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Based on observations and staff interview it was determined the facility failed to maintain the protection for the natural gas piping, in accordance NFPA 101. Specifically, 18.5.1.1 9.1.1 Gas equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. Utilities shall comply with the provisions of Section 9.1. NFPA 54, National Fuel Gas Code, 2012 edition. The deficiency affected two of two smoke compartments.

These failures created the likelihood of serious adverse outcomes for all patients, staff, and visitors if any failing exterior cladding were to dislodge then strike the exposed natural gas piping, which located in an area beneath where façade materials had fallen.

Findings include:

I. Immediate Jeopardy

A. Findings of Immediate Jeopardy

Regulatory Requirements
7.2 Installation of Piping.

7.2.1 Piping installed aboveground shall be securely supported and located where it will be protected from physical damage. Where passing through an exterior wall, the piping shall also be protected from corrosion by coating or wrapping with an inert material approved for such applications. The piping shall be sealed around its circumference at the point of the exterior penetration to prevent the entry of water, insects, and rodents. Where piping is encased in a protective pipe sleeve, the annular spaces between the gas piping and the sleeve and between the sleeve and the wall opening shall be sealed.

Observation and Interview
The exterior of the off-campus location building was observed with staff #1. Observation revealed:
- The building exterior cladding/façade that consisted of brick, stone veneer, and precast concrete. Precast concrete, brick and stone veneer had fallen from multiple areas of the building façade. Veneer was observed to be missing from both upper and lower floors of the building exterior.
- Natural gas pipe ran, exposed and uncovered, along the exterior of the building. Directly above the exposed gas piping, a row of precast concrete was missing. Above the gas piping, there were three additional rows of the precast concrete and approximately nine feet of the brick or stone veneer.

Staff #1 confirmed that the falling façade could strike the exposed natural gas piping. Staff #1 acknowledged such a strike could break the exposed natural gas pipe causing a gas leak and/or an explosion. Staff #1 was unable to determine if the missing precast concrete above the gas piping had fallen off or if it was removed for safety reasons. Staff #1 indicated the failing veneer/exterior cladding was a result of installation problems when the building was constructed fewer than 10 years ago. The problems with the exterior façade had only become apparent in recent months, according to staff #1.

B. Notification of Immediate Jeopardy
Staff #1 was informed of the immediate jeopardy on 4/30/2025 at 11:50 a.m.

C. Facility Plan to Remove Immediate Jeopardy
The plan to remove immediate jeopardy, provided via email by staff #2, read:
"Plan of Correction: Northglenn FSED, 4/30/25, 3:30 pm

Noncompliance:
The exterior of the building has compromised construction. There is brick falling on all sides of the building. Brick has fallen from the top of the building which is a 3-story building. The natural gas emergency generator piping is not protected from falling construction materials.
1. Galvanized metal coverings will be installed over the horizontal sections of the gas pipe identified. These metal coverings will not touch the pipe and will be secured to the wall/overhangs.
2. This work will be completed no later than 6:00 pm tonight. The supplies have been purchased, and the contractor is onsite and has already begun the work.

Serious injury, serious harm:
The natural gas piping not being protected from falling debris could cause significant issues in the building, as the emergency generator could not function properly and could cause an explosion that would be very dangerous to the patients and staff.
1. Galvanized metal coverings will be installed over the horizontal sections of the gas pipe identified. These metal coverings will not touch the pipe and will be secured to the wall/overhangs.
2. This work will be completed no later than 6:00 pm tonight. The supplies have been purchased, and the contractor is onsite and has already begun the work.

Need for Immediate Action: To ensure that the natural gas piping is protected from falling debris and damage.
1. Galvanized metal coverings will be installed over the horizontal sections of the gas pipe identified. These metal coverings will not touch the pipe and will be secured to the wall/overhangs.
2. This work will be completed no later than 6:00 pm tonight. The supplies have been purchased, and the contractor is onsite and has already begun the work."

Based on the submitted plan, the facility was notified the immediate jeopardy was removed on 4/30/2025 at 4:39 p.m.