F0689

D

Exit Door Alarm on Hall 100 Found Disabled, Creating Elopement Hazard

San Antonio, Texas Survey Completed on 03-07-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to accident hazards and inadequate supervision when the exit door alarm on hall 100 was found turned off. Record review showed there were 14 residents on hall 100 out of a total facility census of 47 residents. During an observation around midday, staff were present in the hallway and four resident room doors were open, with two residents in bed and two in wheelchairs; these residents were observed to be non-ambulatory and unable to move their wheelchairs independently. Later that afternoon, during a joint observation and interview with the Maintenance Director, seven exit doors were checked, and the exit door at the end of hall 100 did not alarm when the release bar was pushed and the door opened.

The Maintenance Director used a key to turn on the mounted red exit door alarm, after which the alarm functioned properly. He stated he did not know why the alarm had been off and reported that CNAs had copies of the key and would occasionally use that door to let residents out for smoking breaks or to take residents out because it was closer to the ramps. He also stated he checked the doors every Monday and that this was the first time he had found an unsecured door. The DON stated her expectation was that staff would turn door alarms back on after disabling them with a key and acknowledged that if an alarm was disabled, residents could get out the door without staff knowing. The Administrator stated she expected fire exit doors to alarm when the handle was pushed and indicated staff would not have a reason to disable an alarm unless taking something out the back of the facility. Facility policy on wandering and elopements indicated the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.