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, the facility failed to meet egress door requirements for two of over five egress door pathways.
Findings include:
Observation on May 21, 2026, at 11:00 a.m., revealed the B wing north emergency exit door pathway and the A wing exit pathway had locked fences that required the use of a key to open from the egress side. Interview with two B wing staff revealed the staff members were unaware of the location of the key. Additional interview with three A wing staff members revealed the staff members were unaware of the location of the key.
Interview with the maintenance supervisor on May 21, 2026, at 11:00 a.m., confirmed the egress door deficiencies at the time of the survey.
| | Plan of Correction - To be completed: 07/20/2026
1. All existing staff will be reeducated by corrective action date, and annually thereafter, by maintenance director or designee regarding key locations and procedure to unlock the gate during an evacuation through the B wing north emergency exit door pathway and the A wing exit pathway with locked fences.
2. New hires will be educated upon hire, and annually thereafter, by the maintenance director or designee regarding key locations and procedure to unlock the gate during an evacuation through the B wing north emergency exit door pathway and the A wing exit pathway with locked fences.
2. Random audits will be conducted weekly for four weeks by maintenance director or designee to verify staff response
3. Audit results will be reviewed at the monthly Quality Assurance Performance Improvement (QAPI) Committee.
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