Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
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Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0222
Based on observation and interview, it was determined the facility failed to ensure egress doorswith delayed-egress locking systems had required indicating signage displayed on the doors,affecting one of five levels within the component.
Findings include:
1. Observation made on June 24, 2026, at 12:35 p.m., revealed the west wingdelayed-egress stair tower doors on fifth and fourth floors, lacked the required signage that states:
PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS.
Exit interview with the Administrator and Director of Facilities Operations on June 24, 2026, at 1:00 p.m., confirmed the missing door signage.
| | Plan of Correction - To be completed: 07/20/2026
Delayed egress signage will be added to west stair tower doors on fourth and fifth floor
As a part of the Maintenance Supervisor's quarterly inspection protocol, the Facility Operations Department will inspect this area to ensure signage is posted.
Director of Facility Operations and/or delegate will report areas of concerns, findings, and corrections to the Quality Assurance Performance Improvement (QAPI) Committee for the next two quarters.
Disclaimer:
Preparation and/or execution of this entire Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this Statement of Deficiencies. The entire Plan of Correction is prepared and/or executed solely because it is required by the provisions of Federal and State laws.
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