HospitalInspections.org

This portion applies to Building A8, known as the Broomfield Sleep Lab.

It was determined through observation that the Vertical openings were not protected in accordance with Life Safety Code Section 8.2.5, as required. This was evidenced by:

At the time of the survey, the following self-closing corridor doors serving the emergency egress stair enclosures were not fully closing and positively latching on their own when released from the fully open position:
a) east stair, second floor, and
b) west stair, fourth floor.
Note: both of the above items were corrected during the survey.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The vertical opening deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A9, known as the DTC Sleep Center.

It was determined through observation that the Vertical openings were not protected in accordance with Life Safety Code Section 8.2.5, as required. This was evidenced by:

At the time of the survey, the third floor self-closing corridor door serving the west emergency egress stair enclosure was not fully closing and positively latching on its own when released from the fully open position.
Note: the above item was corrected during the survey.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The vertical opening deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A5, known as South Denver.

It was determined by observation during the survey that the facility failed to properly enclose sprinkler protected 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 area that was sprinkler protected, but was not maintained to be smoke-resistive:

The records storage room was found to have an excessive quantity of combustible materials stored therein, was larger than 55-square feet in size, but failed to have the required self-closure device on the corridor door that would make this sprinkler protected room smoke resistive.

This deficiency has the potential to affect staff, residents, and visitors to the smoke compartment.

The hazardous area deficiency item was discussed during a tour of the facility and again during the exit conference.

This portion applies to Building A5, known as South Denver.

It was determined through observation during the course of the survey that the facility failed to maintain the required battery backed-up emergency lights in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide documentation at the time of the survey to reflect that all the required battery backed-up lights within the facility had been inspected, in accordance with 7.9.3:
a) once yearly for 90-minutes during the last 12-month period, and
b) one monthly for 30-seconds during the last 12-month period.

This deficiency has the potential to affect all facility occupants, including all staff, visitors, and patients.

The emergency light deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A8, known as the Broomfield Sleep Lab.

It was determined through observation during the course of the survey that the facility failed to maintain the required battery backed-up emergency lights in accordance with the Life Safety Code. This was evidenced by:

The battery backed-up emergency light located at the intermediate landing between the second and third floors of the east emergency egress stair failed to operate when the button marked as push to test was depressed.
Note: this item was corrected during the survey.

This deficiency has the potential to affect all facility occupants, including all staff, visitors, and patients.

The emergency light deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

It was determined through observation and record review during the survey that the facility failed to maintain the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

At the time of the survey the facility supplied documentation to reflect that the facility had been maintaining the fire alarm system in-house. Upon review of the documentation it was discovered that the facility had not been documenting the completion of all the required testing and maintenance in accordance with NFPA 72 (1999), sections 7-3.2 and 7-5.2, specifically the required annual testing of all batteries serving the fire alarm system.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A2, known as the Goodman Building.

It was determined through observation and record review during the survey that the facility failed to maintain the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

At the time of the survey the facility supplied documentation to reflect that the facility had been maintaining the fire alarm system in-house. Upon review of the documentation it was discovered that the facility had not been documenting the completion of all the required testing and maintenance in accordance with NFPA 72 (1999), sections 7-3.2 and 7-5.2, specifically the required annual testing of all batteries serving the fire alarm system.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A3, known as the Smith Addition.

It was determined through observation and record review during the survey that the facility failed to maintain the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

At the time of the survey the facility supplied documentation to reflect that the facility had been maintaining the fire alarm system in-house. Upon review of the documentation it was discovered that the facility had not been documenting the completion of all the required testing and maintenance in accordance with NFPA 72 (1999), sections 7-3.2 and 7-5.2, specifically the required annual testing of all batteries serving the fire alarm system.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

It was determined by observation during the survey, that the facility failed to provide and install the automatic fire sprinkler system in accordance with NFPA 13 - Installation of Sprinkler Systems, as required. This was evidenced by the following:

1) Two sprinkler heads located in room A202 management were found to be closer than 6-feet from one another. In accordance with NFPA 13 (1999), section 5-6.3.4, pendant sprinklers shall not be located closer than 6-feet to each other.

2) Electrical room # A028 was not found to be sprinkler protected and was only surrounded by a one-hour fire rated enclosure. In accordance with NFPA 13 (1999), section 5-13.11, sprinkler protection shall be provided in electrical equipment rooms.

These deficiencies have the potential to affect all occupants of the rooms listed, which is limited to staff only in the electrical room and staff, visitors, and possibly patients in the room A202.

The automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code (2000) and NFPA 25 - Standard for Inspecting, Testing, and Maintenance of Water-Based Fire Protection Systems (1998). This was evidenced by:

1) The required escutcheon plates to pendant style sprinkler heads were missing in the following locations:
a. in office A02B,
b. in the corridor outside of room A020,
c. in the hall outside room A187a, and
d. in the basement elevator lobby outside elevator D.
Note: the above items were corrected during the survey.

2) At the time of the survey, there were numerous data and/or other electrical lines attached to the sprinkler piping in mechanical room L01. In accordance with NFPA 25 (1998), section 2-2.2, sprinkler piping shall not be subjected to external loads.

These deficiencies have the potential to affect all occupants of the above-stated rooms or locations within the facility, which may be patients, visitors, and/or staff, depending on the particular location.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A4, known as the Highlands Ranch Medical Pavilion.

It was determined through observation during the survey that the facility failed to maintain the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 25, Inspection Testing, and Maintenance of Water-based Fire Protection Systems. This was evidenced by:

1) At the time of the survey the facility failed to provide documentation to reflect that an interior inspection of the check valve(s) serving the automatic fire sprinkler system had been completed in the past five years, as required by NFPA 25, 9-4.2.

2) At the time of the survey the facility failed to provide documentation to reflect that quarterly testing of each water flow switch serving the system, as required by NFPA 25, 9-3.4, had been conducted during the following quarters:
a) third quarter of 2013, and
b) the first quarter of 2014.

These deficiencies have the potential to affect all building occupants, including staff, visitors, and patients.

The maintenance of the automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A4, known as the Highlands Ranch Medical Pavilion.

It was determined through observation and document review during the survey that the facility failed to maintain the smoke and/or fire dampers in accordance with the Life Safety Code and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every six years, as required by NFPA 90A, 3-4.7.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The heating, venting, and air conditioning deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A5, known as South Denver.

It was determined through observation and document review during the survey that the facility failed to maintain the smoke and/or fire dampers in accordance with the Life Safety Code and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every six years, as required by NFPA 90A, 3-4.7.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The heating, venting, and air conditioning deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A8, known as the Broomfield Sleep Lab.

It was determined through observation and document review during the survey that the facility failed to maintain the smoke and/or fire dampers in accordance with the Life Safety Code and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every six years, as required by NFPA 90A, 3-4.7.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The heating, venting, and air conditioning deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A9, known as the DTC Sleep Center.

It was determined through observation and document review during the survey that the facility failed to maintain the smoke and/or fire dampers in accordance with the Life Safety Code and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every six years, as required by NFPA 90A, 3-4.7.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The heating, venting, and air conditioning deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

It was determined by observation and staff interview during the survey that the facility failed to prohibit combustible decorations in accordance with Life Safety Code section 19.7.5.4. This was evidenced by the following:

1) Elevator room L010 was found to have foam accustical material attached to the walls.

2) Nurse work room A176 was found to have combustible decorations on the walls and ceiling.

Note: Both of these items were corrected at the time of the survey.

These deficiencies have the potential to affect all occupants of the above-stated rooms or locations within the facility, which may be patients, visitors, and/or staff, depending on the particular location.

Each of the above deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A2, known as the Goodman Building.

It was determined by observation during the course of the survey that the facility failed to provide safeguards for the one-hour fire-rated enclosure for the transfer of non-flammable medical oxidizing gases arranged in accordance with NFPA 99, Health Care Facilities. This was evidenced by the following:

1) The oxygen storage and transfer room on the second floor was found to have an electrical light switch located lower than the allowable 5-feet above floor level.
Note: In accordance with NFPA 99, Health Care Facilities, 4-3.1.1.2(a)4, "electrical installation in storage locations...shall be installed in fixed locations not less than 152 cm (5 ft) above the floor."

2) The facility failed to prohibited the storage of combustible items in the oxygen transfer and storage room, as required. At the time of the survey the oxygen storage and transfer room on the second floor was found to have the storage of combustible therein, including, but not limited to, plastic oxygen concentrators and fabric vests. Further, the oxygen transfer and storage room was found to be equipped with wood cabinetry.
Note: In accordance with NFPA 99, Health Care Facilities, 4-3.1.1.2(a)5&7, these locations shall be kept free of flammable and combustible material.

3) The means of egress from the IT closet, which is considered a habitable room due to use and function, must traverse the oxygen storage and transfer room on the second floor as an intervening room. In accordance with the Life Safety Code, section 19.2.5.5, intervening rooms shall not be hazardous areas; an oxygen storage and transfer room is considered a hazardous area by definition.

These deficincies have the potential to affect the occupants of the room, which should only include staff.

The oxygen storage and transfer room deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

It was determined through observation and through staff interview during the course of the survey that the facility failed to maintain the emergency backup generator that provides emergency lighting for egress in accordance with NFPA 101, Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

The facility failed to provide a remote manual stop station for the generator, as required by NFPA 110, 2000 edition, 3-5.5.6.

This deficiency has the potential to affect all building occupants, including all staff, all visitors, and all residents.

The generator deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

Through observation during the survey, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70. This was evidenced by:

1) There was a surge protected electrical power strip into a second surge protected electrical power strip in MD workroom B125.

2) Room A310a had two surge protected electrical power strips plugged into two extension cords, which were plugged into a third surge protected electrical power strip.

3) Room A317 has extension cord and a surge protected electrical power strip plugged into second surge protected electrical power strip.

Note: The above deficiencies were corrected at the time of the survey.

These deficiencies have the potential to affect all occupants of the above-stated rooms or locations within the facility, which may be patients, visitors, and/or staff, depending on the particular location.

The electrical system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A2, known as the Goodman Building.

Through observation during the survey, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70. This was evidenced by:

There was a surge protected electrical power strip into a second surge protected electrical power strip, which was plugged into an extension cord at the main desk in the library.

Note: The above deficiency was corrected at the time of the survey.

This deficiency has the potential to affect all occupants of the room which may be patients, visitors, and/or staff.

The electrical system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A5, known as South Denver.

Through observation during the survey, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70. This was evidenced by:

There was an electrical extension cord being used in place of the permanent wiring of the facility in the JW doctor's office.

Note: The above deficiency was corrected at the time of the survey.

This deficiency has the potential to affect all occupants of the room which may be patients, visitors, and/or staff.

The electrical system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A8, known as the Broomfield Sleep Lab.

It was determined through observation that the Vertical openings were not protected in accordance with Life Safety Code Section 8.2.5, as required. This was evidenced by:

At the time of the survey, the following self-closing corridor doors serving the emergency egress stair enclosures were not fully closing and positively latching on their own when released from the fully open position:
a) east stair, second floor, and
b) west stair, fourth floor.
Note: both of the above items were corrected during the survey.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The vertical opening deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A9, known as the DTC Sleep Center.

It was determined through observation that the Vertical openings were not protected in accordance with Life Safety Code Section 8.2.5, as required. This was evidenced by:

At the time of the survey, the third floor self-closing corridor door serving the west emergency egress stair enclosure was not fully closing and positively latching on its own when released from the fully open position.
Note: the above item was corrected during the survey.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The vertical opening deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A5, known as South Denver.

It was determined by observation during the survey that the facility failed to properly enclose sprinkler protected 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 area that was sprinkler protected, but was not maintained to be smoke-resistive:

The records storage room was found to have an excessive quantity of combustible materials stored therein, was larger than 55-square feet in size, but failed to have the required self-closure device on the corridor door that would make this sprinkler protected room smoke resistive.

This deficiency has the potential to affect staff, residents, and visitors to the smoke compartment.

The hazardous area deficiency item was discussed during a tour of the facility and again during the exit conference.

This portion applies to Building A5, known as South Denver.

It was determined through observation during the course of the survey that the facility failed to maintain the required battery backed-up emergency lights in accordance with the Life Safety Code. This was evidenced by:

The facility failed to provide documentation at the time of the survey to reflect that all the required battery backed-up lights within the facility had been inspected, in accordance with 7.9.3:
a) once yearly for 90-minutes during the last 12-month period, and
b) one monthly for 30-seconds during the last 12-month period.

This deficiency has the potential to affect all facility occupants, including all staff, visitors, and patients.

The emergency light deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A8, known as the Broomfield Sleep Lab.

It was determined through observation during the course of the survey that the facility failed to maintain the required battery backed-up emergency lights in accordance with the Life Safety Code. This was evidenced by:

The battery backed-up emergency light located at the intermediate landing between the second and third floors of the east emergency egress stair failed to operate when the button marked as push to test was depressed.
Note: this item was corrected during the survey.

This deficiency has the potential to affect all facility occupants, including all staff, visitors, and patients.

The emergency light deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

It was determined through observation and record review during the survey that the facility failed to maintain the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

At the time of the survey the facility supplied documentation to reflect that the facility had been maintaining the fire alarm system in-house. Upon review of the documentation it was discovered that the facility had not been documenting the completion of all the required testing and maintenance in accordance with NFPA 72 (1999), sections 7-3.2 and 7-5.2, specifically the required annual testing of all batteries serving the fire alarm system.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A2, known as the Goodman Building.

It was determined through observation and record review during the survey that the facility failed to maintain the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

At the time of the survey the facility supplied documentation to reflect that the facility had been maintaining the fire alarm system in-house. Upon review of the documentation it was discovered that the facility had not been documenting the completion of all the required testing and maintenance in accordance with NFPA 72 (1999), sections 7-3.2 and 7-5.2, specifically the required annual testing of all batteries serving the fire alarm system.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A3, known as the Smith Addition.

It was determined through observation and record review during the survey that the facility failed to maintain the Fire Alarm System in accordance with the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by:

At the time of the survey the facility supplied documentation to reflect that the facility had been maintaining the fire alarm system in-house. Upon review of the documentation it was discovered that the facility had not been documenting the completion of all the required testing and maintenance in accordance with NFPA 72 (1999), sections 7-3.2 and 7-5.2, specifically the required annual testing of all batteries serving the fire alarm system.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The Fire Alarm System deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

It was determined by observation during the survey, that the facility failed to provide and install the automatic fire sprinkler system in accordance with NFPA 13 - Installation of Sprinkler Systems, as required. This was evidenced by the following:

1) Two sprinkler heads located in room A202 management were found to be closer than 6-feet from one another. In accordance with NFPA 13 (1999), section 5-6.3.4, pendant sprinklers shall not be located closer than 6-feet to each other.

2) Electrical room # A028 was not found to be sprinkler protected and was only surrounded by a one-hour fire rated enclosure. In accordance with NFPA 13 (1999), section 5-13.11, sprinkler protection shall be provided in electrical equipment rooms.

These deficiencies have the potential to affect all occupants of the rooms listed, which is limited to staff only in the electrical room and staff, visitors, and possibly patients in the room A202.

The automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code (2000) and NFPA 25 - Standard for Inspecting, Testing, and Maintenance of Water-Based Fire Protection Systems (1998). This was evidenced by:

1) The required escutcheon plates to pendant style sprinkler heads were missing in the following locations:
a. in office A02B,
b. in the corridor outside of room A020,
c. in the hall outside room A187a, and
d. in the basement elevator lobby outside elevator D.
Note: the above items were corrected during the survey.

2) At the time of the survey, there were numerous data and/or other electrical lines attached to the sprinkler piping in mechanical room L01. In accordance with NFPA 25 (1998), section 2-2.2, sprinkler piping shall not be subjected to external loads.

These deficiencies have the potential to affect all occupants of the above-stated rooms or locations within the facility, which may be patients, visitors, and/or staff, depending on the particular location.

The Automatic Fire Sprinkler System deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A4, known as the Highlands Ranch Medical Pavilion.

It was determined through observation during the survey that the facility failed to maintain the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 25, Inspection Testing, and Maintenance of Water-based Fire Protection Systems. This was evidenced by:

1) At the time of the survey the facility failed to provide documentation to reflect that an interior inspection of the check valve(s) serving the automatic fire sprinkler system had been completed in the past five years, as required by NFPA 25, 9-4.2.

2) At the time of the survey the facility failed to provide documentation to reflect that quarterly testing of each water flow switch serving the system, as required by NFPA 25, 9-3.4, had been conducted during the following quarters:
a) third quarter of 2013, and
b) the first quarter of 2014.

These deficiencies have the potential to affect all building occupants, including staff, visitors, and patients.

The maintenance of the automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A4, known as the Highlands Ranch Medical Pavilion.

It was determined through observation and document review during the survey that the facility failed to maintain the smoke and/or fire dampers in accordance with the Life Safety Code and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every six years, as required by NFPA 90A, 3-4.7.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The heating, venting, and air conditioning deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A5, known as South Denver.

It was determined through observation and document review during the survey that the facility failed to maintain the smoke and/or fire dampers in accordance with the Life Safety Code and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every six years, as required by NFPA 90A, 3-4.7.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The heating, venting, and air conditioning deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A8, known as the Broomfield Sleep Lab.

It was determined through observation and document review during the survey that the facility failed to maintain the smoke and/or fire dampers in accordance with the Life Safety Code and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every six years, as required by NFPA 90A, 3-4.7.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The heating, venting, and air conditioning deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A9, known as the DTC Sleep Center.

It was determined through observation and document review during the survey that the facility failed to maintain the smoke and/or fire dampers in accordance with the Life Safety Code and NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every six years, as required by NFPA 90A, 3-4.7.

This deficiency has the potential to affect all occupants of the facility, including all staff, visitors, and patients.

The heating, venting, and air conditioning deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

It was determined by observation and staff interview during the survey that the facility failed to prohibit combustible decorations in accordance with Life Safety Code section 19.7.5.4. This was evidenced by the following:

1) Elevator room L010 was found to have foam accustical material attached to the walls.

2) Nurse work room A176 was found to have combustible decorations on the walls and ceiling.

Note: Both of these items were corrected at the time of the survey.

These deficiencies have the potential to affect all occupants of the above-stated rooms or locations within the facility, which may be patients, visitors, and/or staff, depending on the particular location.

Each of the above deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A2, known as the Goodman Building.

It was determined by observation during the course of the survey that the facility failed to provide safeguards for the one-hour fire-rated enclosure for the transfer of non-flammable medical oxidizing gases arranged in accordance with NFPA 99, Health Care Facilities. This was evidenced by the following:

1) The oxygen storage and transfer room on the second floor was found to have an electrical light switch located lower than the allowable 5-feet above floor level.
Note: In accordance with NFPA 99, Health Care Facilities, 4-3.1.1.2(a)4, "electrical installation in storage locations...shall be installed in fixed locations not less than 152 cm (5 ft) above the floor."

2) The facility failed to prohibited the storage of combustible items in the oxygen transfer and storage room, as required. At the time of the survey the oxygen storage and transfer room on the second floor was found to have the storage of combustible therein, including, but not limited to, plastic oxygen concentrators and fabric vests. Further, the oxygen transfer and storage room was found to be equipped with wood cabinetry.
Note: In accordance with NFPA 99, Health Care Facilities, 4-3.1.1.2(a)5&7, these locations shall be kept free of flammable and combustible material.

3) The means of egress from the IT closet, which is considered a habitable room due to use and function, must traverse the oxygen storage and transfer room on the second floor as an intervening room. In accordance with the Life Safety Code, section 19.2.5.5, intervening rooms shall not be hazardous areas; an oxygen storage and transfer room is considered a hazardous area by definition.

These deficincies have the potential to affect the occupants of the room, which should only include staff.

The oxygen storage and transfer room deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

It was determined through observation and through staff interview during the course of the survey that the facility failed to maintain the emergency backup generator that provides emergency lighting for egress in accordance with NFPA 101, Life Safety Code and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

The facility failed to provide a remote manual stop station for the generator, as required by NFPA 110, 2000 edition, 3-5.5.6.

This deficiency has the potential to affect all building occupants, including all staff, all visitors, and all residents.

The generator deficiency item was discussed during the survey and again during the exit conference.

This portion applies to Building A1, known as the May Building.

Through observation during the survey, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70. This was evidenced by:

1) There was a surge protected electrical power strip into a second surge protected electrical power strip in MD workroom B125.

2) Room A310a had two surge protected electrical power strips plugged into two extension cords, which were plugged into a third surge protected electrical power strip.

3) Room A317 has extension cord and a surge protected electrical power strip plugged into second surge protected electrical power strip.

Note: The above deficiencies were corrected at the time of the survey.

These deficiencies have the potential to affect all occupants of the above-stated rooms or locations within the facility, which may be patients, visitors, and/or staff, depending on the particular location.

The electrical system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A2, known as the Goodman Building.

Through observation during the survey, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70. This was evidenced by:

There was a surge protected electrical power strip into a second surge protected electrical power strip, which was plugged into an extension cord at the main desk in the library.

Note: The above deficiency was corrected at the time of the survey.

This deficiency has the potential to affect all occupants of the room which may be patients, visitors, and/or staff.

The electrical system deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A5, known as South Denver.

Through observation during the survey, it was determined that the facility failed to install and maintain the electrical system in accordance with NFPA 70. This was evidenced by:

There was an electrical extension cord being used in place of the permanent wiring of the facility in the JW doctor's office.

Note: The above deficiency was corrected at the time of the survey.

This deficiency has the potential to affect all occupants of the room which may be patients, visitors, and/or staff.

The electrical system deficiency items were discussed during the survey and again during the exit conference.