Complaint Investigation Report

Allegation: Facility locking residents in facility. Complaint alleges that Fire Crew observed a dead bolt lock on the front door that required a key to open from the inside, locking residents in the facility.

LPA reviewed a report from local authorities, dated 10/28/22. which includes a photo taken of the inside of the front entrance door showing that a skeleton key type lock had been installed on the door frame and a photo of the key that was kept in a nearby drawer. On 10/28/22, LPA took photos of the facility front door showing a small hole on the right side of the door frame where an additional lock was installed. Administrator stated that she had just installed this additional lock because the door would not close properly.

On 12/15/22, LPA observed the hole on the door frame to have been filled and only (1) lock to be in place on the front door that is able to be unlocked from the inside without a key. LPA took a photo. Administrator stated to LPA on 12/15/22 that prior to receiving the facility license, the fire department approved the front entrance door as an entrance only and required (3) additional interior doors as well as (2) additional glass sliding doors to be installed to be in compliance with fire code. LPA observed exit signs posted above each glass sliding door (3) and also posted in each resident room indicating the exit route to be used to exit through the glass doors. LPA also observed an exit sign above the inside of the front entrance door.

On 12/15/22, LPA observed each glass sliding door to not have a locking mechanism in place and to be able to be opened easily. Administrator stated the doors have always had this specific non-locking mechanism. LPA interviewed resident (R1), who was awake during the early morning hours on 10/28/22 when 9-1-1 was called. R1 stated he has never had difficulty opening the glass sliding door in the common area from either the inside or outside patio area of the facility. There were no additional ambulatory residents able to be interviewed. Administrator Designee stated on 12/15/22 that the front entrance door at the facility is "always unlocked from the inside and always locked from the outside". The Administrator stated on 12/15/22 that the glass doors are "never locked" from the inside or outside and the doors have "always worked this way", asserting "the front door was "not considered an emergency exit" when fire issued their facility clearance during the licensing process. Fire clearance documentation shows the facility was approved for (6) non-ambulatory residents on 11-28-2017 and shows (4) designated or approved exits.

R1 stated to LPA that he is always able to open the glass door and it has "never been a problem", but he was not able to open the front door when 9-1-1 arrived on 10/28/22. LPA observed R1 to be able to ambulate without any assistive device.