Clarendale Arcadia

Based on the documentation review and interview, the manager failed to ensure that policies and procedures were established, documented, and implemented to ensure the safety of residents who may wander. Findings include: 1. A review of Department documentation revealed AL12431 was licensed to provide directed care services. 2. A review of the facility's policies and procedures revealed that no policy was established to cover the safety of residents who may wander. The Compliance Officer was provided a document titled "Missing Resident Policy;” however, the policy did not include how the facility would ensure the safety of residents who may wander. 3. In an interview, E1 acknowledged that the "Missing Resident Policy" did not include how the facility would ensure the safety of a wandering resident.

Based on the record review, documentation review, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. 1 A review of R1's and R2’s medical records revealed that R1 and R2 received directed care services 2. A review of R1’s service plan dated May 14, 2025, revealed a section titled “wandering/ Elopement risk”, it stated that “R1 has a current or history of wandering within the residence or facility and may wander outside, but does not jeopardize health or safety (of self or others).” 3. A review of R2’s service plan dated March 13, 2025, revealed a section titled “wandering/ Elopement risk”, it stated that “R2 has a current or history of wandering within the residence or facility and may wander outside, but does not jeopardize health or safety (of self or others).” 4. A review of facility documentation revealed an incident report dated May 5, 2025. The incident report stated that “the welcome desk attendant noted that at approximately 2:55 PM, a resident walked into the community via the front door, accompanied by another resident. The resident presented no distress and asked for assistance getting back home. The welcome desk attendant immediately called the Memory Care Director to report the two Memory Care residents at the welcome desk. The Memory Care Director arrived at the front desk and escorted the residents back into Memory Care. No sign of pain or discomfort noted, no signs of distress. The resident stated I was out on a walk. Upon assessment, no injuries were noted. Further investigation revealed that the residents had walked out of Memory Care unnoticed around 2:47 PM, as witnessed by surveillance cameras, due to an unlocked door that was in use for a move-out. The door was immediately locked, and the alarms were turned on.” 5. In an Interview, E1 reported that R1 and R2 got out when the doors were used for a move-out at the facility. E1 acknowledged that there was no means of exiting the facility that controlled or alerted employees of the egress of the resident. This is a repeat deficiency from a complaint inspection conducted on June 28, 2023

Based on documentation review and interview the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1 . A review of facility documentation revealed documentation of an evacuation drill conducted in July 2024. However, documentation of an evacuation drill conducted after July 2024 was not available for review at the time of inspection. 2 . In an interview, E1 reported E1 had no documentation of an evacuation drill conducted after July 2024. E1 acknowledged an evacuation drill was not conducted at least once every six months as required.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a lockable cabinet under the kitchen sink in the "Mountain Vista" common room. When the Compliance Officer pulled on the cabinet door, it was unlocked. Inside the cabinet was a bottle of "Spic and Span" disinfecting all-purpose spray. 2. During an environmental inspection of the facility, the Compliance Officers observed a door with an electronic lock with a sign next to the door labeled "Housekeeping." When the Compliance Officer pulled on the doorknob, the door opened. Inside the room was an electronic unit to dispense cleaning agents, which included "Spic and Span" disinfecting all-purpose spray, and "Mr.Clean" finished floor cleaner. 3 . During an environmental inspection of the facility, the Compliance Officers observed a lockable cabinet under the kitchen sink in the memory care kitchen area. When the Compliance Officer pulled on the cabinet door, it was unlocked. The cabinet contained the following: -A bottle of "Spic and Span" disinfecting cleaner; -A bottle of "Comet" disinfecting-sanitizing cleaner; -A can of "Scrubbing Bubbles" Multi-purpose cleaner; and -A can of "Zep" carpet and upholstery spot remover. 4 . During an environmental inspection of the facility, the Compliance Officers observed a lockable cabinet near a washer and dryer in a common area of the memory care unit. When the Compliance Officer pulled on the cabinet door, it was unlocked. Inside was a bag of "Gain Flings" laundry detergent pods. 5 . In an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility were accessible to residents.

Based on documentation review, record review, 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 controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. Review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. Review of a document titled "Incident Investigation Report" dated June 17, 2023 stated "On 6/17/23 at approximately 4:00pm an Independent Living resident entered the community with (R1) and approached the front desk. The IL resident explained to the desk attendant that (the IL resident) came across (R1) in the south parking lot...Upon being notified of the elopement, the Executive Director immediately began an investigation. It was discovered that a staff member used an exit door that should not have been used and failed to ensure it was fully closed. This door is operated using a key fob and, when operating properly, automatically closes. The auto function failed in this instance, thus leaving the door ajar and allowing (R1) to exit the community and find (R1's) way to the south parking lot." 3. During an interview, E1 acknowledged on June 17, 2023, there was not a means of exiting the facility that controlled or alerted employees of the egress of R1.