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Based on observation the facility failed to indicate on the face of the Fire Alarm Control Panel (FACP) the panel name and circuit number that provides power to the FACP and the mark the circuit breaker that provides power to the Fire Alarm system in red within the panel, as required by:

NFPA 72(1999)1-5.2.5.2.

The Facility Director stated on 02/22/23 at 2:45pm that the facility would make required revisions.
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Based on observation the facility failed to provide a fully functioning exhaust system throughout the facility, as required by:

Department of State Health Services, Facility Licensing Group, Title 25, Texas Administrative Code, Chapter 133, Hospital Licensing State Regulations
§133.162. New Construction Requirements.
(d)(3)(D) Heating, ventilating and air conditioning (HVAC) systems. All HVAC systems shall comply with and shall be installed in accordance with the requirements of National Fire Protection Association 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, 2002 edition, (NFPA 90A), NFPA 99, Chapter 6, the requirements contained in this subparagraph, and the specific requirements for a particular unit in accordance with §133.163 of this title.

(i) General ventilation requirements. All rooms and areas in the hospital listed in Table 3 of §133.169(c) of this title shall have provision for positive ventilation. Fans serving exhaust systems shall be located at the discharge end and shall be conveniently accessible for service. Exhaust systems may be combined, unless otherwise noted, for efficient use of recovery devices required for energy conservation. The ventilation rates shown in Table 3 of §133.169(c) of this title shall be used only as minimum requirements since they do not preclude the use of higher rates that may be appropriate. Supply air to the building and exhaust air from the building shall be regulated to provide a positive pressure within the building with respect to the exterior.

(VII) Areas requiring fully ducted systems. Fully ducted supply, return and exhaust air for HVAC systems shall be provided for all critical care areas, sensitive care areas, all patient care areas, all areas requiring a sterile regimen, storage rooms, food prepar

911
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Based on observation the facility is to be commended for employing Nurse Call Technicians to repair a non-opearable system at certain locations. Please provide an Acceptance Letter from the Manufacturer/Installer stating that a fully functioning nurse call system is currently provided, as required by:

NFPA 99, 2002: 4.4.2.2.2.3 ..... The critical branch ... (5) nurse call systems.

Department of State Health Services, Facility Licensing Group, Title 25, Texas Administrative Code, Chapter 133, Hospital Licensing State Regulations
§133.162. New Construction Requirements.
(d)(5)(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 corri