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 (ORIGINAL & SUBACUTE CARE BLDG) - Component: 01 - Tag: 0222
Based on Observation and interview, it was determined the facility failed to maintain delayed egress doors, affecting two of four levels in the facility.
Findings include:
Observations on June 15, 2026, between 9:36 am and 10:06 am, revealed the delayed egress doors failed to open in the following locations:a. 9:36 am, first floor, Stair 3;
b. 10:06 am, third floor, Center Stairwell.
Exit interview with the Administrator and the Maintenance Director on June 15, 2026, at 10:15 am, confirmed the doors failed to open.
| | Plan of Correction - To be completed: 07/24/2026
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truths or facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared in accordance with federal and state law requirements.
K222
-The delayed egress doors were repaired in the following locations: first floor, Stair 3 and third floor, Center Stairwell to ensure proper function.
-The egress doors in the facility will be audited to ensure proper function.
-The Plant Director was educated on the requirements for the opening of delayed egress doors.
-The Plant Director/designee will audit monthly for three months that the delayed egress doors open. The review findings will be reported at the monthly Quality Assurance and Performance Improvement meeting.
-To be completed by 7/24/2026.
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