Rule/Regulation Violated:
F. A manager of an assisted living facility authorized to provide directed care services shall ensure that:
2. There is a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort that meets one of the following:
a. Provides access to an outside area that:
i. Allows the resident to be at least 30 feet away from the facility, and
ii. Controls or alerts employees of the egress of a resident from the facility;
Evidence/Findings:
Based on documentation review, observation, and interview, the manager failed to ensure 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 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 egress of a resident from the facility.
Findings include:
1. A review of Department documentation revealed the facility was authorized to provide directed care services.
2. During the environmental inspection of the facility, the Compliance Officers observed a sliding glass door in the master bedroom. The Compliance Officers observed the door did not have a control installed but did have an alert installed. However, upon opening the door, the Compliance Officers observed the alert did not sound.
3. In an interview, E3 reported R1 wandered throughout the facility often, stating, "[R1's] everywhere." E1 acknowledged the door did not control or alert employees of the egress of a resident from the facility.
Summary:
The following deficiency was found during the on-site abbreviated initial follow-up inspection attempted on August 15, 2024, and completed on September 4, 2024: