Arcadia Assisted Care

Based on observation, record review, and interview, the governing authority failed to designate, in writing, a manager who either had a certificate as an assisted living facility manager issued under Arizona Revised Statutes (A.R.S.) § 36-446.04(C), or a temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06. The deficient practice posed a risk as the assisted living facility was unable to ensure compliance with applicable Rules. Findings include: 1. During the environmental inspection of the facility, the Compliance Officer observed a temporary assisted living facility manager's license for R1 with an issue date of July 16, 2025, posted in the facility. 2. A review of E1's personnel record revealed E1 had received their temporary assisted living facility manager's license on July 16, 2025. 3. In an interview, E3 reported they had been the manager for 15 years at the facility, and their assisted living facility manager's license had expired on May 7, 2025, and the facility was without an assisted living facility manager from May 7, 2025, until E1 was issued their temporary assisted living facility manager's license on July 16, 2025. 2. In an interview, E1 and E3 acknowledged the facility was without an assisted living facility manager from May 7, 2025, to July 16, 2025.

Based on documentation review, record review, and interview, the manager failed to establish, document, and implement policies and procedures that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility was authorized to provide. Findings include: 1. A review of Department documentation revealed the license issued by the Department stated the facility was authorized to provide directed care services. 2. A review of the facility's policies and procedures revealed no policy to include the methods by which the assisted living facility is aware of the general or specific whereabouts of a resident. The facility policies and procedures only included a policy titled "Wandering." This policy did not cover methods by which the assisted living facility was aware of the general or specific whereabouts of a resident. 3. A review of resident records revealed a document titled "Front Door Entrance Key Authorization." The document revealed residents were in possession of a key to the front door and could leave and reenter the facility at any time. 4. In an interview, E1 reviewed the facilities policies and procedures. E1 acknowledged E1 could not locate the policy that covered methods by which the assisted living facility was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident. E1 reported residents have left the facility independently and the facility was not aware of the residents whereabouts until the resident returned. E1 acknowledged a policy was not available that established, documented, and implemented methods by which the assisted living facility was aware of the general or specific whereabouts of a resident.

Based on documentation review, observation, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, that provided access to an outside area that allowed residents to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During the facility tour with E1, the surveyor observed the front door, allowed residents to be a least 30 feet away from the facility. The door was locked by a key that maintained by caregivers and personal care resident. The door however did not have a device that was intended to alert employees to the egress of a resident to the outside area. 3. During an interview, E1 acknowledged personal care residents have been provided a key to the access the front door and leave the facility without the door alerting the facility to the residents egress. E1 acknowledged the front door exiting the facility did not have a device that was intended to alert employees to the egress of the resident.