HospitalInspections.org

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the one-hour fire rating protection to the building structure. This deficient practice could affect all patients, staff and visitors should the fire protection rating of the building structure not be adequate to withstand fire exposure, as originally designed. This was evidenced by the following:

A) Spray-on cementitious fireproofing (Monocoat) was not maintained at minimum thickness to achieve one-hour minimum rating, as required. Structural steel was observed to have missing sections of spray-on fireproofing in the first floor MRI shell space/storage room.
Grace Construction Products spec/data sheet 07812 item #1 product name: Monokote. Item 8-Maintenance: " No maintenance is required. Contact a qualified Monokote contractor to patch areas of fireproofing material disturbed by later activity. "

B) Gypsum board membrane protection was not maintained, as required. The second floor nurse's storage room was observed to have a 5" x 10" section of gypsum board cut out of the protective membrane.
Engineering staff acknowledged the missing fireproofing during a tour of the facility, and reported that the gypsum board had been cut out due to a recent roof leak.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3. This deficient practice could affect all patients, staff and visitors within the atrium area should the area become untenable for egress due to smoke transfer via unprotected openings to the corridor. This was evidenced by the following:

Use areas were not separated from the corridor by doors that could be closed with a push or a pull, as required. The second floor outpatient reception area was equipped with two roll down doors that were arranged with an operating switch (to open or close) inside the reception area. The door release switches were not accessible from the corridor side of the doors which would prevent an occupant on the corridor side from closing the doors.
Engineering staff reported that smoke detectors, installed on the corridor/atrium side of the doors would activate the door release, in addition to the atrium smoke evacuation system.
Life Safety Code Section 18.3.6.3.3: Hold open devices that release when the door is pushed or pulled shall be permitted.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 19.3.6.3. This deficient practice could affect all patients, staff and visitors within the west smoke compartment should the egress corridor become untenable due to smoke transfer via the non-latching doors separating rooms from the egress corridor.
This was evidenced by the following:

A) Corridor doors were not equipped with positive latching hardware, as required. The radiology suite corridor doors (power-operated double door set-across from emergency department) were not equipped with positive latching hardware.

B) The wiring closet corridor doors were not arranged to automatically latch into the door frame, as required. The wiring closet (across from the sleep lab) was equipped with double doors separating the closet from the corridor. One of two door leafs was not equipped with automatic latching hardware. The leaf equipped with the latchset was arranged to latch into the " fixed " door leaf that was equipped with manual latching hardware. If the manual latching hardware was not engaged, neither leaf would be positively latched.
Engineering staff acknowledged the door latching arrangement during a tour of the facility.
The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Latching devices must not require the use of keys or special tools.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain vertical opening enclosures in accordance with Life Safety Code Section 18.3.1.1 and Section 8.2.5. This deficient practice could affect all patients, staff and visitors within the atrium area should the area become untenable for egress due to smoke transfer via unprotected openings to the atrium/corridor.
This was evidenced by the following:

Atrium separation doors were not maintained to positively latch, as required. One of two 90 minute rated atrium separation doors (first floor-north) would not positively latch into the door frame, as required. Engineering staff acknowledged the non-latching door during a tour of the facility.
Life Safety Code Section 8.2.5.6 requires, in part, that atrium opening protectives meet the requirement for installation within corridor walls.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to mark access to exits in accordance with Life Safety Code Section 19.2.10.1 and Section 7.10. This deficient practice could affect staff occupying the first administration area if the way to reach the exit is not readily apparent to the occupants.
This was evidenced by the following:

Illuminated exit signs were not installed where the way to reach the exit was not readily apparent to occupants. Three additional exit signs are required in the exit access corridor, first floor outside the medical records area, at two corridor intersections and at the exit door to the ramped corridor.
Engineering Staff acknowledged the means of egress signage deficiencies during a tour of the facility.
The Life Safety Code Section 7.10.1.4 requires that access to exits be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to construct new enclosures in accordance with the Life Safety Code Sections 19.3.2.1, 4.67, and 8.4. This deficient practice could affect patients, staff and visitors on both the first and second floors, should there be smoke and heat transfer between the hazardous area and the egress corridor.
This was evidenced by the following:

A) Door openings in newly constructed hazardous areas were not a minimum of 45 minute fire rated, as required. The newly constructed MRI first floor shelled/storage hazardous area was separated from the corridor by non-fire rated doors.

Engineering Staff acknowledged the protection of the newly constructed hazardous areas during a tour of the facility.
The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 19.3.2.1 and Section 8.4. Section 8.4.1.3 requires that doors in fire rated barriers have a minimum ? hour fire resistance rating and that the doors be self-closing or automatic closing. Rated fire doors must positively latch into the door frame in accordance with NFPA 80.
Life Safety Code Section 4.6.7 requires, in part, that altered, modernized or renovated portions of an existing building, system or individual component meet the applicable code requirements for new construction.

B) The corridor door to dietary storage room #235 was not equipped with a self-closer, as required.
Section 19.3.6.3.2 requires that corridor doors be provided with a means suitable for keeping the door closed.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to install and maintain horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 18.2.2.5 and 7.2.4. This deficient practice could affect patients, staff and visitors on the second floor, should there be smoke and heat transfer between the two buildings. This was evidenced by the following:

A) Cross-corridor horizontal exit doors did not positively latch, as required. One of two door leafs (door set S2N) did not latch into the door frame when tested.
Life Safety Code Section 8.2.3 requires that fire doors be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

B) Two hour fire rated separation walls were not maintained, as required. The second floor patient sleeping wing separation wall (above corridor doors-both north and south corridors) were observed to have unsealed penetrations.
1. Above the corridor doors, near room 234, unsealed 1/2 inch gap around an electrical conduit penetration.
2. Above the corridor doors (N2C) an unsealed 3 inch low-voltage conduit. Fire stopping had been installed, but was pulled out on both sides of the conduit.
The unsealed penetrations were acknowledged by Engineering Staff during a tour of the facility.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to install and maintain horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 19.2.2.5 and 7.2.4. This deficient practice could affect patients, staff and visitors on the second floor, should there be smoke and heat transfer between the two buildings. This was evidenced by the following:

A) Cross-corridor horizontal exit doors did not positively latch, as required. One of two door leafs (door set S2N) did not latch into the door frame when tested.
Life Safety Code Section 8.2.3 requires that fire doors be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

B) Two hour fire rated separation walls were not maintained, as required. The second floor patient sleeping wing separation wall (above corridor doors-both north and south corridors) were observed to have unsealed penetrations.
1. Above the corridor doors, near room 234, unsealed 1/2 inch gap around an electrical conduit penetration.
2. Above the corridor doors (N2C) an unsealed 3 inch low-voltage conduit. Fire stopping had been installed, but was pulled out on both sides of the conduit.
The unsealed penetrations were acknowledged by Engineering Staff during a tour of the facility.

2007 Building (Aspen ID: A-2)
Based on record review and staff interview during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 18.7.1.2 and 4.7. This deficient practice could affect all patients when staff are not trained in the emergency actions required during the unusual conditions that can occur in an actual emergency. This was evidenced by the following:

A) A coded announcement was not used as a substitute for audible alarms, as required. Engineering Staff reported that the fire alarm was not sounded during drills on the overnight shift and that a coded announcement was not used as a substitute.

B) Fire drills were not conducted at unexpected times and under varying conditions, as required. A review of fire drill records for the prior 12 month period documented the following drill times:

First Shift (0700 - 1900):
01/31/13 - 1:20 pm
12/28/12 - 2:30 pm
10/31/12 - 1:20 pm
08/30/12 - 9:30 am
07/31/12 - 2:50 pm
06/28/12 - 1:50 pm

The Life Safety Code, Section 18.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Original 1975 Building (Aspen ID: A-1)
Based on record review and staff interview during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 19.7.1.2 and 4.7. This deficient practice could affect all patients when staff are not trained in the emergency actions required during the unusual conditions that can occur in an actual emergency. This was evidenced by the following:

A) A coded announcement was not used as a substitute for audible alarms, as required. Engineering Staff reported that the fire alarm was not sounded during drills on the overnight shift and that a coded announcement was not used as a substitute.

B) Fire drills were not conducted at unexpected times and under varying conditions, as required. A review of fire drill records for the prior 12 month period documented the following drill times:

First Shift (0700 - 1900):
01/31/13 - 1:20 pm
12/28/12 - 2:30 pm
10/31/12 - 1:20 pm
08/30/12 - 9:30 am
07/31/12 - 2:50 pm
06/28/12 - 1:50 pm

The Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect all patients, staff and visitors should the fire alarm system fail to function as designed. This was evidenced by the following:

The fire alarm control unit was observed to have a silenced trouble signal. The panel annunciated "Negative Earth Ground". Engineering Staff reported that the same condition had been corrected by the fire alarm maintenance company in January 2013.
NFPA 72, National Fire Alarm Code, Section 7-1.1.2 states "System defects and malfunctions shall be corrected."

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect all patients, staff and visitors should the fire alarm system fail to function as designed and fail to notify staff in all areas of the building.
This was evidenced by the following:

A) The fire alarm control unit was observed to have a silenced trouble signal. The panel annunciated "Negative Earth Ground". Engineering Staff reported that the same condition had been corrected by the fire alarm maintenance company in January 2013.
NFPA 72, National Fire Alarm Code, Section 7-1.1.2 states "System defects and malfunctions shall be corrected."

B) Fire alarm system visual notification appliances were not maintained in operable condition, as requires. The visual appliance (strobe) installed in the corridor (outside of the Emergency Department) was not functioning during a test of the fire alarm system.

C) Power-limited fire alarm wiring was not installed with cable splices inside a listed box or enclosure, and was not installed to assure maximum protection against physical damage, as required. Fire alarm wiring for the Medical Records corridor door magnetic hold device was observed to have exposed cable splices with wire nuts. The wiring was unsupported and looped over the wood arm that supported the magnet/junction box assembly. The unsupported wiring was less than 7 feet above the floor and was subject to damage.
NFPA 72 requires that fire alarm wiring be installed in accordance with NFPA 70, National Electric Code, Article 760. Article 760 requires that power-limited fire alarm circuit conductors and cables be installed such that cable splices or terminations be made in listed fittings, boxes, enclosures, fire alarm devices or utilization equipment. Section 760-54 requires (in part) that exposed cables be adequately supported and installed in such a way that maximum protection against physical damage is afforded by building construction such as baseboards, door frames, ledges, etc. Where located within 7 ft. of the floor, cables shall be securely fastened in an approved manner at intervals of not more than 18 in.

2007 Building (Aspen ID: A-2)
Based on observation during the survey, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation. This was evidenced by the following:

Sprinkler heads were not installed to insure prompt operation, as required. The enclosure walls in three data rooms did not extend to the roof deck and did not have a suspended ceiling installed within the rooms. The condition was noted in the 2nd floor wiring closet and utility closet in the O/R suite.
Upright sprinkler heads, installed above the two rooms, were installed near the upper level roof deck. This area was open to the remainder of the concealed space above the suspended ceiling and would not effectively collect heat to insure prompt operation of the existing upright sprinkler heads. The room walls must extend to the roof deck or each room must be equipped with a ceiling and have sprinkler protection installed below the room ceiling.

Original 1975 Building (Aspen ID: A-1)
Based on observation during the survey, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation. This was evidenced by the following:

Sprinkler heads were not installed to insure prompt operation, as required. The enclosure walls in the 2nd floor data closet (across from the sleep lab) did not extend to the roof deck and did not have a suspended ceiling installed within the room.
An upright sprinkler head was installed near the upper level roof deck. This area was open to the remainder of the concealed space above the suspended ceiling and would not effectively collect heat to insure prompt operation of the existing upright sprinkler heads. The room walls must extend to the roof deck or each room must be equipped with a ceiling and have sprinkler protection installed below the room ceiling.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all 85 residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation and maintenance.
This was evidenced by the following:

A) Non-sprinklered, non-combustible crawl spaces were not maintained free of combustible storage, as required. The main crawlspace area was observed to have a small accumulation of both combustible and non-combustible storage that included fluorescent light tubes in cardboard boxes and plumbing fixtures. The non-sprinkler protected crawlspace must be maintained free of storage in accordance with NFPA 13 Section 5-13.7.

B) Sprinkler heads subject to physical damage were not protected with listed guards, as required. The first floor wheelchair storage area had two pendant sprinkler heads installed approximately 5 ft. above the floor and were subject to damage. NFPA 13 Section 3-2.8 requires that sprinklers subject to mechanical damage be protected with listed guards.

C) The ambulance canopy was observed to have two concealed sprinkler heads that were missing the retainer/covers.

D) 2nd floor nursing storage room was missing a suspended ceiling tile and had a damaged tile with a large hole.

E) The Case Managers office had two pendant sprinkler heads with 1/2" to 3/4" gaps around the escutcheon plates.

F) The sidewall sprinkler head, installed in the walk-in cooler was missing the required escutcheon plate and was obstructed by top shelf storage. NFPA 25 Section 2-2.1.2 states "Unacceptable obstructions to spray patterns shall be corrected."

Engineering Staff acknowledged the sprinkler system deficiencies during a tour of the facility.

Original 1975 Building (Aspen ID: A-1)
Based on record review during the survey, it was determined that the facility failed to maintain the kitchen exhaust system in accordance with National Fire Protection Association (NFPA) Standard 96. This deficient practice could affect all patients, staff and visitors within the 2nd floor north smoke compartment should grease accumulations within the exhaust system ignite.
This was evidenced by the following:

Kitchen exhaust systems were not cleaned to bare metal, prior to the surfaces becoming heavily contaminated with grease and at least semi-annually, as required. Records on premises documented cleaning by a service contractor on April 1, 2013 and March 10, 2012. The semi-annual fire extinguishing system inspection reports, dated 03-04-13 and 09-12-12, both noted that the hood, plenum and duct were "greasy".
NFPA 96 Section 8-3.1 states " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to the surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.Table 8-3.1 requires systems serving moderate volume cooking operations be inspected semi-annually.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10. This deficient practice could affect staff and out-patients throughout the 1st floor south smoke compartment by obstructing and impeding the egress corridor for full instant use during an emergency evacuation. This was evidenced by the following:

Egress corridors were not maintained free of obstructions and impediments to full instant use, as required. The first floor corridor, near stair #1, was observed to have unattended storage of cleaning equipment that included 4 floor cleaning machines and a mop bucket.
Engineering Staff acknowledged the corridor obstructions during a tour of the facility.

The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.

2007 Building (Aspen ID: A-2)
Based on record review during the survey, it was determined that the facility failed to maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all patients should the medical gas system not function as designed. This was evidenced by the following:

Medical air systems were not maintained to provide air at a maximum dew point of 35 degrees F, as required. The medical gas system inspection supplemental report, April 2013, noted that the medical air dew point exceeded 35 degrees F due to a defective sensor.
NFPA 99 Section 4-3.1.1.9(g): Dryer systems shall be, at a minimum, duplexed and valved to permit isolation of individual components to allow for maintenance or repair in the event of failure, while still continuing to adequately treat the flow of air. Under normal operation, only one dryer shall be open to airflow with the other dryer valved off. Each dryer system shall be designed to provide air at a maximum dew point of 35?F at the peak calculated demand of the system. System design shall preclude formation of liquid water in the air line.

Original 1975 Building (Aspen ID: A-1)
Based on record review during the survey, it was determined that the facility failed to maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all patients should the medical gas system not function as designed. This was evidenced by the following:

Medical air systems were not maintained to provide air at a maximum dew point of 35 degrees F, as required. The medical gas system inspection supplemental report, April 2013, noted that the medical air dew point exceeded 35 degrees F due to a defective sensor.
NFPA 99 Section 4-3.1.1.9(g): Dryer systems shall be, at a minimum, duplexed and valved to permit isolation of individual components to allow for maintenance or repair in the event of failure, while still continuing to adequately treat the flow of air. Under normal operation, only one dryer shall be open to airflow with the other dryer valved off. Each dryer system shall be designed to provide air at a maximum dew point of 35?F at the peak calculated demand of the system. System design shall preclude formation of liquid water in the air line.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain anesthetizing location equipment in accordance with NFPA 99, Health Care Facilities. This deficient practice could affect all patients and staff in the operating rooms should the line isolation electrical system not function as designed.
This was evidenced by the following:

The line isolation monitor systems, installed in Operating Rooms #1 and #2, were not tested every 6 months in accordance with NFPA 99 Section 3-3.3.4.2. Records were not available that documented the 6 month testing of the line isolation monitors. The O/R Director confirmed that there were monthly test records only.

NFPA 99 Section 3-3.3.4.2 Line Isolation Monitor Tests:
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

2007 Building (Aspen ID: A-2)
Based on record review, observation and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This deficient practice could affect all patients should the essential electrical system not function as designed due to lack of maintenance and testing. This was evidenced by the following:

NFPA 110 Section 6-4.5: Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

Original 1975 Building (Aspen ID: A-1)
Based on record review, observation and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This deficient practice could affect all patients should the essential electrical system not function as designed due to lack of maintenance and testing. This was evidenced by the following:

Automatic transfer switches were not exercised monthly, as required. Two of four automatic transfer switches were not exercised monthly due to differences in test sequence and execution by various staff. During the survey, ATS #3 was utilized to conduct a load test on Generator #2 which resulted in the transfer of ATS #3 only and not ATS #1 or ATS #2.

NFPA 110 Section 6-4.5: Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the one-hour fire rating protection to the building structure. This deficient practice could affect all patients, staff and visitors should the fire protection rating of the building structure not be adequate to withstand fire exposure, as originally designed. This was evidenced by the following:

A) Spray-on cementitious fireproofing (Monocoat) was not maintained at minimum thickness to achieve one-hour minimum rating, as required. Structural steel was observed to have missing sections of spray-on fireproofing in the first floor MRI shell space/storage room.
Grace Construction Products spec/data sheet 07812 item #1 product name: Monokote. Item 8-Maintenance: " No maintenance is required. Contact a qualified Monokote contractor to patch areas of fireproofing material disturbed by later activity. "

B) Gypsum board membrane protection was not maintained, as required. The second floor nurse's storage room was observed to have a 5" x 10" section of gypsum board cut out of the protective membrane.
Engineering staff acknowledged the missing fireproofing during a tour of the facility, and reported that the gypsum board had been cut out due to a recent roof leak.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3. This deficient practice could affect all patients, staff and visitors within the atrium area should the area become untenable for egress due to smoke transfer via unprotected openings to the corridor. This was evidenced by the following:

Use areas were not separated from the corridor by doors that could be closed with a push or a pull, as required. The second floor outpatient reception area was equipped with two roll down doors that were arranged with an operating switch (to open or close) inside the reception area. The door release switches were not accessible from the corridor side of the doors which would prevent an occupant on the corridor side from closing the doors.
Engineering staff reported that smoke detectors, installed on the corridor/atrium side of the doors would activate the door release, in addition to the atrium smoke evacuation system.
Life Safety Code Section 18.3.6.3.3: Hold open devices that release when the door is pushed or pulled shall be permitted.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 19.3.6.3. This deficient practice could affect all patients, staff and visitors within the west smoke compartment should the egress corridor become untenable due to smoke transfer via the non-latching doors separating rooms from the egress corridor.
This was evidenced by the following:

A) Corridor doors were not equipped with positive latching hardware, as required. The radiology suite corridor doors (power-operated double door set-across from emergency department) were not equipped with positive latching hardware.

B) The wiring closet corridor doors were not arranged to automatically latch into the door frame, as required. The wiring closet (across from the sleep lab) was equipped with double doors separating the closet from the corridor. One of two door leafs was not equipped with automatic latching hardware. The leaf equipped with the latchset was arranged to latch into the " fixed " door leaf that was equipped with manual latching hardware. If the manual latching hardware was not engaged, neither leaf would be positively latched.
Engineering staff acknowledged the door latching arrangement during a tour of the facility.
The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Latching devices must not require the use of keys or special tools.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain vertical opening enclosures in accordance with Life Safety Code Section 18.3.1.1 and Section 8.2.5. This deficient practice could affect all patients, staff and visitors within the atrium area should the area become untenable for egress due to smoke transfer via unprotected openings to the atrium/corridor.
This was evidenced by the following:

Atrium separation doors were not maintained to positively latch, as required. One of two 90 minute rated atrium separation doors (first floor-north) would not positively latch into the door frame, as required. Engineering staff acknowledged the non-latching door during a tour of the facility.
Life Safety Code Section 8.2.5.6 requires, in part, that atrium opening protectives meet the requirement for installation within corridor walls.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to mark access to exits in accordance with Life Safety Code Section 19.2.10.1 and Section 7.10. This deficient practice could affect staff occupying the first administration area if the way to reach the exit is not readily apparent to the occupants.
This was evidenced by the following:

Illuminated exit signs were not installed where the way to reach the exit was not readily apparent to occupants. Three additional exit signs are required in the exit access corridor, first floor outside the medical records area, at two corridor intersections and at the exit door to the ramped corridor.
Engineering Staff acknowledged the means of egress signage deficiencies during a tour of the facility.
The Life Safety Code Section 7.10.1.4 requires that access to exits be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to construct new enclosures in accordance with the Life Safety Code Sections 19.3.2.1, 4.67, and 8.4. This deficient practice could affect patients, staff and visitors on both the first and second floors, should there be smoke and heat transfer between the hazardous area and the egress corridor.
This was evidenced by the following:

A) Door openings in newly constructed hazardous areas were not a minimum of 45 minute fire rated, as required. The newly constructed MRI first floor shelled/storage hazardous area was separated from the corridor by non-fire rated doors.

Engineering Staff acknowledged the protection of the newly constructed hazardous areas during a tour of the facility.
The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 19.3.2.1 and Section 8.4. Section 8.4.1.3 requires that doors in fire rated barriers have a minimum ? hour fire resistance rating and that the doors be self-closing or automatic closing. Rated fire doors must positively latch into the door frame in accordance with NFPA 80.
Life Safety Code Section 4.6.7 requires, in part, that altered, modernized or renovated portions of an existing building, system or individual component meet the applicable code requirements for new construction.

B) The corridor door to dietary storage room #235 was not equipped with a self-closer, as required.
Section 19.3.6.3.2 requires that corridor doors be provided with a means suitable for keeping the door closed.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to install and maintain horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 18.2.2.5 and 7.2.4. This deficient practice could affect patients, staff and visitors on the second floor, should there be smoke and heat transfer between the two buildings. This was evidenced by the following:

A) Cross-corridor horizontal exit doors did not positively latch, as required. One of two door leafs (door set S2N) did not latch into the door frame when tested.
Life Safety Code Section 8.2.3 requires that fire doors be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

B) Two hour fire rated separation walls were not maintained, as required. The second floor patient sleeping wing separation wall (above corridor doors-both north and south corridors) were observed to have unsealed penetrations.
1. Above the corridor doors, near room 234, unsealed 1/2 inch gap around an electrical conduit penetration.
2. Above the corridor doors (N2C) an unsealed 3 inch low-voltage conduit. Fire stopping had been installed, but was pulled out on both sides of the conduit.
The unsealed penetrations were acknowledged by Engineering Staff during a tour of the facility.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to install and maintain horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 19.2.2.5 and 7.2.4. This deficient practice could affect patients, staff and visitors on the second floor, should there be smoke and heat transfer between the two buildings. This was evidenced by the following:

A) Cross-corridor horizontal exit doors did not positively latch, as required. One of two door leafs (door set S2N) did not latch into the door frame when tested.
Life Safety Code Section 8.2.3 requires that fire doors be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

B) Two hour fire rated separation walls were not maintained, as required. The second floor patient sleeping wing separation wall (above corridor doors-both north and south corridors) were observed to have unsealed penetrations.
1. Above the corridor doors, near room 234, unsealed 1/2 inch gap around an electrical conduit penetration.
2. Above the corridor doors (N2C) an unsealed 3 inch low-voltage conduit. Fire stopping had been installed, but was pulled out on both sides of the conduit.
The unsealed penetrations were acknowledged by Engineering Staff during a tour of the facility.

2007 Building (Aspen ID: A-2)
Based on record review and staff interview during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 18.7.1.2 and 4.7. This deficient practice could affect all patients when staff are not trained in the emergency actions required during the unusual conditions that can occur in an actual emergency. This was evidenced by the following:

A) A coded announcement was not used as a substitute for audible alarms, as required. Engineering Staff reported that the fire alarm was not sounded during drills on the overnight shift and that a coded announcement was not used as a substitute.

B) Fire drills were not conducted at unexpected times and under varying conditions, as required. A review of fire drill records for the prior 12 month period documented the following drill times:

First Shift (0700 - 1900):
01/31/13 - 1:20 pm
12/28/12 - 2:30 pm
10/31/12 - 1:20 pm
08/30/12 - 9:30 am
07/31/12 - 2:50 pm
06/28/12 - 1:50 pm

The Life Safety Code, Section 18.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Original 1975 Building (Aspen ID: A-1)
Based on record review and staff interview during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 19.7.1.2 and 4.7. This deficient practice could affect all patients when staff are not trained in the emergency actions required during the unusual conditions that can occur in an actual emergency. This was evidenced by the following:

A) A coded announcement was not used as a substitute for audible alarms, as required. Engineering Staff reported that the fire alarm was not sounded during drills on the overnight shift and that a coded announcement was not used as a substitute.

B) Fire drills were not conducted at unexpected times and under varying conditions, as required. A review of fire drill records for the prior 12 month period documented the following drill times:

First Shift (0700 - 1900):
01/31/13 - 1:20 pm
12/28/12 - 2:30 pm
10/31/12 - 1:20 pm
08/30/12 - 9:30 am
07/31/12 - 2:50 pm
06/28/12 - 1:50 pm

The Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect all patients, staff and visitors should the fire alarm system fail to function as designed. This was evidenced by the following:

The fire alarm control unit was observed to have a silenced trouble signal. The panel annunciated "Negative Earth Ground". Engineering Staff reported that the same condition had been corrected by the fire alarm maintenance company in January 2013.
NFPA 72, National Fire Alarm Code, Section 7-1.1.2 states "System defects and malfunctions shall be corrected."

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This deficient practice could affect all patients, staff and visitors should the fire alarm system fail to function as designed and fail to notify staff in all areas of the building.
This was evidenced by the following:

A) The fire alarm control unit was observed to have a silenced trouble signal. The panel annunciated "Negative Earth Ground". Engineering Staff reported that the same condition had been corrected by the fire alarm maintenance company in January 2013.
NFPA 72, National Fire Alarm Code, Section 7-1.1.2 states "System defects and malfunctions shall be corrected."

B) Fire alarm system visual notification appliances were not maintained in operable condition, as requires. The visual appliance (strobe) installed in the corridor (outside of the Emergency Department) was not functioning during a test of the fire alarm system.

C) Power-limited fire alarm wiring was not installed with cable splices inside a listed box or enclosure, and was not installed to assure maximum protection against physical damage, as required. Fire alarm wiring for the Medical Records corridor door magnetic hold device was observed to have exposed cable splices with wire nuts. The wiring was unsupported and looped over the wood arm that supported the magnet/junction box assembly. The unsupported wiring was less than 7 feet above the floor and was subject to damage.
NFPA 72 requires that fire alarm wiring be installed in accordance with NFPA 70, National Electric Code, Article 760. Article 760 requires that power-limited fire alarm circuit conductors and cables be installed such that cable splices or terminations be made in listed fittings, boxes, enclosures, fire alarm devices or utilization equipment. Section 760-54 requires (in part) that exposed cables be adequately supported and installed in such a way that maximum protection against physical damage is afforded by building construction such as baseboards, door frames, ledges, etc. Where located within 7 ft. of the floor, cables shall be securely fastened in an approved manner at intervals of not more than 18 in.

2007 Building (Aspen ID: A-2)
Based on observation during the survey, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation. This was evidenced by the following:

Sprinkler heads were not installed to insure prompt operation, as required. The enclosure walls in three data rooms did not extend to the roof deck and did not have a suspended ceiling installed within the rooms. The condition was noted in the 2nd floor wiring closet and utility closet in the O/R suite.
Upright sprinkler heads, installed above the two rooms, were installed near the upper level roof deck. This area was open to the remainder of the concealed space above the suspended ceiling and would not effectively collect heat to insure prompt operation of the existing upright sprinkler heads. The room walls must extend to the roof deck or each room must be equipped with a ceiling and have sprinkler protection installed below the room ceiling.

Original 1975 Building (Aspen ID: A-1)
Based on observation during the survey, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation. This was evidenced by the following:

Sprinkler heads were not installed to insure prompt operation, as required. The enclosure walls in the 2nd floor data closet (across from the sleep lab) did not extend to the roof deck and did not have a suspended ceiling installed within the room.
An upright sprinkler head was installed near the upper level roof deck. This area was open to the remainder of the concealed space above the suspended ceiling and would not effectively collect heat to insure prompt operation of the existing upright sprinkler heads. The room walls must extend to the roof deck or each room must be equipped with a ceiling and have sprinkler protection installed below the room ceiling.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all 85 residents, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant installation and maintenance.
This was evidenced by the following:

A) Non-sprinklered, non-combustible crawl spaces were not maintained free of combustible storage, as required. The main crawlspace area was observed to have a small accumulation of both combustible and non-combustible storage that included fluorescent light tubes in cardboard boxes and plumbing fixtures. The non-sprinkler protected crawlspace must be maintained free of storage in accordance with NFPA 13 Section 5-13.7.

B) Sprinkler heads subject to physical damage were not protected with listed guards, as required. The first floor wheelchair storage area had two pendant sprinkler heads installed approximately 5 ft. above the floor and were subject to damage. NFPA 13 Section 3-2.8 requires that sprinklers subject to mechanical damage be protected with listed guards.

C) The ambulance canopy was observed to have two concealed sprinkler heads that were missing the retainer/covers.

D) 2nd floor nursing storage room was missing a suspended ceiling tile and had a damaged tile with a large hole.

E) The Case Managers office had two pendant sprinkler heads with 1/2" to 3/4" gaps around the escutcheon plates.

F) The sidewall sprinkler head, installed in the walk-in cooler was missing the required escutcheon plate and was obstructed by top shelf storage. NFPA 25 Section 2-2.1.2 states "Unacceptable obstructions to spray patterns shall be corrected."

Engineering Staff acknowledged the sprinkler system deficiencies during a tour of the facility.

Original 1975 Building (Aspen ID: A-1)
Based on record review during the survey, it was determined that the facility failed to maintain the kitchen exhaust system in accordance with National Fire Protection Association (NFPA) Standard 96. This deficient practice could affect all patients, staff and visitors within the 2nd floor north smoke compartment should grease accumulations within the exhaust system ignite.
This was evidenced by the following:

Kitchen exhaust systems were not cleaned to bare metal, prior to the surfaces becoming heavily contaminated with grease and at least semi-annually, as required. Records on premises documented cleaning by a service contractor on April 1, 2013 and March 10, 2012. The semi-annual fire extinguishing system inspection reports, dated 03-04-13 and 09-12-12, both noted that the hood, plenum and duct were "greasy".
NFPA 96 Section 8-3.1 states " Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to the surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.Table 8-3.1 requires systems serving moderate volume cooking operations be inspected semi-annually.

Original 1975 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10. This deficient practice could affect staff and out-patients throughout the 1st floor south smoke compartment by obstructing and impeding the egress corridor for full instant use during an emergency evacuation. This was evidenced by the following:

Egress corridors were not maintained free of obstructions and impediments to full instant use, as required. The first floor corridor, near stair #1, was observed to have unattended storage of cleaning equipment that included 4 floor cleaning machines and a mop bucket.
Engineering Staff acknowledged the corridor obstructions during a tour of the facility.

The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.

2007 Building (Aspen ID: A-2)
Based on record review during the survey, it was determined that the facility failed to maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all patients should the medical gas system not function as designed. This was evidenced by the following:

Medical air systems were not maintained to provide air at a maximum dew point of 35 degrees F, as required. The medical gas system inspection supplemental report, April 2013, noted that the medical air dew point exceeded 35 degrees F due to a defective sensor.
NFPA 99 Section 4-3.1.1.9(g): Dryer systems shall be, at a minimum, duplexed and valved to permit isolation of individual components to allow for maintenance or repair in the event of failure, while still continuing to adequately treat the flow of air. Under normal operation, only one dryer shall be open to airflow with the other dryer valved off. Each dryer system shall be designed to provide air at a maximum dew point of 35?F at the peak calculated demand of the system. System design shall preclude formation of liquid water in the air line.

Original 1975 Building (Aspen ID: A-1)
Based on record review during the survey, it was determined that the facility failed to maintain the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This deficient practice could affect all patients should the medical gas system not function as designed. This was evidenced by the following:

Medical air systems were not maintained to provide air at a maximum dew point of 35 degrees F, as required. The medical gas system inspection supplemental report, April 2013, noted that the medical air dew point exceeded 35 degrees F due to a defective sensor.
NFPA 99 Section 4-3.1.1.9(g): Dryer systems shall be, at a minimum, duplexed and valved to permit isolation of individual components to allow for maintenance or repair in the event of failure, while still continuing to adequately treat the flow of air. Under normal operation, only one dryer shall be open to airflow with the other dryer valved off. Each dryer system shall be designed to provide air at a maximum dew point of 35?F at the peak calculated demand of the system. System design shall preclude formation of liquid water in the air line.

2007 Building (Aspen ID: A-2)
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain anesthetizing location equipment in accordance with NFPA 99, Health Care Facilities. This deficient practice could affect all patients and staff in the operating rooms should the line isolation electrical system not function as designed.
This was evidenced by the following:

The line isolation monitor systems, installed in Operating Rooms #1 and #2, were not tested every 6 months in accordance with NFPA 99 Section 3-3.3.4.2. Records were not available that documented the 6 month testing of the line isolation monitors. The O/R Director confirmed that there were monthly test records only.

NFPA 99 Section 3-3.3.4.2 Line Isolation Monitor Tests:
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

2007 Building (Aspen ID: A-2)
Based on record review, observation and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This deficient practice could affect all patients should the essential electrical system not function as designed due to lack of maintenance and testing. This was evidenced by the following:

NFPA 110 Section 6-4.5: Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

Original 1975 Building (Aspen ID: A-1)
Based on record review, observation and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This deficient practice could affect all patients should the essential electrical system not function as designed due to lack of maintenance and testing. This was evidenced by the following:

Automatic transfer switches were not exercised monthly, as required. Two of four automatic transfer switches were not exercised monthly due to differences in test sequence and execution by various staff. During the survey, ATS #3 was utilized to conduct a load test on Generator #2 which resulted in the transfer of ATS #3 only and not ATS #1 or ATS #2.

NFPA 110 Section 6-4.5: Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.