HospitalInspections.org

Bldg. A-1
It was determined by observation, during the course of the survey on August 10-12, 2010, that the fire-rated communicating opening/separation wall between the licensed facility and the adjacent building structure was not maintained. This was evidenced by the following:

An improperly sealed, or unsealed transition joint was observed at the top of the corridor wall, above the suspended ceiling, at the juncture where the mineral wool insulation meets the corrugated roof deck pan at the following locations:

1.) The 1-hour fire separation wall, was observed to not be properly sealed in order to maintain the integrity of the one hour fire rating, located between the East Wing and the Gift Shop.

2.) The 2-hour fire separation wall, was observed to not be properly sealed in order to maintain the integrity of the two hour fire rating, located between the West Wing Patient Care area and Radiology.

In accordance with product information sheets that were supplied by the facility at the time of survey, UL 2079, Construction Joints Fire Tests for fire rated assemblies states "For one hour rated wall requires a ?" thickness of fill material compound, Type FC, applied to each side of the wall; for a two hour rating, minimum 1" thickness of fill material compound, Type FC, is applied to each side of the wall."

3.) The two hour fire rated wall between the Procedure Center and Emergency Department, was provided with a wooden 1?" thick double door set. The fire rating of these two doors was not able to be determined at the time of survey. These two doors were not identified with a listing label affixed to the door, however, they were identified with a red/white/blue colored dowel located on the edge of the door. These doors must be rated for a minimum of 1? hours.

Each of the fire rated wall/door deficiency items were discussed with the Facility Director during a tour of the facility.

Bldg. #2:
The Occupational Health/Therapy Works (Bldg. #2), located at 2004 N. 12th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide minimum construction requirements, including construction type and limitation on the number of stories in accordance with LSC section 19.1.6.

Bldg. #3:
Grand Valley Urgent Care/Mesa State College Student Health Center (Bldg. #3), located at 1060 Orchard, Suite N, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide minimum construction requirements, including construction type and limitation on the number of stories in accordance with LSC section 19.1.6.

A two-story of Type V, nonrated wood frame construction, will not meet minimum construction requirements.

Bldg. A-1
It was determined by observation and staff interview, during the course of the survey on August 10-12, 2010, that the facility failed to provide and maintain documentation of the interior finish materials within the egress corridor as having a flame spread rating of Class A or Class B in accordance with Life Safety Code section 19.3.3.2 and NFPA 255. This was evidenced by the following:

The flame spread rating/fire retardancy of the wallpaper covering that was applied to the lower 43 inches of the eight (8) foot high walls of the egress corridors within East Wing, could not be determined. The cumulative length of the two corridors were approximately 220 feet.

Staff stated that records were not available, or could not be located during the survey, to document the Class A or Class B flame spread rating of the wall covering.

The interior finish deficiency item was discussed with the Facilities Director, during a tour of the facility and during review of the facility's required documentation.

Bldg. A-1
It was determined by observation, during the course of the survey on August 10-12, 2010, that the facility failed to provide at least one-hour fire rated construction to vertical openings between floors. This was evidenced by the following:

The vertical opening stairwell between floor levels, was observed to not be enclosed at the top and bottom of stairs, and was without a fire rated wall and door equipped with a self-closer and positive latching fire rated hardware at the following stair locations:

a) at the top of the stairway between the Laboratory and basement, and
b) at the top of the stairway between the Respiratory Therapy and basement.

Life Safety Code section 19.3.1.1 states that "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating."

The vertical opening deficiency items were discussed with the Facilities Director during a tour of the facility.

Bldg. A-1
It was determined by observation, during the survey on August 10-12, 2010, that the facility failed to properly protect the hazardous areas with construction that was smoke-resisting in accordance with section 19.3.2.1 of the Life Safety Code. This was evidenced by the following hazardous areas that were sprinkler protected, but were not maintained to be smoke-resistive:

It was observed and staff stated that an operating room in the OR/Surgical unit had been converted and was being used as a storage location for medical supplies that consisted of combustible paper cardboard boxes of individually plastic wrapped items. This room was greater than 50 sq. ft. and was observed to be open to the corridor and without a corridor door (the door was removed from the frame).

Hazardous areas, such as combustible storage locations, are required to be provided with a 1?" thick corridor door that is equipped with a positive latch mechanism and a means of self-closing and remain closed at all times when not in use, unless placed on a magnetic holding device.

This hazardous area deficiency item was discussed with the Facilities Director during a tour of the facility.

Bldg. A-1
1.) It was determined by record review and staff interview, during the course of the survey on August 10-12, 2010, that documentation was not available on the required annual testing of battery operated emergency corridor, "exit" and task lighting units that will be used to illuminate the means of egress and/or essential work space during a power outage in accordance with LSC section 19.2.9 and referenced section 7.9. This was evidenced by the following:

Staff stated that documentation was not available regarding an annual 90 minute functional test on each battery operated lighting unit located at the facility. Battery operated emergency lighting units were observed in, but not limited to, the following locations within the facility:

a) in the Laboratory basement (2x) and "exit" lights,
b) the Therapy Gym,
c) Kitchen,
d) Library,
e) Volunteers office, and
f) at the exterior site for the emergency power supply system's generator location where a solar powered battery was used for the lighting system.

2.) It was determined by observation, during the course of the survey on August 10-12, 2010, that the facility failed to provide emergency power in accordance with Life Safety Code sections 19.2.9 and 7.9 and referenced NFPA 110, Standard for Emergency and Standby Power Systems section 5-3, for Type I units. This was evidenced by the following:

Emergency lighting for task illumination had not been provided at the generator's automatic transfer switch, located in the basement level electrical room, in the event the generator failed to start.

The battery operated lights are required to be on the load side of the transfer switch (powered from the emergency panel branch circuit).
Note: The use of battery operated emergency lighting requires a monthly 30 second functional test, as well as a 1? hour annual test on each battery operated unit within the facility, with documentation provided accordingly.

The emergency lighting deficiency items were discussed with the Facilities Director and Electrician, during a review of the facility's required documentation.

Bldg #1:
The Administrative Reception Center (Bldg. #1), located at 2120 N. 12th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg. #2:
The Occupational Health/Therapy Works (Bldg. #2), located at 2004 N. 12th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg. #3:
Grand Valley Urgent Care/Mesa State College Student Health Center (Bldg. #3), located at 1060 Orchard, Suite N, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg. #4:
Grand Valley Primary Care (Bldg. #4), located at 603 28-1/4 Road, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg. #5:
Community Hospital Behavioral Health Services and EAP (Bldg. #5), located at 1300 N. 7th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg #1:
The Administrative Reception Center (Bldg. #1), located at 2120 N. 12th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg. #2:
The Occupational Health/Therapy Works (Bldg. #2), located at 2004 N. 12th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 13 automatic fire sprinkler system installed throughout in accordance with sections 19.3.5.

Bldg. #3:
Grand Valley Urgent Care/Mesa State College Student Health Center (Bldg. #3), located at 1060 Orchard, Suite N, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 13 automatic fire sprinkler system installed throughout in accordance with sections 19.3.5.

Bldg. #4:
Grand Valley Primary Care (Bldg. #4), located at 603 28-1/4 Road, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 13 automatic fire sprinkler system installed throughout in accordance with sections 19.3.5.

Bldg. #5:
Community Hospital Behavioral Health Services and EAP (Bldg. #5), located at 1300 N. 7th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 13 automatic fire sprinkler system installed throughout in accordance with sections 19.3.5.

Bldg. A-1
It was determined by observation and/or record review, during the course of the survey on August 10-12, 2010, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and/or NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1.) It was determined by observation, during the course of the survey on August 10-12, 2010, that portions of the facility were equipped with recalled sprinkler heads. This was evidenced by the following:

The facility's sprinkler system was observed to be equipped with different models of sprinkler heads that were effected by a recall, with each having the common factor of a "flat cap." Recalled sprinkler heads observed consisted of:

? 1996 residential model Optima LF pendent K=3.0;
? 1994 GB4 Quick Response (QR) pendent;
? 1994 GB QR pendent.

These models were recalled by Central Sprinkler Company and the U.S. Consumer Product Safety Commission, effective in December 2001. These sprinkler heads must be removed from the following locations and replaced with approved residential style automatic sprinkler heads:

a) West Wing Tub Room,
b) the adjacent overflow room from the above noted West Wing Tub Room (2x),
c) West Wing Patient Rooms #132, #133 and it's restroom and #134,
d) West Wing shower room,
e) Radiology CT Scan Room (4x) and
f) the Laboratory Director's office (2x).

2.) The following locations were observed to not be protected by the automatic fire sprinkler system in accordance with LSC section 19.1.6.2 and section 19.3.5:

a) a mobile trailer, approximately 10' x 60', attached to the Laboratory used for business office (a two hour rated separation was not provided),
b) an EVS closet near Exit #2 to PACU,
c) a closet within ICU patient room #1.

3.) The exterior courtyard and Healing Garden, located between East Wing and Radiology contained:

a) a combustible wooden sun screen of 2 x 6 construction placed over noncombustible steel bar joists. This partially combustible assembly was then observed to be attached to the facility structure and was not protected by the automatic sprinkler system. Size of the assembly was approximately 12 ft. x 16 ft.
b) a combustible wood framed sun screen with a fabric shade cloth and two lattice sides. This combustible assembly was then observed to be in contact with the facility structure and was not protected by the automatic sprinkler system. Size of the assembly was approximately 6 ft. wide x 10 ft. long x 8 ft. high.

NFPA 13 section 5-13.8.1 requires sprinklers be installed under exterior roofs or canopies of combustible construction and exceeding 4 ft. in width.

4.) The automatic sprinkler system's water flow alarms were not tested on a quarterly basis as required. Sprinkler system inspection records, dated September 2009 and March 2010, documented the only testing of the water flow alarm during the past 12 month period. Maintenance staff stated that other documentation was not available regarding quarterly testing that should have been scheduled in a timely manner to take place in June 2010 and December 2009.

NFPA 13 requires sprinkler systems to be inspected, tested, and maintained in accordance with NFPA 25. NFPA 25 (1998) section 9-2.7 requires that water flow alarms be tested quarterly in accordance with manufacturer's instructions.

5.) Patient rooms #102, #104, #105, #109, #110 and #113, within the East Wing were provided with two (2) privacy curtains that had a close mesh in the top panel measured to be approximately 1/8" x 1/4". This tight/close mesh panel is presented as a suspended vertical obstruction to the establishment of a spray pattern for the fire sprinkler system in accordance with NFPA 13 section 5-6.5.2.3.

6.) The Respiratory Therapy's Stress Test Room, was observed with two (2) standard response sprinkler heads within a 3 ft. distance.

In accordance with (1999) NFPA 13 section 5-6.3.4 standard response sprinklers shall not be spaced less than six feet on center.

The fire sprinkler system deficiency items were discussed with the Facilities Director, during a tour of the facility or during review of the facility's required documentation.

Bldg. A-1
It was determined by review of documentation, during the course of the survey on August 10-12, 2010, that the facility failed to properly maintain the kitchen exhaust hood and duct system in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. This was evidenced by the following:

Cleaning documentation provided, had remarks that indicated the entire Kitchen Hood Exhaust System was not completely accessible for proper cleaning to bare metal as required.

Staff provided documentation for the past 12 months as evidence of the cleaning of the Kitchen Hood and Exhaust system. This documentation consisted of two (2) invoices from an independent steam-cleaning and pressure wash contractor, dated 10/15/2009 and 3/31/2010. Each document contained the statement "Clean ducts above hoods, as I could" within the description block.

Facilities staff inquired about the statement on the invoice with a response that a horizontal portion of the exhaust duct work was difficult to access.
(1998) NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations section 1-3.1.3 states "All interior surfaces of the exhaust system shall be reasonably accessible for cleaning and inspection purposes." Section 4-3.1 states "Openings shall be provided at the sides or at the top of the duct, whichever is more accessible, and at changes of direction. Openings shall be protected by approved access panels that comply with 4-3.4.4."

This hood cleaning system deficiency item was discussed with the Facilities Director, during a review of the facility's required documentation.

Bldg. A-1
It was determined by observation, during the survey on August 10-12, 2010, that the facility failed to provide exit corridors that were maintained clear and unobstructed in accordance with (2000) LSC section 19.2.1 and referenced section 7.1.10. This was evidenced by the following:

1.) It was observed that the following items were being stored within the 8 ft. wide egress Corridor #E142 of the OR/Surgical unit:

a) a soiled linen cart,
b) a portable Pyxis Medication Station,
c) a portable compact refrigerator unit.

2.) A wall-mounted cabinet housing the Line Isolation Monitor, projected from the wall into the egress corridor approximately 10" from a height approximately 18" to 70" above the floor level and exceeded the 6" maximum projection distance from the wall that is permitted when at 38 in. and below.

S&C-10-18-LSC letter allows wall-mounted items provided they do not project out more than six inches from the wall, does not exceed 36 inches in length, is separated from other wall-mounted projections by at least 48 inches, and is located at least 40 inches above the floor.

3.) It was observed that the following items were being stored within the 8 ft. wide egress Corridor #E143 of the OR/Surgical unit:

a) with five (5) portable medical storage racks, each approximately 6' high x 5' long x 16" deep along the north wall and containing several combustible paper cardboard boxes of individually plastic wrapped items in storage.
b) with one (1) portable storage rack, approximately 6' high x 5' long x 16" deep along the south wall and containing several bins of individually plastic wrapped items in storage.
c) an oxygen transport cart with 12 series "E" cylinders along the south wall.

4.) It was observed that the following items were being stored within the 8 ft. wide egress corridor of the West Wing Patient Care Area:

a) a Dining Tray cart, approximately 3'x 4'x 2';
b) a portable soiled linen bucket, approximately 3'x 20' diameter; and
c) a clean linen cart, approximately 5'x 4'x 18'.

5.) It was observed that the following items were being stored within the 8 ft. wide central sterile egress corridor of the PACU area:

a) three (3) portable orthopedic Xray C-arms, each approximately 5'x 5'x 2';
b) three (3) portable display units/cabinets, each approximately 5'x 2'x 2'; and
c) one (1) portable mini C-arm, approximately 4'x 3'x 2'.

6.) It was observed that the following items were being stored within the 8 ft. wide egress corridor of the Emergency Department:

a) the distance between the fixed position Reception Desk and the fixed position north Laptop Charting Desk, was reduced to 71 inches.
b) the distance between the fixed position north Laptop Charting Desk/Towel Warming Cabinet and the fixed position south Laptop Charting Desk/Clean Linen Cart, was reduced to 75 inches.
c) a Pyxis Medication Station system, consisting of three units, approximately 77"x 78"x 34"; and
d) a medication refrigerator unit, approximately 30"x 30"x 58".

7.) It was observed that the following items were being stored within the 8 ft. wide egress corridor of the Radiology Department:

a) a blanket warmer and stand, 36"x 18"x 18", and
b) a water fountain/chiller, approximately 3'x 2'x 2'.

Each of the above stored items reduce the width of the exit corridors, which must be maintained clear and unobstructed.

The corridor obstruction deficiency items were discussed with the Facilities Director, during a tour of the facility.

Bldg. A-1
It was determined by record review, during the survey on August 10-12, 2010, that the facility failed to provide a medical gas system meeting the requirements of NFPA 99. This was evidenced by the following:

A review of the medical gas system annual inspection, test and maintenance records, provided by an independent medical gas system contractor, and dated July 2010, documented deficiency items that had not yet been corrected at the time of this survey, to include:

1.) The zone valve box that serves
a) Patient rooms #131-136 in the West Wing, as well as
b) the zone valve box that serves the Radiology Department, were located behind doors that were normally open or normally closed.

In accordance with (1999) NFPA 99 section 4-3.1.2.3 and (2005) section 5.1.4.8.5 "Zone valve boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view."

2.) The zone valve box was missing a pressure/VAC indicator that serves a) OR #2,
b) ER/Endoscopy Lab,
c) Patient rooms #101-109 in the East Wing and
d) Patient rooms #110-118 in the East Wing.

In accordance with (1999) NFPA 99 section 4-3.1.2.4 and (2005) section 5.1.4.8.3 "A pressure/vacuum indicator shall be provided on the station outlet/inlet side of each zone valve."

3.) The "Emergency Oxygen Supply Connection" piping assembly was not identified, or could not be located on the exterior of the facility. Additionally, it could not be determined if this connection was provided with the required pressure relief valve of adequate size to protect the downstream piping system and related equipment from exposure to pressures in excess of 50 percent higher than normal pipeline pressure as required by NFPA 99 section 4-3.1.1.8.(h).

The medical gas system deficiency items were discussed with the Facilities Director and facility Engineering Staff, during a review of the facility's required documentation or during a tour of the facility.

Bldg. A-1
It was determined by staff interview and record review, during the survey on August 10-12, 2010, that the facility failed to provide protection to anesthetizing locations in accordance with Life Safety Code section 19.3.2 and NFPA 99, Standard for Health Care Facilities. This was evidenced by the following:

Staff interview indicated that four of four anesthetizing locations were not maintained with a minimum humidity levels of 35%, or greater, in accordance with NFPA 99, Chapter 5, section 5-4.1.

Records provided during the survey, documented the humidity levels within four of four anesthetizing locations/surgical operating rooms. Staff stated that humidity levels were recorded only one time each day, per operating room, in the morning and prior to any surgical activity. The recorded values for each operating room, were consistently below the 35% required threshold with values commonly within the 20-29% range.

The deficiency item regarding the anesthetizing locations was discussed with the Facilities Director, during a tour of the facility and review of the operating room humidity level documentation.

Bldg. A-1
It was determined by record review and staff interview, during the course of the survey on August 10-12, 2010, that the facility failed to properly maintain and test the emergency power source in accordance with (1999) NFPA 99 Health Care Facilities, section 3-4 and referenced NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. This was evidenced by the following:

Maintenance staff stated that documentation was not available for review regarding, at minimum, an annual inspection and preventive maintenance to the Emergency Power Supply System, including the three (3) automatic transfer switches, by a properly trained, qualified, and certified company that performs maintenance, inspection and testing of the emergency generator secondary power supply system.

Available records document the last annual inspection, service and testing conducted by an independent and qualified contractor occurred on May 31, 2008.

The emergency power supply system deficiency item was discussed with the Facilities Director and Electrician, during a review of the facility's required documentation.

Bldg. A-1
It was determined by observation, during the course of the survey on August 10-12, 2010, that the fire-rated communicating opening/separation wall between the licensed facility and the adjacent building structure was not maintained. This was evidenced by the following:

An improperly sealed, or unsealed transition joint was observed at the top of the corridor wall, above the suspended ceiling, at the juncture where the mineral wool insulation meets the corrugated roof deck pan at the following locations:

1.) The 1-hour fire separation wall, was observed to not be properly sealed in order to maintain the integrity of the one hour fire rating, located between the East Wing and the Gift Shop.

2.) The 2-hour fire separation wall, was observed to not be properly sealed in order to maintain the integrity of the two hour fire rating, located between the West Wing Patient Care area and Radiology.

In accordance with product information sheets that were supplied by the facility at the time of survey, UL 2079, Construction Joints Fire Tests for fire rated assemblies states "For one hour rated wall requires a ?" thickness of fill material compound, Type FC, applied to each side of the wall; for a two hour rating, minimum 1" thickness of fill material compound, Type FC, is applied to each side of the wall."

3.) The two hour fire rated wall between the Procedure Center and Emergency Department, was provided with a wooden 1?" thick double door set. The fire rating of these two doors was not able to be determined at the time of survey. These two doors were not identified with a listing label affixed to the door, however, they were identified with a red/white/blue colored dowel located on the edge of the door. These doors must be rated for a minimum of 1? hours.

Each of the fire rated wall/door deficiency items were discussed with the Facility Director during a tour of the facility.

Bldg. #2:
The Occupational Health/Therapy Works (Bldg. #2), located at 2004 N. 12th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide minimum construction requirements, including construction type and limitation on the number of stories in accordance with LSC section 19.1.6.

Bldg. #3:
Grand Valley Urgent Care/Mesa State College Student Health Center (Bldg. #3), located at 1060 Orchard, Suite N, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide minimum construction requirements, including construction type and limitation on the number of stories in accordance with LSC section 19.1.6.

A two-story of Type V, nonrated wood frame construction, will not meet minimum construction requirements.

Bldg. A-1
It was determined by observation and staff interview, during the course of the survey on August 10-12, 2010, that the facility failed to provide and maintain documentation of the interior finish materials within the egress corridor as having a flame spread rating of Class A or Class B in accordance with Life Safety Code section 19.3.3.2 and NFPA 255. This was evidenced by the following:

The flame spread rating/fire retardancy of the wallpaper covering that was applied to the lower 43 inches of the eight (8) foot high walls of the egress corridors within East Wing, could not be determined. The cumulative length of the two corridors were approximately 220 feet.

Staff stated that records were not available, or could not be located during the survey, to document the Class A or Class B flame spread rating of the wall covering.

The interior finish deficiency item was discussed with the Facilities Director, during a tour of the facility and during review of the facility's required documentation.

Bldg. A-1
It was determined by observation, during the course of the survey on August 10-12, 2010, that the facility failed to provide at least one-hour fire rated construction to vertical openings between floors. This was evidenced by the following:

The vertical opening stairwell between floor levels, was observed to not be enclosed at the top and bottom of stairs, and was without a fire rated wall and door equipped with a self-closer and positive latching fire rated hardware at the following stair locations:

a) at the top of the stairway between the Laboratory and basement, and
b) at the top of the stairway between the Respiratory Therapy and basement.

Life Safety Code section 19.3.1.1 states that "Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating."

The vertical opening deficiency items were discussed with the Facilities Director during a tour of the facility.

Bldg. A-1
It was determined by observation, during the survey on August 10-12, 2010, that the facility failed to properly protect the hazardous areas with construction that was smoke-resisting in accordance with section 19.3.2.1 of the Life Safety Code. This was evidenced by the following hazardous areas that were sprinkler protected, but were not maintained to be smoke-resistive:

It was observed and staff stated that an operating room in the OR/Surgical unit had been converted and was being used as a storage location for medical supplies that consisted of combustible paper cardboard boxes of individually plastic wrapped items. This room was greater than 50 sq. ft. and was observed to be open to the corridor and without a corridor door (the door was removed from the frame).

Hazardous areas, such as combustible storage locations, are required to be provided with a 1?" thick corridor door that is equipped with a positive latch mechanism and a means of self-closing and remain closed at all times when not in use, unless placed on a magnetic holding device.

This hazardous area deficiency item was discussed with the Facilities Director during a tour of the facility.

Bldg. A-1
1.) It was determined by record review and staff interview, during the course of the survey on August 10-12, 2010, that documentation was not available on the required annual testing of battery operated emergency corridor, "exit" and task lighting units that will be used to illuminate the means of egress and/or essential work space during a power outage in accordance with LSC section 19.2.9 and referenced section 7.9. This was evidenced by the following:

Staff stated that documentation was not available regarding an annual 90 minute functional test on each battery operated lighting unit located at the facility. Battery operated emergency lighting units were observed in, but not limited to, the following locations within the facility:

a) in the Laboratory basement (2x) and "exit" lights,
b) the Therapy Gym,
c) Kitchen,
d) Library,
e) Volunteers office, and
f) at the exterior site for the emergency power supply system's generator location where a solar powered battery was used for the lighting system.

2.) It was determined by observation, during the course of the survey on August 10-12, 2010, that the facility failed to provide emergency power in accordance with Life Safety Code sections 19.2.9 and 7.9 and referenced NFPA 110, Standard for Emergency and Standby Power Systems section 5-3, for Type I units. This was evidenced by the following:

Emergency lighting for task illumination had not been provided at the generator's automatic transfer switch, located in the basement level electrical room, in the event the generator failed to start.

The battery operated lights are required to be on the load side of the transfer switch (powered from the emergency panel branch circuit).
Note: The use of battery operated emergency lighting requires a monthly 30 second functional test, as well as a 1? hour annual test on each battery operated unit within the facility, with documentation provided accordingly.

The emergency lighting deficiency items were discussed with the Facilities Director and Electrician, during a review of the facility's required documentation.

Bldg #1:
The Administrative Reception Center (Bldg. #1), located at 2120 N. 12th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg. #2:
The Occupational Health/Therapy Works (Bldg. #2), located at 2004 N. 12th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg. #3:
Grand Valley Urgent Care/Mesa State College Student Health Center (Bldg. #3), located at 1060 Orchard, Suite N, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg. #4:
Grand Valley Primary Care (Bldg. #4), located at 603 28-1/4 Road, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg. #5:
Community Hospital Behavioral Health Services and EAP (Bldg. #5), located at 1300 N. 7th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg #1:
The Administrative Reception Center (Bldg. #1), located at 2120 N. 12th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 72 fire alarm system installed in accordance with sections 19.3.4 and 9.6.

Bldg. #2:
The Occupational Health/Therapy Works (Bldg. #2), located at 2004 N. 12th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 13 automatic fire sprinkler system installed throughout in accordance with sections 19.3.5.

Bldg. #3:
Grand Valley Urgent Care/Mesa State College Student Health Center (Bldg. #3), located at 1060 Orchard, Suite N, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 13 automatic fire sprinkler system installed throughout in accordance with sections 19.3.5.

Bldg. #4:
Grand Valley Primary Care (Bldg. #4), located at 603 28-1/4 Road, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 13 automatic fire sprinkler system installed throughout in accordance with sections 19.3.5.

Bldg. #5:
Community Hospital Behavioral Health Services and EAP (Bldg. #5), located at 1300 N. 7th Street, Grand Junction, Colorado, was identified to be outpatient care centers at the time of survey. This structure was observed to be without significant construction and protection provisions necessary to meet the requirements in accordance with NFPA 101, Life Safety Code (2000) Chapter 19, including, but not limited to:

It was determined by observation, during the survey on August 10-12, 2010, the facility failed to provide an NFPA 13 automatic fire sprinkler system installed throughout in accordance with sections 19.3.5.

Bldg. A-1
It was determined by observation and/or record review, during the course of the survey on August 10-12, 2010, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems and/or NFPA 25, Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. This was evidenced by the following:

1.) It was determined by observation, during the course of the survey on August 10-12, 2010, that portions of the facility were equipped with recalled sprinkler heads. This was evidenced by the following:

The facility's sprinkler system was observed to be equipped with different models of sprinkler heads that were effected by a recall, with each having the common factor of a "flat cap." Recalled sprinkler heads observed consisted of:

? 1996 residential model Optima LF pendent K=3.0;
? 1994 GB4 Quick Response (QR) pendent;
? 1994 GB QR pendent.

These models were recalled by Central Sprinkler Company and the U.S. Consumer Product Safety Commission, effective in December 2001. These sprinkler heads must be removed from the following locations and replaced with approved residential style automatic sprinkler heads:

a) West Wing Tub Room,
b) the adjacent overflow room from the above noted West Wing Tub Room (2x),
c) West Wing Patient Rooms #132, #133 and it's restroom and #134,
d) West Wing shower room,
e) Radiology CT Scan Room (4x) and
f) the Laboratory Director's office (2x).

2.) The following locations were observed to not be protected by the automatic fire sprinkler system in accordance with LSC section 19.1.6.2 and section 19.3.5:

a) a mobile trailer, approximately 10' x 60', attached to the Laboratory used for business office (a two hour rated separation was not provided),
b) an EVS closet near Exit #2 to PACU,
c) a closet within ICU patient room #1.

3.) The exterior courtyard and Healing Garden, located between East Wing and Radiology contained:

a) a combustible wooden sun screen of 2 x 6 construction placed over noncombustible steel bar joists. This partially combustible assembly was then observed to be attached to the facility structure and was not protected by the automatic sprinkler system. Size of the assembly was approximately 12 ft. x 16 ft.
b) a combustible wood framed sun screen with a fabric shade cloth and two lattice sides. This combustible assembly was then observed to be in contact with the facility structure and was not protected by the automatic sprinkler system. Size of the assembly was approximately 6 ft. wide x 10 ft. long x 8 ft. high.

NFPA 13 section 5-13.8.1 requires sprinklers be installed under exterior roofs or canopies of combustible construction and exceeding 4 ft. in width.

4.) The automatic sprinkler system's water flow alarms were not tested on a quarterly basis as required. Sprinkler system inspection records, dated September 2009 and March 2010, documented the only testing of the water flow alarm during the past 12 month period. Maintenance staff stated that other documentation was not available regarding quarterly testing that should have been scheduled in a timely manner to take place in June 2010 and December 2009.

NFPA 13 requires sprinkler systems to be inspected, tested, and maintained in accordance with NFPA 25. NFPA 25 (1998) section 9-2.7 requires that water flow alarms be tested quarterly in accordance with manufacturer's instructions.

5.) Patient rooms #102, #104, #105, #109, #110 and #113, within the East Wing were provided with two (2) privacy curtains that had a close mesh in the top panel measured to be approximately 1/8" x 1/4". This tight/close mesh panel is presented as a suspended vertical obstruction to the establishment of a spray pattern for the fire sprinkler system in accordance with NFPA 13 section 5-6.5.2.3.

6.) The Respiratory Therapy's Stress Test Room, was observed with two (2) standard response sprinkler heads within a 3 ft. distance.

In accordance with (1999) NFPA 13 section 5-6.3.4 standard response sprinklers shall not be spaced less than six feet on center.

The fire sprinkler system deficiency items were discussed with the Facilities Director, during a tour of the facility or during review of the facility's required documentation.

Bldg. A-1
It was determined by review of documentation, during the course of the survey on August 10-12, 2010, that the facility failed to properly maintain the kitchen exhaust hood and duct system in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. This was evidenced by the following:

Cleaning documentation provided, had remarks that indicated the entire Kitchen Hood Exhaust System was not completely accessible for proper cleaning to bare metal as required.

Staff provided documentation for the past 12 months as evidence of the cleaning of the Kitchen Hood and Exhaust system. This documentation consisted of two (2) invoices from an independent steam-cleaning and pressure wash contractor, dated 10/15/2009 and 3/31/2010. Each document contained the statement "Clean ducts above hoods, as I could" within the description block.

Facilities staff inquired about the statement on the invoice with a response that a horizontal portion of the exhaust duct work was difficult to access.
(1998) NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations section 1-3.1.3 states "All interior surfaces of the exhaust system shall be reasonably accessible for cleaning and inspection purposes." Section 4-3.1 states "Openings shall be provided at the sides or at the top of the duct, whichever is more accessible, and at changes of direction. Openings shall be protected by approved access panels that comply with 4-3.4.4."

This hood cleaning system deficiency item was discussed with the Facilities Director, during a review of the facility's required documentation.

Bldg. A-1
It was determined by observation, during the survey on August 10-12, 2010, that the facility failed to provide exit corridors that were maintained clear and unobstructed in accordance with (2000) LSC section 19.2.1 and referenced section 7.1.10. This was evidenced by the following:

1.) It was observed that the following items were being stored within the 8 ft. wide egress Corridor #E142 of the OR/Surgical unit:

a) a soiled linen cart,
b) a portable Pyxis Medication Station,
c) a portable compact refrigerator unit.

2.) A wall-mounted cabinet housing the Line Isolation Monitor, projected from the wall into the egress corridor approximately 10" from a height approximately 18" to 70" above the floor level and exceeded the 6" maximum projection distance from the wall that is permitted when at 38 in. and below.

S&C-10-18-LSC letter allows wall-mounted items provided they do not project out more than six inches from the wall, does not exceed 36 inches in length, is separated from other wall-mounted projections by at least 48 inches, and is located at least 40 inches above the floor.

3.) It was observed that the following items were being stored within the 8 ft. wide egress Corridor #E143 of the OR/Surgical unit:

a) with five (5) portable medical storage racks, each approximately 6' high x 5' long x 16" deep along the north wall and containing several combustible paper cardboard boxes of individually plastic wrapped items in storage.
b) with one (1) portable storage rack, approximately 6' high x 5' long x 16" deep along the south wall and containing several bins of individually plastic wrapped items in storage.
c) an oxygen transport cart with 12 series "E" cylinders along the south wall.

4.) It was observed that the following items were being stored within the 8 ft. wide egress corridor of the West Wing Patient Care Area:

a) a Dining Tray cart, approximately 3'x 4'x 2';
b) a portable soiled linen bucket, approximately 3'x 20' diameter; and
c) a clean linen cart, approximately 5'x 4'x 18'.

5.) It was observed that the following items were being stored within the 8 ft. wide central sterile egress corridor of the PACU area:

a) three (3) portable orthopedic Xray C-arms, each approximately 5'x 5'x 2';
b) three (3) portable display units/cabinets, each approximately 5'x 2'x 2'; and
c) one (1) portable mini C-arm, approximately 4'x 3'x 2'.

6.) It was observed that the following items were being stored within the 8 ft. wide egress corridor of the Emergency Department:

a) the distance between the fixed position Reception Desk and the fixed position north Laptop Charting Desk, was reduced to 71 inches.
b) the distance between the fixed position north Laptop Charting Desk/Towel Warming Cabinet and the fixed position south Laptop Charting Desk/Clean Linen Cart, was reduced to 75 inches.
c) a Pyxis Medication Station system, consisting of three units, approximately 77"x 78"x 34"; and
d) a medication refrigerator unit, approximately 30"x 30"x 58".

7.) It was observed that the following items were being stored within the 8 ft. wide egress corridor of the Radiology Department:

a) a blanket warmer and stand, 36"x 18"x 18", and
b) a water fountain/chiller, approximately 3'x 2'x 2'.

Each of the above stored items reduce the width of the exit corridors, which must be maintained clear and unobstructed.

The corridor obstruction deficiency items were discussed with the Facilities Director, during a tour of the facility.

Bldg. A-1
It was determined by record review, during the survey on August 10-12, 2010, that the facility failed to provide a medical gas system meeting the requirements of NFPA 99. This was evidenced by the following:

A review of the medical gas system annual inspection, test and maintenance records, provided by an independent medical gas system contractor, and dated July 2010, documented deficiency items that had not yet been corrected at the time of this survey, to include:

1.) The zone valve box that serves
a) Patient rooms #131-136 in the West Wing, as well as
b) the zone valve box that serves the Radiology Department, were located behind doors that were normally open or normally closed.

In accordance with (1999) NFPA 99 section 4-3.1.2.3 and (2005) section 5.1.4.8.5 "Zone valve boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view."

2.) The zone valve box was missing a pressure/VAC indicator that serves a) OR #2,
b) ER/Endoscopy Lab,
c) Patient rooms #101-109 in the East Wing and
d) Patient rooms #110-118 in the East Wing.

In accordance with (1999) NFPA 99 section 4-3.1.2.4 and (2005) section 5.1.4.8.3 "A pressure/vacuum indicator shall be provided on the station outlet/inlet side of each zone valve."

3.) The "Emergency Oxygen Supply Connection" piping assembly was not identified, or could not be located on the exterior of the facility. Additionally, it could not be determined if this connection was provided with the required pressure relief valve of adequate size to protect the downstream piping system and related equipment from exposure to pressures in excess of 50 percent higher than normal pipeline pressure as required by NFPA 99 section 4-3.1.1.8.(h).

The medical gas system deficiency items were discussed with the Facilities Director and facility Engineering Staff, during a review of the facility's required documentation or during a tour of the facility.

Bldg. A-1
It was determined by staff interview and record review, during the survey on August 10-12, 2010, that the facility failed to provide protection to anesthetizing locations in accordance with Life Safety Code section 19.3.2 and NFPA 99, Standard for Health Care Facilities. This was evidenced by the following:

Staff interview indicated that four of four anesthetizing locations were not maintained with a minimum humidity levels of 35%, or greater, in accordance with NFPA 99, Chapter 5, section 5-4.1.

Records provided during the survey, documented the humidity levels within four of four anesthetizing locations/surgical operating rooms. Staff stated that humidity levels were recorded only one time each day, per operating room, in the morning and prior to any surgical activity. The recorded values for each operating room, were consistently below the 35% required threshold with values commonly within the 20-29% range.

The deficiency item regarding the anesthetizing locations was discussed with the Facilities Director, during a tour of the facility and review of the operating room humidity level documentation.

Bldg. A-1
It was determined by record review and staff interview, during the course of the survey on August 10-12, 2010, that the facility failed to properly maintain and test the emergency power source in accordance with (1999) NFPA 99 Health Care Facilities, section 3-4 and referenced NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. This was evidenced by the following:

Maintenance staff stated that documentation was not available for review regarding, at minimum, an annual inspection and preventive maintenance to the Emergency Power Supply System, including the three (3) automatic transfer switches, by a properly trained, qualified, and certified company that performs maintenance, inspection and testing of the emergency generator secondary power supply system.

Available records document the last annual inspection, service and testing conducted by an independent and qualified contractor occurred on May 31, 2008.

The emergency power supply system deficiency item was discussed with the Facilities Director and Electrician, during a review of the facility's required documentation.