Caroline Baylon

Based on record review, documentation review, and interview, the manager failed to ensure a residency agreement included the policy and procedure for a resident to terminate residency. Findings include: 1. Review of R2's record revealed a residency agreement. The residency agreement stated; "Termination: The management will provide the resident or resident's representative 30 days written notice before terminating the residency agreement except in the following circumstances: a. The management will terminate the residency agreement without notice if the resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in the assisted living facility; the resident's medical or health needs require immediate transfer to another health care institution; the resident's care and service needs exceed the services the facility is licensed to provide; The management will terminate the residency agreement after providing 14 days written notice to a resident or the resident's representative for any of the following reasons; documented failure to pay fee's or changes; documented non-compliance with the residency agreement or internal facility requirements." 2. During an interview, E1 acknowledged R2's residency agreement did not include the correct policy and procedure for a resident to terminate residency.

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 E1, the compliance officers 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 controlling or alerting employees of the egress of residents to the outside area. 3. During an interview, E1 reported E1 was unaware of the identified rule. E1 acknowledged the patio door exiting to the outside area did not have a means of controlling or alerting employees to egress. E1 reported E1 used a wooden rod to place in the door to stop the door from opening. E1 acknowledged this wooden rod could be removed by the compliance officer and a resident. 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.