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During the survey, the following is an example of what was observed:

An Exit sign was observed at the door to the Doctor's Dictation Office, thus providing exiting from the facility through this office.

NFPA 101 7.5.1 General

7.5.1.1 Exits shall be located and exit access shall be arranged so that exits are readily accessible at all times.

7.5.1.2* Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel. Exit access corridors shall provide access to not less than two approved exits without passing through any intervening rooms other than corridors, lobbies, and other spaces permitted to be open to the corridor.

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The facility failed to maintain the fire alarm system in proper working order. Findings include: During the survey, the following is an example of what was observed:

The audible device in the OR was not operable during the test of the fire alarm system.


2000 NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
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