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Based on observation the facility failed to provide adequate smoke barrier.

The inspector observed, while accompanied by The Director of Intake during the hours of the inspection from 1:30 PM to 5:30 PM on 08/25/2015 that there was the following issues:

A.)There was missing fire rated sealant/ caulking missing at one of the above ceiling of the fire rate and smoke barrier cross corridor door.
B.) The middle cross corridor doors into the adolescent unit on hold open was not released upon the fire alarm system test.
C.) The cross corridor door located at the smoke barrier compartment was not fully closed at PICU unit.

The inspector observed, while accompanied by The Director of Intake during the hours of the inspection from 1:30 PM to 5:30 PM on 08/25/2015 that there was the following issues:

A.) The door stop was utilized at the one hour fire rated electrical room. Please remove door stop.

The inspector observed, while accompanied by The Director of Intake during the hours of the inspection from 1:30 PM to 5:30 PM on 08/25/2015 that there was the following issues:

A.) The door into the courtyard which have no exit access to the public way did not have a signage " Not an Exit " provided.

Based on observation the facility failed to maintain the fire alarm system operation.

The inspector observed, while accompanied by The Director of Intake during the hours of the inspection from 1:30 PM to 5:30 PM on 08/25/2015 that there was the following issues:

A.) The K TYPE fire extinguisher inspection was overdue at the dietary suite.

The inspector observed, while accompanied by The Director of Intake during the hours of the inspection from 1:30 PM to 5:30 PM on 08/25/2015 that there was the following issues:

A.) The escutcheon plates of the sprinkler head assembly were missing at the electrical room, shower room of gym, therapy office.
B.) The sprinkler head at the storage room at PICU unit appeared to be less than 4 " from the wall. Please relocate the sprinkler head so that sprinkler head is more than 4 " from the wall.

The inspector observed, while accompanied by The Director Clinical Service, The Director of Nursing, and The Director of Intake during the hours of the inspection from 1:30 PM to 5:30 PM on 08/25/2015 that there was the following issues:



1) The Grounding system testing at inpatient areas on TDSHS form were not performed.
2) The letters indicating preferred customer status report in case of emergency situation for water and fuel source was not available.
3) Fire department inspection certificate was not available.
4) The facility did not provide adequate history of The HVAC filter inspection/ change logs.
5) The facility did not provide adequate history of Fire Drill logs for each shift quarterly for three shifts.
6) The Biomedical electrical semi-annual and annual inspection was overdue.
7) The facility did not provide adequate history of The Fire Alarm system testing inspection logs.
8) The facility did not provide adequate history of The Sprinkler system test inspection logs.
9) Some component of the generator annual system test was inadequate.

The inspector observed, while accompanied by The Director of Intake during the hours of the inspection from 1:30 PM to 5:30 PM on 08/25/2015 that there was the following issues:

A.) At the essential transfer switch location there was a missing battery powered light fixture.

" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.