the bathroom, a broken shower head, and a broken bed frame propped up with a box of cans. Residents reported these issues had been communicated but not corrected for over a year.

The visit was conducted in conjunction with Complaint Control #31-AS-20251003161950. The complaint was substantiated as deficiencies were found.

The visit was an unannounced complaint investigation triggered by an allegation that staff opened residents' mail and packages without the residents' consent.

The investigation found that mailboxes were secured with keys and numbered by room. Staff assist residents who need help with their keys, and residents confirmed no issues with mail being opened by staff. The allegation was unsubstantiated based on observations and interviews.

The complaint alleged that staff opened residents' mail and packages without consent. Interviews with staff and residents, as well as physical observations, did not substantiate the allegation.

An unannounced complaint investigation visit was conducted to investigate the allegation that staff do not communicate with the responsible party regarding a resident's care.

The investigation found that the facility staff have communicated all aspects of the resident's care with the responsible party, and the allegation was deemed unsubstantiated.

The complaint alleged that staff did not communicate with the responsible party regarding Resident #1's care. After interviews with the administrator, staff, and resident, and review of records, the allegation was found to be unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate allegations that staff did not ensure the personal property of a resident was safely secured.

The investigation found that although the allegation may have occurred, there was insufficient evidence to verify that the facility failed to safeguard the resident's personal belongings. The allegation was deemed unsubstantiated.

The complaint alleged that Resident #2 stole gold coins from Resident #1 when hired to clean their closet. The police investigation concluded with the coins returned to Resident #1. Interviews and record reviews did not substantiate the facility's failure to safeguard belongings.

An unannounced complaint investigation visit was conducted due to an allegation that facility staff did not seek timely medical attention for a resident in care.

The investigation found that the allegation was unsubstantiated. Interviews with the Executive Director, Wellness Director, Engagement Director, and residents indicated that the resident did not report symptoms to staff on the alleged date, and prior medical concerns had been addressed promptly.

The complaint alleged that on 06/05/2025, facility staff sent Resident #1 to the senior program with constipation and neck pain without providing medical attention. The investigation revealed that Resident #1 did not report these symptoms to staff on that date, and previous medical issues were addressed immediately. Sixteen residents interviewed expressed no concerns. The allegation was deemed unsubstantiated.

The visit was an unannounced complaint investigation initiated due to an allegation that facility staff did not provide a copy of the admission agreement to a resident.

The investigation found that staff did provide a copy of the admission agreement to the resident, but the resident refused to take it due to a dispute over cost sharing. Other residents confirmed receiving their admission agreements. The allegation was determined to be unsubstantiated with no health and safety issues noted.

The complaint was unsubstantiated. The allegation was that facility staff did not provide a copy of the admission agreement to resident #1 (R1). Interviews and records review showed staff did provide the copy, but R1 refused it. Other residents confirmed receiving copies. No health and safety issues were found.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff failed to provide emergency medical services in a timely manner and did not respond promptly to a resident's call pendant.

The complaint that staff failed to provide timely emergency medical services was substantiated, with evidence showing delayed 911 call for a resident who was vomiting and weak. The allegation regarding delayed response to call pendants was unsubstantiated, with staff response times within 14 minutes and no resident concerns noted.

The complaint investigation was initiated due to allegations that staff failed to provide emergency medical services timely and did not respond promptly to a resident's call pendant. The emergency medical services allegation was substantiated; the call pendant response allegation was unsubstantiated. The resident involved (R1) had been vomiting since 7:00 p.m. on 06/21/24, but 911 was not called until 11:00 p.m. R1 passed away on 06/22/24.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2025-04-14 regarding staff response to emergency alerts, provision of medical attention, and room maintenance at the facility.

The investigation found insufficient evidence to substantiate the allegations. Interviews with residents and staff, as well as record reviews, indicated that staff responded to emergency alerts, provided medical attention when needed, and maintained residents' rooms properly. No health and safety hazards were noted during the visit.

The complaint included three allegations: 1) staff did not respond timely to a resident's emergency alerts, 2) staff did not provide required medical attention to a resident, and 3) staff did not properly maintain a resident's room. All allegations were found to be unsubstantiated based on interviews and record reviews.

The inspection was a required unannounced one-year visit to evaluate compliance with licensing requirements at the assisted living facility.

The facility was found to be generally compliant with no health and safety hazards noted. The physical plant was toured, medication was inaccessible to residents, first aid kits were complete, and environmental conditions such as temperature and cleanliness were adequate.

The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that the facility elevator was in disrepair and not working, affecting residents who use wheelchairs on the third floor.

The Licensing Program Analyst observed the elevator to be working, conducted 17 interviews with residents and 3 with staff, all confirming the elevator was operational and that residents on the second and third floors did not use wheelchairs. The allegation was found to be unsubstantiated, no citations were issued.

The complaint alleged that the facility elevator was in disrepair and not working, impacting residents using wheelchairs on the third floor. The investigation found the elevator operational and the allegation unsubstantiated.

An unannounced complaint investigation visit was conducted to investigate allegations that staff did not follow up with a resident's medical coverage.

The investigation found that the resident's issue with medical coverage was a mix-up that was resolved immediately, and the resident received needed care. Staff assist residents with appointments and insurance management, and no health or safety hazards were noted. The allegation was unsubstantiated.

The complaint alleged that staff did not follow up with Resident #1's HMO insurance coverage. Interviews with residents and staff revealed the resident had an expired HMO card but was rescheduled and received treatment. The allegation was unsubstantiated due to insufficient evidence.

An unannounced Case Management visit was conducted to address an incident of alleged financial abuse by Staff #1 involving multiple residents, with police reports filed by some residents.

The investigation confirmed financial abuse involving six residents, with four interviewed victims confirming abuse. The facility failed to submit an incident report timely for the 09/25/2024 incident. No other health and safety hazards were noted during the visit.

The visit was complaint-related due to allegations of financial abuse by Staff #1 involving six residents, with three residents filing police reports. Four of six alleged victims were interviewed and confirmed some form of financial abuse. The investigation is ongoing with unknown dollar amounts involved.

The visit was an unannounced complaint investigation triggered by an allegation that staff did not provide adequate supervision, resulting in a resident eloping from the facility.

The investigation found that Resident #1 was independent and authorized to leave the facility unassisted. Staff interviews and record reviews indicated the incident was isolated, and there was insufficient evidence to substantiate the allegation. No health and safety hazards were noted during the visit.

The allegation that staff did not provide adequate supervision resulting in resident eloping was investigated and found to be unsubstantiated.

An unannounced complaint investigation visit was conducted in response to an allegation that facility staff did not provide a copy of the admission agreement to a resident.

The investigation found that staff did provide a copy of the admission agreement to the resident, and records confirmed this. The allegation was determined to be unsubstantiated with no health or safety issues noted during the visit.

The complaint alleged that facility staff did not provide a copy of the admission agreement to a resident. The allegation was unsubstantiated based on staff interviews and record reviews.

An unannounced complaint investigation was conducted due to allegations that facility staff did not respond in a timely manner to a resident's call pendant and failed to provide emergency medical services promptly.

Based on interviews and records review, there was insufficient information to support the allegations. The resident was monitored frequently, and emergency services were called appropriately when the resident showed signs of distress. No health and safety issues were noted at the time of the visit.

The complaint investigation was unsubstantiated. Allegations included delayed staff response to a resident's call pendant and failure to provide timely emergency medical services. Interviews and record reviews did not support these allegations.

An unannounced complaint investigation was conducted to investigate allegations that staff mismanaged a resident's medication and did not meet the resident's medical needs.

The investigation found that the facility followed all physician orders and properly assisted the resident with their medication and medical needs. Both allegations were deemed unsubstantiated. No immediate health and safety risks were observed during the visit.

The complaint involved allegations of medication mismanagement and failure to meet medical needs. After interviews and record reviews, both allegations were found unsubstantiated.

An unannounced complaint investigation was conducted regarding an allegation that staff did not prevent an altercation between residents.

The investigation found that staff did not intervene in time to prevent a physical altercation between Resident #1 and Resident #2. The allegation was substantiated, and a deficiency was cited related to personal rights of residents.

The complaint alleged that staff did not prevent an altercation between residents. The allegation was substantiated based on interviews and record review. Staff failed to intervene in time to prevent the altercation between Resident #1 and Resident #2. The facility has agreed to update service plans and schedule staff training.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not safeguard residents' belongings.

The investigation found insufficient information to support the allegation. Resident #1 left the facility before completing admission and their belongings were placed in facility storage. No health and safety issues were noted.

The complaint alleging staff did not safeguard residents' belongings was unsubstantiated.

An unannounced complaint investigation visit was conducted in response to an allegation that staff does not provide a safe environment for residents.

The investigation found insufficient information to support the allegation. Interviews and record reviews confirmed that the alleged resident was not present at the facility during the visit and staff were not aware of any threats or assaults. No health and safety issues were noted at the time of the visit.

The allegation that staff does not provide a safe environment for a resident was unsubstantiated after investigation. Resident #1 was out of the community due to being a danger to others and placed on a 5150 hold. Staff reported no knowledge of any threats or assaults against the resident.

An unannounced complaint investigation visit was conducted due to allegations of lack of supervision resulting in resident assaults and staff not providing a safe environment for residents.

The investigation found insufficient evidence to substantiate the allegations. One resident was hospitalized after an altercation, but staff intervened promptly and residents reported feeling safe. No health and safety issues were noted at the time of the visit.

The complaint involved allegations of lack of supervision leading to resident assaults and unsafe environment. The allegations were found to be unsubstantiated based on interviews and records review.

An unannounced complaint investigation visit was conducted in response to an allegation that the licensee does not allow a resident to have a cat.

The investigation found that the resident's medical doctor stated the resident is not capable of caring for service animals, and staff explained this to the resident and their case manager. Facility records confirmed this information. The allegation was unsubstantiated.

The complaint alleged that the licensee does not allow a resident to have a cat. The allegation was found to be unsubstantiated based on staff interviews and record review.

An unannounced complaint investigation was conducted due to an allegation that a resident was able to leave the facility unassisted because of lack of supervision.

The investigation found that Resident #1 left the facility unassisted before completing admission paperwork. Records and staff interviews confirmed the resident is ambulatory and the facility is not locked down. The allegation was unsubstantiated with no health or safety issues noted at the time of the visit.

The complaint alleged lack of supervision allowing a resident to leave unassisted. The allegation was found unsubstantiated based on interviews and records review.

The visit was an announced Pre-Licensing inspection conducted to evaluate the facility for licensing approval.

The facility was toured and inspected including the kitchen, bedrooms, bathrooms, medication room, common areas, and surroundings. No deficiencies were found and the facility met all requirements for pre-licensing.

The visit was conducted as a Component II evaluation for a Change in Ownership (CHOW) application for a Residential Care Facility for Elderly (RCFE).

The Component II evaluation was completed successfully, confirming that the Applicant and Administrator understand the community care facility licensing laws and regulations, including facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints and reporting, and pre-licensing readiness.