Follow-up·May 7, 2025

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Case Management - Other visit. LPA met with Administrator, Lynn Torino and discussed the purpose of the visit. The facility submitted a request for delayed egress exits in the facility's East Building on the first, and third floors, only. On 02/20/25, the fire department inspected, verified, and granted the delayed egress exits, for the requested areas. Today, LPA toured the first, second, and third floors and observed delayed egress on each floor. One of the delayed egress exits located on the third floor was not working. The Environmental Services Director stated it was inoperable and they needed to order parts. They were not aware it was inoperable, until LPA made them aware. LPA reviewed the facility's sketch requesting delayed egress. The second floor was not included on the sketch to identify delay egress will be in use. LPA spoke with the Executive Director (ED), Reginald Jones via telephone, while at the facility. The ED stated they walked each floor of the East Building with the Fire Marshal and it was confirmed the facility could use delayed egress on the first, second, and third floor. Therefore, they have been using delayed egress on all three floors. LPA confirmed with the Fire Marshal that the facility sketch was followed to grant the fire clearance for delayed egress on two of the four floors. The Fire Marshall confirmed the facility never had approval for delayed egress on the second floor. As of today, the ED requested staff cease the use of delayed egress on the second floor and understood it must be approved by the fire department before operating. LPA also observed the first floor was made a secured floor by the use of key pad located by the elevator. The key pad requires a code in order to exit the first floor by elevator. Only staff have the key code. If residents want to leave the floor they require staff to escort them and enter the code to exit. Staff explained the first floor of the East building is being made into a another memory care unit. However, the licensee did not apply for secured/locked perimeter on the first floor. Continued on an LIC 809C. The ED was made aware and under the assumption delayed egress was the same as secured perimeter. The ED requested today that the staff disable the key pad on the first floor, until approved. Today, the ED had staff appointed to oversee the elevator, while the key pad is deactivated to ensure residents with a Major Neurocognitive Disorder are safe from elopement and harm. The ED was made aware the delayed egress and secured perimeter require the fire department's approval. The ED was also made aware civil penalties are being assessed and will continue until corrected, by submission of applications. deficiencies were issued along with civil penalties. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Lynn Torino whose signature below confirms receipt of these rights.