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Based on observations, interviews, and record review during the complaint survey completed on March 17, 2023, it was determined that the facility failed to maintain building construction standards in accordance with with 2012 Life Safety Code 101 section 19.3.7.3 to comply with section 8.5. Specifically, the facility's corridor doors, floors and rated walls were not maintained (cross reference K363, K371, K372) to provide the intended containment of smoke and fire.

These failures created the likelihood of serious adverse outcome for all patients, staff, and visitors in if there were a fire event within the facility.

The findings include:

I. Immediate Jeopardy

A. Findings of Immediate Jeopardy

Regulatory Requirement:
2012 Life Safety Code 101 section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Observations:
Cross reference to K363 for observations of patient rooms with doors that do not positively latch to prevent the passage of smoke.
Cross reference to K371 for observations of open penetrations for all floors and rated walls throughout the facility.
Cross reference to K372 for observations of blow-out patches used on numerous rated smoke/fire barriers throughout the facility.

The building was observed to have patients, staff, and others present throughout the survey.

Record Review:
A review of the fire door inspection reports, provide by the facilities maintenance manager, documented the inspection vendor found approximately 20-30% of fire and smoke rated doors were out of compliance. The facility had corrected only a portion of the noncompliant door concerns identified by their vendor.

A review of work orders, provided by the life safety specialist, demonstrated staff had been reporting open penetrations in rated walls, which observations confirmed, remained uncorrected or were insufficiently corrected with the use of blow-out patches.

Staff Interview:
On 3/2/2023 an interview with the facilities maintenance manager revealed the facility was aware of the need to repair doors to provide adequate smoke containment, but the facility had not made the necessary corrections to many of the doors identified by their vendor as being in need of repairs.

On 3/9/2023 the facility life safety specialist confirmed the facility was aware of concerns with open penetrations of rated walls and of inadequate repairs to rated walls made with blow-out patches. The facility life safety specialist acknowledged damage to the rated walls created a lack of fire and smoke containment intended by the building's planned construction.

B. Notification of Immediate Jeopardy
On March 9, 2023 at 9:00 a.m., the System Director was informed the facility's failures to maintain all rated assemblies, as designed, to prevent smoke and fire penetration created the likelihood for serious harm if the failures were not corrected immediately.

C. Facility Plan to Remove Immediate Jeopardy
On March 10, 2023 at 5:11 p.m., the facility submitted a plan to remove the immediate jeopardy. The removal plan read:
"A comprehensive evaluation by DFPC/CMS surveyors has shown a pervasive and systematic condition related to fire/smoke-rated barriers in both the Memorial Central and North hospital facilities and off-campus locations. This condition also includes fire-rated and patient room doors.
Due to the scope of this condition, CMS has issued an Immediate Jeopardy finding for all the locations noted. The IJ begins immediately and will extend for 90 days. We recognize the severity of this condition impacts all patients, visitors, and staff (all occupants of the facilities).
In this time frame, the UCHealth Memorial Hospital will complete the following:
24/7 fire watch in each hospital and fire watch during business hours in non-hospital occupancies - this will be initiated today at 5:00 PM on 3/8/2023 and continue until the conditions have been verified and corrected by the DFPC.
Abatement of all fire/smoke barriers will be evaluated and all deficiencies corrected. This will include an initial and follow-up inspection of every linear foot of all rated separations in every impacted facility. Documentation will be developed to demonstrate full compliance.
Door maintenance will include adjustments, replacement of hardware, and full door replacement based on existing ITM reports.
The final inspection of barriers will be completed by individuals knowledgeable of the facility code plans and requirements for appropriate fire/smoke assemblies.
The resources needed for this Plan of Abatement have already been dedicated and work is moving forward seven days a week. The Fire watch will be documented using the standards established by the Colorado Department of Fire Prevention and Control."

D. Removal of Immediate Jeopardy
On March 17, 2023 at 9:00 a.m., the System Director and CHC Manager, Regulatory and ADA Standards Manager, weres notified the immediate jeopardy was removed. Deficient practice remains until all fire barriers and smoke barriers are restored to their rated assemblies per NFPA 101 2012.

Based on observation and staff interview during the course of the survey conducted ,it was determined the facility failed to maintain the means of egress in accordance with NFPA 101, 19.2.1 and Chapter 7. The following evidenced this:

Means of egress is not maintained by visual observation of equipment being stored in the path of egress in front of the super track nurse's station.

This was corrected during the survey.

Based on observation during the survey, conducted February 24 - March 17, 2023, it was determined the facility failed to install and maintain the fire alarm system in accordance with NFPA 101, section 19.3.4, 19.3.4.5, and 9.6, including NFPA 72 National Fire Alarm Code. The following evidenced this:

Smoke detectors located in North Dining have been installed within 3 feet of a return or supply diffuser, which could prevent the operation of the detector.

Detectors are not installed in accordance with NFPA 72, 17.7.4

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 72. This was evidenced by:

No alarm notification in sleeping room 2N2169

Life Safety Code section 19.3.4.3.1 to comply with section 9.6.3 Occupant notification and comply with NFPA 72. NFPA 72 section 10.10.2

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 13. This was evidenced by:

1) Sprinkler heads were found to be spaced less than 6 feet apart outside BG215ES and Pod 4300.

Life Safety Code section 19.3.5.1 to comply with section 9.7. Section 9.7.1.1(1) to comply NFPA 13. NFPA 13 section 8.6.3.4 Minimum Distances Between Sprinklers.
8.6.3.4.1 Unless the requirements of 8.6.3.4.2, 8.6.3.4.3, or
8.6.3.4.4 are met, sprinklers shall be spaced not less than 6 feet (1.8 m) on center.

2) Missing escutcheon plate for sprinkler head assembly multiple heads throughout building.

Life Safety Code section 19.3.5.1 to comply with section 9.7. Section 9.7.1.1(1) to comply NFPA 13. NFPA 13 section 6.2.7.2, in part, escutcheons shall be part of a listed sprinkler assembly.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 13. This was evidenced by:

1) Sprinkler pendent discharge outside of elevator banks on all floors in the hallway closest to Elevator E501 is obstructed by ceiling mounted corner mirror.

Life Safety Code Section 19.3.5.1 to be in compliance with Section 9.7. Section 9.7.1.1(1) to comply with NFPA 13, Section 8.6.4.1.1.1, in part, in unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of one inch.
Life Safety Code Section 19.3.5.1 to be in compliance with Section 9.7. Section 9.7.1.1(1) to comply with NFPA 13, 8.6.5.1.1, in part, sprinklers shall be located so as to minimize obstructions to discharge.

2) Missing escutcheon plate for sprinkler head assembly multiple heads throughout building.

Life Safety Code section 19.3.5.1 to comply with section 9.7. Section 9.7.1.1(1) to comply NFPA 13. NFPA 13 section 6.2.7.2, in part, escutcheons shall be part of a listed sprinkler assembly.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 13. This was evidenced by:

Missing escutcheon plate for sprinkler head assembly multiple heads throughout building.

Life Safety Code section 19.3.5.1 to comply with section 9.7. Section 9.7.1.1(1) to comply NFPA 13. NFPA 13 section 6.2.7.2, in part, escutcheons shall be part of a listed sprinkler assembly.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 25. This was evidenced by:

1) Loaded sprinkler heads in multiple locations
2) Sprinkler head corroded in kitchen

NFPA 25 2011 section 5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion.

Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 25. This was evidenced by:

Loaded sprinkler heads in multiple locations

NFPA 25 2011 section 5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion.

Based on observation and staff interview during the course of the survey conducted February 24 - March 17, 2023, it was determined the facility failed to maintain doors that protect corridor openings in accordance with NFPA 101, section 19.3.6.3. The following evidenced this:

Several patient room doors throughout the facility do not positively latch into the frame.

Life Safety Code Section 19.3.6.3.1, in part, requires doors protecting openings in a corridor to be constructed to resist the passage of smoke. Section 19.3.6.3.5, in part, doors shall be provided with means for keeping the doors closed, the device shall be capable of keeping the door closed when 5lb is applied to the latch side of the door.

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

All floors and rated walls have open penetrationsin multiple locations throughout the facility.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

All floors and rated walls throughout the facility have open penetrations.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

All floors and rated walls throughout the facility having open penetrations in multiple locations.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

Blow-out patches used on all rated smoke/fire barriers in multiple locations throughout the facility.
Drywall patches must be an approved UL listed assembly and flush with the smoke/fire barrier wall.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."


43825

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

By room 1419, pentrations and blow out patches through fire wall. Central Tower
Corridor opposite 1N001A, pentrations and blow out patches through fire wall. Central Tower
By room C14-7A, pentrations and blow out patches through fire wall. Central Tower.
Clean supply 4th floor, pentrations and blow out patches through fire wall. Central Tower.
By room 7541, pentrations and blow out patches through fire wall.
By room 7539, pentrations and blow out patches through fire wall.
By room 7631, pentrations and blow out patches through fire wall.
By room 4659, pentrations and blow out patches through fire wall. 4th floor ICU north tower.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within affected smoke compartments. Deficient items were discussed with the maintenance staff and facility administrator during the exit conference

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

1) Blow-out patches used on all rated smoke/fire barriers in multiple locations throughout the facility.
Drywall patches must be an approved UL listed assembly and flush with the smoke/fire barrier wall.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

Blow-out patches used on all rated smoke/fire barriers in multiple locations throughout the facility.
Drywall patches must be an approved UL listed assembly and flush with the smoke/fire barrier wall.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

Blow-out patches used on all rated smoke/fire barriers in multiple locations throughout the facility.
Drywall patches must be an approved UL listed assembly and flush with the smoke/fire barrier wall.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:

Blow-out patches used on all rated smoke/fire barriers. Locations: Multiple rated walls throughout the facility.
Drywall patches must be an approved UL listed assembly and flush with the smoke/fire barrier wall.

Life Safety Code section 19.3.7.3 to comply with section 8.5. Section 8.5.2.2, "Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces."

Through observation during the survey, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by:

Appliance plugged into a power-strip in room 4570b

NFPA 70, Section 400.8 Uses Not Permitted. Corrected during survey.

Through observation during the survey, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 99 and NEC 70. This was evidenced by:

Power-strip not plugged directly into an electrical outlet, "daisy-chain." Nurse's station - 7N7120

NFPA 70, Section 400.8 Uses Not Permitted. Corrected during survey.

Through observation during the survey, it was determined that the facility failed to meet the health care facilities code requirements in accordance with NFPA 101 and NFPA 99. This was evidenced by:

Improper stacking and storage of gas cylinders in room 107SD.

NFPA 101 19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.