Based on interview and observation, it was confirmed the facility failed to ensure exit door alarms or other acceptable system is provided for security purposes and to alert staff when residents exit the RCF. Findings include, but not limited to:

On 6/28/2022 Compliance Specialist (CS) observed facility exit doors to the MCC outdoor courtyards open and close multiple times with no audible alarms or system in place to alert onsite staff.  

Separate interviews with Staff #1 & 2 (S1-S2) on 6/28/2022, stated that when doors from the facility to the outside courtyard are opened, they are supposed to get an alert on an iPad or IPhone located at the front desk who then alerts staff. S1 showed this CS the iPad system and the phones that they are to get the alerts on and there were no alerts that came through when this CS opened the patio doors.

Findings were reviewed with S1 and acknowledged on 6/28/2022 with Staff #1& Staff#3

Facility Plan Of Care Correction

Administrator stated the company who provides the system will be contacted 6/28/2022 to get them out to look at the system and fix as quickly as possible. Sustainable plan once system is repaired will be to check system monthly.