Comfort Assisted Living Home 2, LLC

Based on observations, documentation review, 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. 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 Officer observed that when the patio door was opened, no alarm sounded to alert employees that a person was entering or exiting the facility. 3. E1 reached up and turned the switch on and and the patio door alerted. 4. A documentation review of the facility's Policies and Procedures titled, "Wandering" and "Equipment and Inspection Maintenance", revealed that the facility was responsible for ensuring that the patio door alert worked properly. 5. In an interview, E1 reported that the patio door alarm was turned off because it would startle the residents. E1 acknowledged that personnel would not be alerted to a resident exiting the facility due to the lack of alarm or alert on the patio door.