LOYALE ASSISTED LIVING

Based on documentation review, observation, and interview, the manager failed to ensure the 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, 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. During the facility tour with E2, the compliance officer observed a patio door that led to an outside area, in the backyard, allowed residents to be a least 30 feet away from the facility. The door leading out to the backyard did not have a means of alerting employees of the egress of residents to the outside area.

3. During an interview, E1 and E2 reported E1 and E2 were unaware the identified rule. E1 acknowledged the patio door exiting to the outside area did not have a means of alerting employees to egress. E1 acknowledged the manager failed to ensure the 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, controlled or alerted employees of the egress of a resident from the facility.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented.

Findings include:

1. A review of the facility's documentation identified the facility's work schedule identified as the following:

7 am-7 pm
7 pm-7 am

2. A documentation review of the facility's disaster drills revealed the last documentation disaster drill was conducted on the following dates:

December 2, 2022, at 2:50 am
December 24, 2022, at 8:25 am, 1:20 pm and 7:20 pm

3. In an interview, E2 reviewed the identified disaster drills and acknowledged the drills were last documented as conducted in December 2022. E2 reported no additional drills were available for review. E1 acknowledged the disaster drills were not conducted on each shift at least once every three months.

4. In an interview, E1 reviewed the identified disaster drills and acknowledged the drills were last documented as conducted in December 2022. E1 reported disaster drills were conducted since December 2022 however E1 could not locate the documented drills. E1 reported no additional drills were available for review.