Shea Estates Assisted Living

Based on documentation review, record review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, the 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 to the outside area allowing the resident to be at least 30 feet away from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of R1's and R2's medical records revealed service plans indicating R1 and R2 received directed care services. 3. During the environmental inspection of the facility, the Compliance Officer observed an unlocked door which led from an unoccupied resident bedroom in the northwest corner of the facility, out into the facility's front driveway. The door into the unoccupied bedroom was unlocked, and the door leading from the bedroom to the facility's driveway did not have a mechanism to alert employees of the egress of a resident from the facility. The Compliance Officer observed the driveway was connected with the facility's front yard and a public street. The front yard allowed residents to be at least 30 feet away from the facility. 4. In an interview, E1 reported the facility had just replaced the door in the unoccupied bedroom at the beginning of August 2023. E1 reported the facility had not yet installed an alert mechanism on the door because they were waiting for all other doors to be replaced first. E1 reported no residents at the facility were at risk for wandering, but the facility would install a lock to control egress from the door. E1 acknowledged the door was not controlled and did not alert employees of the egress of a resident from the facility.