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Based on observation and interview during the survey of the facility on 04/19/23 with the Assistant Director of Maintenance, the facility failed to provide at least a 1 hour fire resistance rating at required rooms per NFPA 101, 8.2.3.2.2 and 21.3.7.1.

Observation on 04/19/23 revealed holes and unsealed penetrations at several locations at rated walls in the adjacent facility, as required by:

NFPA 101: 8.3.5.1 ..... Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.

In an interview on 04/19/23, the Assistant Director of Maintenance stated that the holes will be properly sealed.

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Based on observation and interview during the survey of the facility on 04/19/23 with the Assistant Director of Maintenance, the facility failed to provide at least a 1 hour fire resistance rating at required rooms per NFPA 101, 8.2.3.2.2 and 21.3.7.1.

Observation on 04/19/23 revealed holes and unsealed penetrations at several locations at rated walls in the adjacent facility, as required by:

NFPA 101: 8.3.5.1 ..... Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a fire barrier shall be protected by a firestop system or device.

In an interview on 04/19/23, the Assistant Director of Maintenance stated that the holes will be properly sealed.

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Based on observation and interview during the survey of the facility on 04/19/23 with the Assistant Director of Maintenance, the facility failed to provide verification the fire extinguishers throughout the facility are inspected monthly.

Observation on 04/19/23 revealed the inspection tags at fire extinguishers had not been marked in March or April of 2023. Please verify required inspection has been performed and provide Fire Extinguisher Inspection Logs for 2023 and 2022.

In an interview on 04/19/23, the Assistant Director of Maintenance stated that the logs will be provided.

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Based on observation and interview during the survey of the facility on 04/19/23 with the Assistant Director of Maintenance, the facility failed to provide Fire Drill documentation.

Please provide required Fire Drill Documentation for 2023 and 2022.

In an interview on 04/19/23, the Assistant Director of Maintenance stated that the documents will be provided.

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Based on observation and interview during the survey of the facility on 04/19/23 with the Assistant Director of Maintenance, the facility failed to provide Door Inspection Logs and it appeared doors and frames without proper tags were installed at rated partitions.

Please provide Door Inspection Logs for 2023 and 2022 and verify the correct doors and frames with proper identification are installed at corresponding rated walls.

In an interview on 04/19/23, the Assistant Director of Maintenance stated that the logs will be provided.

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Based on observation and interview during the survey of the facility on 04/19/23 with the Assistant Director of Maintenance, the facility failed to provide a fully functioning Nurse Calling System throughout the facility.

Observation on 04/19/23 revealed a non-functioning nurse call during the testing of the system. Please verify the entire Nurse Calling System is functioning correctly, as required by:

(L) Nurses calling systems. Three different types of nurses calling systems are required to be installed in a hospital: a nurses regular calling system; a nurses emergency calling system; and a staff emergency assistance calling system. The hospital shall comply with the requirements of this subparagraph in addition to any specific requirements for nurses calling systems for the particular unit of the hospital in accordance with §133.163 and Table 7 of §133.169(g) of this title. Where required in this subparagraph, a distinct visible signal is provided when a colored dome light lamp, or particular combination of colored lamps is used for only one type of call. Different flash rates do not meet this requirement.

(i) A nurses regular calling system is intended for routine communication between each patient and the nursing staff. Activation of the system at a patient's regular calling station will sound a repeating (every 20 seconds or less) distinct audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The audible signal shall be canceled and two-way voice communication between the patient room and the nursing staff shall be established at the unit's nursing station when the c