Dignity Care Homes LLC

Based on document review, observation, 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. A review of department documentation revealed the facility was licensed for directed care services. 2. During a tour of the facility, the Compliance Officer observed the back door leading to the backyard was equipped with two devices to alert employees of the egress of a resident; however, the alarms were not audible at the time of the inspection. In an interview, E2, the caregiver on duty was unable to determine if they sounded or where. 3. During the inspection, E1 arrived and determined the alert sounded on a control panel in a hallway, at the front of the house. It was very low and not audible outside of the front hallway and entrance area. 4. In an interview, E1 acknowledged that the facility did not have a way to control or alert employees of the egress of a resident from the facility on the back door. E1 further stated E1 would replace batteries in one of the devices and determine how to increase the volume of the other device.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months which posed a safety risk. Findings include: 1. During the review of the facility's documents that were requested earlier at the beginning of the compliance inspection revealed there was no documentation as evidence the facility had reviewed the disaster plan and documented as required during the past 12 months. 2. In an interview, E1 acknowledged there was no documented evidence the disaster plan was reviewed and documented as required in the past 12 months. This is a repeat deficiency from the compliance inspection conducted on November 30, 2022.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted at least once every three months on each shift and documented. Findings include: 1. During an interview, E1 reported and the review of the facility's work schedule revealed the facility had two shifts: First shift from 7:00 AM to 7:00 PM, and the second shift from 7:00 PM to 7:00 AM. 2. Review of the employee disaster drill documentation on each shift for the past 12 months revealed the second shift drills were dated March 15, 2023, June 26, 2023, and September 8, 2023. There was no other documentation available for review. 3. In an interview, E1 acknowledged the employee disaster drills were not conducted at least once every three months on the second shift, as required. This is a repeat deficiency from the compliance inspection conducted on November 30, 2022.

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 the facility's documentation revealed one evacuation drill, dated December 2, 2023 was conducted during the past 12 months. At the time of the compliance inspection records revealed the facility had residents during this 12-month time period. 2. In an interview, E1 acknowledged an evacuation drill for employees and residents was not conducted at least every six months, as required, during the past 12 months.