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Through observation during the survey, November 8 through 15, 2011, it was determined that the facility failed to maintain the two-hour fire resistance rating of the common wall between the nursing facility and the independent living facility.

During the walk through of the facility with the Director of Plant Operations, the 3-1/2-hour, fire-rated doors did not latch when closed as required by 19.1.2.2. This set of double doors is an intricate part of the two-hour fire-rated separation between the hospital and the Central Utility Plant. The doors did not latch into their frame and did not maintain a smoke seal (corrected onsite).

Through observation, during the survey, November 8 through November 15, 2011, it was determined that the facility failed to maintain the two-hour fire resistance rating of the common wall between the generator room and the chiller room.

During the walk through of the facility with the Director of Plant Operations, the 1-1/2-hour, fire-rated door did not self close as required by 7.2.1.8. This door is an intricate part of the two-hour fire-rated separation between the generator room and the rest of the building. The door catches on the concrete floor and keeps the door in the open position (corrected onsite).

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the course of the survey that the facility failed to maintain the corridor doors in accordance with the Life Safety code. This was evidenced by:

1) The following corridor doors to patient rooms had gaps larger than one half inch (1/2") between the door and the door stop:
a) patient room #365, and
b) patient room #372.
Note: these items were corrected during the survey.

2) The following corridor doors to patient rooms would not latch into the frame when closed:
a) patient room #607, and
b) patient room #619.
c) waiting room doors located on the first floor (outpatient entry door #1 and #2).
Note: these items were corrected during the survey.

3) The ground floor clean linen room door.

The corridor door deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A2, known as the 4th and 5th Floors of the South Tower.

It was determined through observation during the course of the survey, that the facility failed to maintain the corridor doors in accordance with the Life Safety code. This was evidenced by:

The 80/20 double doors were not considered to be positive latching, on the "20 side" when in the closed position. The following patient room corridor doors utilized slide locks on the "20 side" of the door for latching:
a. 466,
b. 467,
c. 468,
d. 470, and
e. 471.
Note:items #a-#e were corrected during the survey.

The corridor door deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the course of the survey, that the facility failed to maintain and protect vertical openings in accordance with the Life Safety Code. This was evidenced by:

The East stair (#3) on the sixth floor had unsealed penetrations form the corridor into the stairwell, above the drop-in ceiling. Note: this item was corrected during the survey.

The vertical opening deficiency item was discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A2, known as the 4th and 5th Floors of the South Tower.

It was determined by observation during the course of the survey, that the facility failed to maintain the fire resistance rating of the required smoke barrier in accordance with section 18.3.7.3. This was evidenced by the following:

Smoke wall outside room #475 contained one (1) unsealed pipe penetration.
Note: this item was corrected during the survey.

The smoke barrier deficiency item was discussed during the survey and again during the exit conference on November 15, 2011.

Through observation during the survey, November 8 through November 15, 2011, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility with the Director of Plant Operations, the cross-corridor door located on the ground floor in the one (1) hour separation wall, was not affixed with self closing devices.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain and protect sprinkler protected hazardous areas in accordance with the Life Safety Code. This was evidenced by:

1) The 4 North Equipment Storage room, housing combustible materials and greater than 55 square feet, failed to have the required self-closure device on the corridor door.
Note: this item was corrected during the survey.

The hazardous area deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation during the survey, November 8 through 15, 2011, it was determined that the facility failed to maintain the doors to the hazardous areas.

During the walk-through of the facility with the Director of Plant Operations:
1) The ground floor soiled linen room does not latch into its frame.
2) The second floor trash chute door did not latch into its frame. (Corrected onsite.)

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

1) The Northeast cross-corridor doors on the seventh (7th) floor are equipped with an access-controlled egress function. The doors fail to allow free egress to the required secondary means of egress from the East side of the doors, as required.

2) The secured access-controlled cross-corridor egress doors in the following locations failed to unlock with activation of the fire alarm system, as required:
a. The Southeast cross-corridor doors on the seventh (7th) floor, and
b. The Northeast cross-corridor doors on the seventh (7th) floor.

3) The entry doors into the women and newborn care unit on the third (3rd) floor is labeled as an exit; however, the doors are equipped with access-controlled egress and egress is not allowed from the East side of the corridor during normal operation of these doors.
Note: this item was corrected during the survey.

The means of egress deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A3, known as LAH Medical Imaging.

It was determined by observation and staff interview during the survey that the facility failed to maintain the battery backed-up emergency lighting in mandatory emergency lighting as required by NFPA 101. This was evidenced by the following:

1) No emergency lighting within the facility.

2) Documentation not provided to reflect emergency lighting in the building had been inspected:
a. Monthly for 30-seconds, and
b. Once yearly for 90-minutes.

The emergency lighting deficiency item was discussed during the exit conference on November 15, 2011.

This portion applies to Building A4, known as Outpatient Rehabilitation Physical Medicine.

It was determined by observation and staff interview during the survey that the facility failed to maintain the battery backed-up emergency lighting in mandatory emergency lighting as required by NFPA 101. This was evidenced by the following:

1) No emergency lighting within the facility.

2) Documentation not provided to reflect emergency lighting in the building had been inspected:
a. Monthly for 30-seconds, and
Note: The facility did provide documentation that the systems were being tested quarterly, but not as required above.
b. Once yearly for 90-minutes.

The emergency lighting deficiency item was discussed during the exit conference on November 15, 2011.

This portion applies to Building A5, known as the Perinatal Center.

It was determined by observation and staff interview during the survey, that the facility failed to maintain the battery backed-up emergency lighting in mandatory emergency lighting as required by NFPA 101. This was evidenced by the following:

1) No emergency lighting within the facility.

2) Documentation not provided to reflect emergency lighting in the building had been inspected:
a. Monthly for 30-seconds, and
Note: The facility did provide documentation that the systems were being tested quarterly, but not as required above.
b. Once yearly for 90-minutes.

3) Two (2) of two (2) battery backed-up emergency lights tested failed to illuminate.

The emergency lighting deficiency item was discussed during the exit conference on November 15, 2011.

This portion applies to Building AA, known as the Castle Rock Adventist Health Campus.

It was determined by observation and staff interview during the survey, that the facility failed to maintain the battery backed-up emergency lighting in mandatory emergency lighting as required by NFPA 101. This was evidenced by the following:

Documentation not provided to reflect emergency lighting in the building had been inspected monthly for 30-seconds, as required.

The emergency lighting deficiency item was discussed during the exit conference on November 15, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation, document review, and staff interview during the survey, that the facility failed to conduct fire drills in accordance with the Life Safety Code and the facility's written procedures for response to fire emergencies. This was evidenced by:

1) A fire drill was held on November 10, 2011 during which responders failed to employ the written procedures of the facility's response to fire emergencies. This was evidenced by the following:
a. A Workstation On Wheels (WOW) was left in the corridor on the seventh (7th) floor of the facility, blocking one of two smoke barrier doors from opening as intended.

The fire drill deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation during the survey, November 10, 2011, it was determined that the facility failed to properly train staff on procedures to follow during a fire emergency.

During the fire drill conducted/observed on Thursday, November 10, 2011, the staff failed to follow the facilities plans and procedures for fire drills. Staff failed to:
1) Compartmentalize the fire by closing the door to the room of fire origin.
2) Activate the fire alarm system.

This portion applies to Building A3, known as LAH Medical Imaging.

It was determined through observation and staff interview 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:

1) The facility failed to provide an annual inspection report of the fire alarm system at the time of the survey.

2) The facility to provide a report reflecting that each detector within the facility had been sensitivity tested within the past two-year period, as required.

The fire alarm system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A4, known as Outpatient Rehabilitation Physical Medicine.

It was determined through observation and staff interview 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:

The facility to provide a report reflecting that each detector within the facility had been sensitivity tested within the past two-year period, as required.

The fire alarm system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A5, known as the Perinatal Center.

It was determined through observation and staff interview 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:

The facility to provide a report reflecting that each detector within the facility had been sensitivity tested within the past two-year period, as required.

The fire alarm system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

Through observation during the survey, conducted November 8 through November 15, 2011, it was determined that the facility failed to maintain the fire alarm system equipment in accordance with NFPA 72.

During the walk through of the facility with the Director of Plant Operations, the first floor IT closet smoke detector was found to be installed 4 ft from the ceiling deck.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to install the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems. This was evidenced by:

1) Sprinkler protection not extended to the following areas:
a. The back of patient room #516.
Note: this item was corrected during the survey.
b. The infusion center entry overhang on the ground floor. Although this overhang is constructed of non-combustible material, there were several vehicles and a trailer parked underneath the overhang at the time of the survey.

2) The sprinkler head near the nurse station in the OB/GYN OR corridor was found to be within an inch of the hanging cabinets.

The automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation during the survey, November 8 through November 15, 2011, it was determined that the facility failed to provide an automatic sprinkler system, which provides complete coverage for all portions of the building.

During the walk through of the facility with the Director of Plant Operations:

1) The supply chain receiving area located on the ground floor has one (1) closet without fire sprinkler coverage. (Comm. Equipment.)
2) Administrative office located on the first floor has one (1) closet without fire sprinkler protection.
3) The process improvement office located on the first floor has two (2) closets that have no fire sprinkler protection.
4) The men's changing room located on the second floor has no fire sprinkler protection.

This portion applies to Building A2, known as the 4th and 5th Floors of the South Tower.

It was determined through observation during the survey, that the facility failed to install the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems. This was evidenced by:

Sprinkler protection was not extended to the bathroom in patient room #452.
Note: this item was corrected during the survey.

The automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to install and maintain the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection Testing, and Maintenance of Water-based Fire Protection Systems. This was evidenced by:

1) Escutcheon plates missing:
a. In the 7 North Storage room.
Note: this item was corrected during the survey.
b. In the sub-sterile room between OB/GYN ORs #1 and #2.

2) Sprinkler head obstructions:
a. The sign hanging from the ceiling outside patient room #518 was too close to the sprinkler head (within approximately 8 inches of the sign).
Note: this item was corrected during the survey.

3) Items hanging from sprinkler system piping:
a. Two (2) empty tape rolls hanging from sprinkler pipe in eighth floor penthouse.
Note: this item was corrected during the survey.
b. Cable bundle zip-tied to sprinkler pipe in 7 north LVR closet.
Note: this item was corrected during the survey.
c. Cable bundle zip-tied to sprinkler pipe in 6 north LVR closet.
Note: this item was corrected during the survey.

The maintenance of the automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation and record review during the survey during the survey, November 8 through November 15, 2011, it was determined that the facility failed to maintain the sprinkler system in a reliable operating condition.

During the walk through of the facility with the Director of Plant Operations:

1) One (1) fire sprinkler head in the atrium was found to be in the wrong orientation.

2) The communication equipment room located on the ground floor is missing several ceiling tiles.

3) The first Floor Cafe dish room had a fly trap hanging from one (1) fire sprinkler head. (Corrected onsite.)

4) The first floor administration office closet has storage one (1) inch from the fire sprinkler head. (Corrected onsite.)

5) Escutcheons were missing in the following locations:
1. The kitchen walk in freezer on ground floor.
2. The corridor by equipment room #4 on ground floor. (Corrected onsite.)3. The cafe dish room on first floor.4. The family life office on the first floor.5. The ER forensics closet on the ground floor (by Exam Room #9).

This portion applies to Building A2, known as the 4th and 5th Floors of the South Tower.

It was determined through observation during the survey, that the facility failed to install and maintain the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection Testing, and Maintenance of Water-based Fire Protection Systems. This was evidenced by:

Escutcheon plate missing in patient room #555.
Note: this item was corrected during the survey.

The maintenance of the automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A3, known as LAH Medical Imaging.

It was determined by observation during that survey, that the facility failed to provide and maintain portable fire extinguishers in accordance with the Life Safety Code and NFPA 10. This was evidenced by;

The facility failed to provide any portable fire extinguishers in the facility.

The fire alarm system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

Through observation during the survey, November 8 through November 15, 2011, it was determined that the facility failed to conduct an annual and monthly inspection on one (1) portable fire extinguisher.

During the walk through of the facility with the Director of Plant Operations, one (1) portable fire extinguisher was not marked with an annual and monthly check per 9.7.4.1 and NFPA 10 1999 Edition section 4-3.1.

Through observation during the survey, November 8 through November 15, 2011, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walk through of the facility with the Director of Plant Operations:
1. Storage of card board boxes on the ground floor in the corridor outside of the ASC. (Corrected onsite.)
2. Storage in the corridor (several blue linen carts) by Exam Room #8. (Corrected onsite.)

This portion applies to Building A3, known as LAH Medical Imaging.

It was determined through observation, that the facility failed to maintain the existing fire-rated occupancy separations in accordance with the Life Safety Code and NFPA 221, Standard for Fire walls and Fire Barrier Walls. This was evidenced by:

The occupancy separation between the space licensed and certified under the Hospital and an adjacent space that is not licensed or certified under the Hospital failed to be complete, as evidenced by:
a. The separation door was found to be a 20-minute fire rated door, rather than the required ¾ hour fire rated door.
b. The separation door was found to be propped open at the time of the survey.
c. The separation walls on the South and the West side of the facility were found to:
i. Not be continuous to roof deck,
ii. Have several unsealed penetrations, and
iii. The seams were not finished, as required.

The maintenance of the fire-rated occupancy separation deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A4, known as Outpatient Rehabilitation Physical Medicine.

It was determined through observation, that the facility failed to maintain the existing fire-rated occupancy separations in accordance with the Life Safety Code and NFPA 221, Standard for Fire walls and Fire Barrier Walls. This was evidenced by:

The occupancy separation between the space licensed and certified under the Hospital and an adjacent space that is not licensed or certified under the Hospital failed to be complete, as evidenced by:
a. The separation doors were found to be a 20-minute fire rated doors, rather than the required ¾ hour fire rated doors.
b. The separation wall on the corridor side of the facility was found to have several unsealed penetrations.

The maintenance of the fire-rated occupancy separation deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A5, known as the Perinatal Center.

It was determined through observation, that the facility failed to maintain the existing fire-rated occupancy separations in accordance with the Life Safety Code and NFPA 221, Standard for Fire walls and Fire Barrier Walls. This was evidenced by:

The occupancy separation between the space licensed and certified under the Hospital and an adjacent space that is not licensed or certified under the Hospital failed to be complete, as evidenced by:
a. The separation doors were found to be a 20-minute fire rated doors, rather than the required ¾ hour fire rated doors.
b. The separation wall on the corridor side of the facility was found to have several unsealed penetrations.

The maintenance of the fire-rated occupancy separation deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

1. Through record review during the survey, November 10, 2011, it was determined that the facility failed to conduct fire drills at least quarterly on each shift.

During the review of records, documentation could not be provided showing that fire drills have been conducted.

2. Through a review of the records during the survey, November 10, 2011, it was determined that the facility failed to maintain the fire alarm system.

During the review of records, documentation could not be provided showing that the smoke detectors have been sensitivity tested.

3. Through record review during the survey, November 10, 2011, it was determined that the facility failed to document the generator testing every month.

Documentation could not be provided:
a) showing that the generator has been run under load monthly or that a load bank test has been performed annually.
b) showing that the generator has been annually tested.

4. Through observation, during the survey November 10, 2011, it was determined that the facility failed to provide emergency lighting of 1-1/2 hour duration as required by NFPA 110, Chapter 5, Section 5-3.

During the walk through of the facility with the Director of Plant Operations, no emergency lighting was provided in the immediate area of the emergency generator.

5. Through observation during the survey, November 10, 2011, it was determined that the facility failed to maintain the one-hour fire resistance rating of the common wall.

During the walk through of the facility with the Director of Plant Operations, the South Denver Heart Center did not have a complete one (1) hour separation from the remainder of the building.

6. Through observation during the survey, November 10, 2011, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During the walk through of the facility with the Director of Plant Operations, no documentation could be provided showing that the curtains in all six (6) patient rooms in the Cath Lab and three (3) curtains in the ECP room are inherently flame resistant.

7. Through observation and record review during the survey, November 10, 2011, it was determined that the facility failed to maintain the sprinkler system in a reliable operating condition.

During the walk through of the facility with the Director of Plant Operations, one (1) fire sprinkler head in the pump room was missing an escutcheon (diagnostic area).

8. Through observation during the survey, November 10, 2011, it was determined the facility failed to maintain the door to the hazardous areas.

During the walk through of the facility with the Director of Plant Operations, the door to the oxygen storage room did not latch into the frame (diagnostic area).

9. Through observation during the survey, November 10, 2011, it was determined that the facility failed to maintain the sprinkler system in a reliable operating condition.

During the walk through of the facility with the Director of Plant Operations, several ceiling tile were missing in the video room (CT area).

Through observation during the survey, November 8 through November 15, 2011, it was determined that the facility failed to maintain environments as free from combustible materials.

During the walk through of the facility with the Director of Plant Operations, one (1) tree is located 6 feet from the liquid oxygen tanks. Combustible materials shall not be within 25 of the tanks.

This portion applies to Building AA, known as the Castle Rock Adventist Health Campus.

It was determined through observation during the survey, that the facility failed to maintain the generator and related equipment in accordance with the Life Safety Code, NFPA 99, Healthcare Facilities, and NFPA 110, Standard for Emergency and Standby Power Equipment. This was evidenced by:

Documentation not provided to reflect the emergency generator had been inspected weekly, as required.

The generator deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation, staff interview and document review, that the facility failed to install and maintain the essential electrical system in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

1) Panel LEMPA on the eighth floor penthouse, found to be connected via the Equipment Branch, supplied power to an exit sign (circuit #17) and the elevator shunt trip controller (circuit #12). All portions of the fire alarm system and all exit signs shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

2) Panel LEC3C1 on the third floor, found to be connected via the Critical Branch, supplied power to the Fire Alarm Control Panel (circuit #75) and a Fire Alarm Panel (circuit #77). All portions of the fire alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

3) Panel LEC3D on the third floor, found to be connected via the Critical Branch, supplied power to Fire Alarm Pad 3 (circuit #23). All portions of the fire alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

4) Panel HEC3A on the third floor, found to be connected via the Critical Branch, supplied power to the wing's corridor emergency lights (circuits #1, #3, and #5). All lights utilized for emergency egress lighting shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

5) The following panels were missing their schedules and it could not be determined if all circuits were correctly placed:
a. Panel LEC3C3 on the third floor.
Note: this item was corrected during the survey.
b. Panel LEC4A on the fourth floor.
c. Panel HEC4A on the fourth floor.

The essential electrical system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation during the survey, November 8 through November 15, 2011, it was determined that facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the walk through of the facility with the Director of Plant Operations:
1) Ground floor - Panel LELSBB, circuit #16 was found to be connected via the Life Safety Branch, supplying power to the morgue cooler. The Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2. allows only systems essential for life safety systems to be powered by this branch.
2) Ground floor - Panel LEMBA2:
a. Relocate circuit #3 and #5 (dust machine) from the critical branch to the equipment branch.
b. Relocate circuit #16 (pre-action compressor) from the critical branch to the life safety branch (corrected onsite).
3) Ground floor - panel HEMBB has a jockey pump being powered by the critical branch. The jockey pump shall be powered by the life safety branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.
4) Ground floor - LEMBB, circuit #6 is being powered by the critical branch, supplied power to the Fire Control Panel (FCP). The FCP shall be powered by the Life Safety Branch.
5) 1st floor - panel LEC1CA-Critical branch.
a. Remove the following circuits from this branch (corrected onsite).
i. Circuit #8 - water fall healing garden.
ii. Circuit #11 - Court yard sign.
iii. Circuit #12 - Ball fountain.
6) Ground floor - panel LECBA1, circuit #19, #21, #23, #25, and #29 was found to be connected via the critical branch, supplied power to the E.R. televisions.
7) First floor lab- panel LEC1CA - Critical branch, circuit #10 was found to be connected via the critical branch, supplied power to the fire alarm chime and strobes. Functions of the life safety systems shall be powered by the life safety branch.
8) Second floor - panel LEC2C, circuit #2 was found to be connected via the electrical branch, supplied power to the fire alarm NAC panel, fire alarm components shall be connected via the life safety branch.
9) Second floor - panel HEC2A, circuit #8 was found to be connected to the electrical branch, supplied power to the Southeast emergency lighting. Emergency lighting shall be connected via the Life Safety Branch.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the course of the survey, that the facility failed to provide and maintain the electrical systems in accordance with the NFPA 70, National Electric Code. This was evidenced by:

Television equipment in the eighth floor penthouse had a surge protected power strip plugged into a second multiple outlet electrical power strip.

The electrical system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation during the survey during the survey November 8 through November 15, 2011, it was determined that the facility failed to maintain and install electrical wiring in accordance with NFPA 70, National Electrical Code.

During the walk through of the facility with the Director of Plant Operations, the cafe service line had an extension cord powering the Panini maker (corrected onsite).

This portion applies to Building A2, known as the 4th and 5th Floors of the South Tower.

It was determined by observation during the course of the survey, that the facility failed to provide and maintain the electrical systems in accordance with the NFPA 70, National Electric Code. This was evidenced by:

The respiratory supply room on the fourth floor had an extension cord in place of permanent wiring to provide power to a computer station.
Note: this item corrected during the survey.

The electrical system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A4, known as Outpatient Rehabilitation Physical Medicine.

It was determined by observation during the course of the survey, that the facility failed to provide and maintain the electrical systems in accordance with the NFPA 70, National Electric Code. This was evidenced by:

The front desk was found to have a surge protected power strip plugged into a second multiple outlet electrical power strip.
Note: this item corrected during the survey.

The electrical system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

Through observation during the survey, November 8 through 15, 2011, it was determined that the facility failed to maintain the two-hour fire resistance rating of the common wall between the nursing facility and the independent living facility.

During the walk through of the facility with the Director of Plant Operations, the 3-1/2-hour, fire-rated doors did not latch when closed as required by 19.1.2.2. This set of double doors is an intricate part of the two-hour fire-rated separation between the hospital and the Central Utility Plant. The doors did not latch into their frame and did not maintain a smoke seal (corrected onsite).

Through observation, during the survey, November 8 through November 15, 2011, it was determined that the facility failed to maintain the two-hour fire resistance rating of the common wall between the generator room and the chiller room.

During the walk through of the facility with the Director of Plant Operations, the 1-1/2-hour, fire-rated door did not self close as required by 7.2.1.8. This door is an intricate part of the two-hour fire-rated separation between the generator room and the rest of the building. The door catches on the concrete floor and keeps the door in the open position (corrected onsite).

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the course of the survey that the facility failed to maintain the corridor doors in accordance with the Life Safety code. This was evidenced by:

1) The following corridor doors to patient rooms had gaps larger than one half inch (1/2") between the door and the door stop:
a) patient room #365, and
b) patient room #372.
Note: these items were corrected during the survey.

2) The following corridor doors to patient rooms would not latch into the frame when closed:
a) patient room #607, and
b) patient room #619.
c) waiting room doors located on the first floor (outpatient entry door #1 and #2).
Note: these items were corrected during the survey.

3) The ground floor clean linen room door.

The corridor door deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A2, known as the 4th and 5th Floors of the South Tower.

It was determined through observation during the course of the survey, that the facility failed to maintain the corridor doors in accordance with the Life Safety code. This was evidenced by:

The 80/20 double doors were not considered to be positive latching, on the "20 side" when in the closed position. The following patient room corridor doors utilized slide locks on the "20 side" of the door for latching:
a. 466,
b. 467,
c. 468,
d. 470, and
e. 471.
Note:items #a-#e were corrected during the survey.

The corridor door deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the course of the survey, that the facility failed to maintain and protect vertical openings in accordance with the Life Safety Code. This was evidenced by:

The East stair (#3) on the sixth floor had unsealed penetrations form the corridor into the stairwell, above the drop-in ceiling. Note: this item was corrected during the survey.

The vertical opening deficiency item was discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A2, known as the 4th and 5th Floors of the South Tower.

It was determined by observation during the course of the survey, that the facility failed to maintain the fire resistance rating of the required smoke barrier in accordance with section 18.3.7.3. This was evidenced by the following:

Smoke wall outside room #475 contained one (1) unsealed pipe penetration.
Note: this item was corrected during the survey.

The smoke barrier deficiency item was discussed during the survey and again during the exit conference on November 15, 2011.

Through observation during the survey, November 8 through November 15, 2011, it was determined that the facility failed to maintain the smoke barrier doors.

During the walk through of the facility with the Director of Plant Operations, the cross-corridor door located on the ground floor in the one (1) hour separation wall, was not affixed with self closing devices.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain and protect sprinkler protected hazardous areas in accordance with the Life Safety Code. This was evidenced by:

1) The 4 North Equipment Storage room, housing combustible materials and greater than 55 square feet, failed to have the required self-closure device on the corridor door.
Note: this item was corrected during the survey.

The hazardous area deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation during the survey, November 8 through 15, 2011, it was determined that the facility failed to maintain the doors to the hazardous areas.

During the walk-through of the facility with the Director of Plant Operations:
1) The ground floor soiled linen room does not latch into its frame.
2) The second floor trash chute door did not latch into its frame. (Corrected onsite.)

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to maintain the means of egress in accordance with the Life Safety Code. This was evidenced by:

1) The Northeast cross-corridor doors on the seventh (7th) floor are equipped with an access-controlled egress function. The doors fail to allow free egress to the required secondary means of egress from the East side of the doors, as required.

2) The secured access-controlled cross-corridor egress doors in the following locations failed to unlock with activation of the fire alarm system, as required:
a. The Southeast cross-corridor doors on the seventh (7th) floor, and
b. The Northeast cross-corridor doors on the seventh (7th) floor.

3) The entry doors into the women and newborn care unit on the third (3rd) floor is labeled as an exit; however, the doors are equipped with access-controlled egress and egress is not allowed from the East side of the corridor during normal operation of these doors.
Note: this item was corrected during the survey.

The means of egress deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A3, known as LAH Medical Imaging.

It was determined by observation and staff interview during the survey that the facility failed to maintain the battery backed-up emergency lighting in mandatory emergency lighting as required by NFPA 101. This was evidenced by the following:

1) No emergency lighting within the facility.

2) Documentation not provided to reflect emergency lighting in the building had been inspected:
a. Monthly for 30-seconds, and
b. Once yearly for 90-minutes.

The emergency lighting deficiency item was discussed during the exit conference on November 15, 2011.

This portion applies to Building A4, known as Outpatient Rehabilitation Physical Medicine.

It was determined by observation and staff interview during the survey that the facility failed to maintain the battery backed-up emergency lighting in mandatory emergency lighting as required by NFPA 101. This was evidenced by the following:

1) No emergency lighting within the facility.

2) Documentation not provided to reflect emergency lighting in the building had been inspected:
a. Monthly for 30-seconds, and
Note: The facility did provide documentation that the systems were being tested quarterly, but not as required above.
b. Once yearly for 90-minutes.

The emergency lighting deficiency item was discussed during the exit conference on November 15, 2011.

This portion applies to Building A5, known as the Perinatal Center.

It was determined by observation and staff interview during the survey, that the facility failed to maintain the battery backed-up emergency lighting in mandatory emergency lighting as required by NFPA 101. This was evidenced by the following:

1) No emergency lighting within the facility.

2) Documentation not provided to reflect emergency lighting in the building had been inspected:
a. Monthly for 30-seconds, and
Note: The facility did provide documentation that the systems were being tested quarterly, but not as required above.
b. Once yearly for 90-minutes.

3) Two (2) of two (2) battery backed-up emergency lights tested failed to illuminate.

The emergency lighting deficiency item was discussed during the exit conference on November 15, 2011.

This portion applies to Building AA, known as the Castle Rock Adventist Health Campus.

It was determined by observation and staff interview during the survey, that the facility failed to maintain the battery backed-up emergency lighting in mandatory emergency lighting as required by NFPA 101. This was evidenced by the following:

Documentation not provided to reflect emergency lighting in the building had been inspected monthly for 30-seconds, as required.

The emergency lighting deficiency item was discussed during the exit conference on November 15, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation, document review, and staff interview during the survey, that the facility failed to conduct fire drills in accordance with the Life Safety Code and the facility's written procedures for response to fire emergencies. This was evidenced by:

1) A fire drill was held on November 10, 2011 during which responders failed to employ the written procedures of the facility's response to fire emergencies. This was evidenced by the following:
a. A Workstation On Wheels (WOW) was left in the corridor on the seventh (7th) floor of the facility, blocking one of two smoke barrier doors from opening as intended.

The fire drill deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation during the survey, November 10, 2011, it was determined that the facility failed to properly train staff on procedures to follow during a fire emergency.

During the fire drill conducted/observed on Thursday, November 10, 2011, the staff failed to follow the facilities plans and procedures for fire drills. Staff failed to:
1) Compartmentalize the fire by closing the door to the room of fire origin.
2) Activate the fire alarm system.

This portion applies to Building A3, known as LAH Medical Imaging.

It was determined through observation and staff interview 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:

1) The facility failed to provide an annual inspection report of the fire alarm system at the time of the survey.

2) The facility to provide a report reflecting that each detector within the facility had been sensitivity tested within the past two-year period, as required.

The fire alarm system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A4, known as Outpatient Rehabilitation Physical Medicine.

It was determined through observation and staff interview 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:

The facility to provide a report reflecting that each detector within the facility had been sensitivity tested within the past two-year period, as required.

The fire alarm system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A5, known as the Perinatal Center.

It was determined through observation and staff interview 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:

The facility to provide a report reflecting that each detector within the facility had been sensitivity tested within the past two-year period, as required.

The fire alarm system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

Through observation during the survey, conducted November 8 through November 15, 2011, it was determined that the facility failed to maintain the fire alarm system equipment in accordance with NFPA 72.

During the walk through of the facility with the Director of Plant Operations, the first floor IT closet smoke detector was found to be installed 4 ft from the ceiling deck.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey that the facility failed to install the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems. This was evidenced by:

1) Sprinkler protection not extended to the following areas:
a. The back of patient room #516.
Note: this item was corrected during the survey.
b. The infusion center entry overhang on the ground floor. Although this overhang is constructed of non-combustible material, there were several vehicles and a trailer parked underneath the overhang at the time of the survey.

2) The sprinkler head near the nurse station in the OB/GYN OR corridor was found to be within an inch of the hanging cabinets.

The automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation during the survey, November 8 through November 15, 2011, it was determined that the facility failed to provide an automatic sprinkler system, which provides complete coverage for all portions of the building.

During the walk through of the facility with the Director of Plant Operations:

1) The supply chain receiving area located on the ground floor has one (1) closet without fire sprinkler coverage. (Comm. Equipment.)
2) Administrative office located on the first floor has one (1) closet without fire sprinkler protection.
3) The process improvement office located on the first floor has two (2) closets that have no fire sprinkler protection.
4) The men's changing room located on the second floor has no fire sprinkler protection.

This portion applies to Building A2, known as the 4th and 5th Floors of the South Tower.

It was determined through observation during the survey, that the facility failed to install the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems. This was evidenced by:

Sprinkler protection was not extended to the bathroom in patient room #452.
Note: this item was corrected during the survey.

The automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation during the survey, that the facility failed to install and maintain the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection Testing, and Maintenance of Water-based Fire Protection Systems. This was evidenced by:

1) Escutcheon plates missing:
a. In the 7 North Storage room.
Note: this item was corrected during the survey.
b. In the sub-sterile room between OB/GYN ORs #1 and #2.

2) Sprinkler head obstructions:
a. The sign hanging from the ceiling outside patient room #518 was too close to the sprinkler head (within approximately 8 inches of the sign).
Note: this item was corrected during the survey.

3) Items hanging from sprinkler system piping:
a. Two (2) empty tape rolls hanging from sprinkler pipe in eighth floor penthouse.
Note: this item was corrected during the survey.
b. Cable bundle zip-tied to sprinkler pipe in 7 north LVR closet.
Note: this item was corrected during the survey.
c. Cable bundle zip-tied to sprinkler pipe in 6 north LVR closet.
Note: this item was corrected during the survey.

The maintenance of the automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation and record review during the survey during the survey, November 8 through November 15, 2011, it was determined that the facility failed to maintain the sprinkler system in a reliable operating condition.

During the walk through of the facility with the Director of Plant Operations:

1) One (1) fire sprinkler head in the atrium was found to be in the wrong orientation.

2) The communication equipment room located on the ground floor is missing several ceiling tiles.

3) The first Floor Cafe dish room had a fly trap hanging from one (1) fire sprinkler head. (Corrected onsite.)

4) The first floor administration office closet has storage one (1) inch from the fire sprinkler head. (Corrected onsite.)

5) Escutcheons were missing in the following locations:
1. The kitchen walk in freezer on ground floor.
2. The corridor by equipment room #4 on ground floor. (Corrected onsite.)3. The cafe dish room on first floor.4. The family life office on the first floor.5. The ER forensics closet on the ground floor (by Exam Room #9).

This portion applies to Building A2, known as the 4th and 5th Floors of the South Tower.

It was determined through observation during the survey, that the facility failed to install and maintain the automatic fire sprinkler system in accordance with the Life Safety Code and NFPA 13, Installation of Sprinkler Systems and NFPA 25, Inspection Testing, and Maintenance of Water-based Fire Protection Systems. This was evidenced by:

Escutcheon plate missing in patient room #555.
Note: this item was corrected during the survey.

The maintenance of the automatic fire sprinkler system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A3, known as LAH Medical Imaging.

It was determined by observation during that survey, that the facility failed to provide and maintain portable fire extinguishers in accordance with the Life Safety Code and NFPA 10. This was evidenced by;

The facility failed to provide any portable fire extinguishers in the facility.

The fire alarm system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

Through observation during the survey, November 8 through November 15, 2011, it was determined that the facility failed to conduct an annual and monthly inspection on one (1) portable fire extinguisher.

During the walk through of the facility with the Director of Plant Operations, one (1) portable fire extinguisher was not marked with an annual and monthly check per 9.7.4.1 and NFPA 10 1999 Edition section 4-3.1.

Through observation during the survey, November 8 through November 15, 2011, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency.

During the walk through of the facility with the Director of Plant Operations:
1. Storage of card board boxes on the ground floor in the corridor outside of the ASC. (Corrected onsite.)
2. Storage in the corridor (several blue linen carts) by Exam Room #8. (Corrected onsite.)

This portion applies to Building A3, known as LAH Medical Imaging.

It was determined through observation, that the facility failed to maintain the existing fire-rated occupancy separations in accordance with the Life Safety Code and NFPA 221, Standard for Fire walls and Fire Barrier Walls. This was evidenced by:

The occupancy separation between the space licensed and certified under the Hospital and an adjacent space that is not licensed or certified under the Hospital failed to be complete, as evidenced by:
a. The separation door was found to be a 20-minute fire rated door, rather than the required ¾ hour fire rated door.
b. The separation door was found to be propped open at the time of the survey.
c. The separation walls on the South and the West side of the facility were found to:
i. Not be continuous to roof deck,
ii. Have several unsealed penetrations, and
iii. The seams were not finished, as required.

The maintenance of the fire-rated occupancy separation deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A4, known as Outpatient Rehabilitation Physical Medicine.

It was determined through observation, that the facility failed to maintain the existing fire-rated occupancy separations in accordance with the Life Safety Code and NFPA 221, Standard for Fire walls and Fire Barrier Walls. This was evidenced by:

The occupancy separation between the space licensed and certified under the Hospital and an adjacent space that is not licensed or certified under the Hospital failed to be complete, as evidenced by:
a. The separation doors were found to be a 20-minute fire rated doors, rather than the required ¾ hour fire rated doors.
b. The separation wall on the corridor side of the facility was found to have several unsealed penetrations.

The maintenance of the fire-rated occupancy separation deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A5, known as the Perinatal Center.

It was determined through observation, that the facility failed to maintain the existing fire-rated occupancy separations in accordance with the Life Safety Code and NFPA 221, Standard for Fire walls and Fire Barrier Walls. This was evidenced by:

The occupancy separation between the space licensed and certified under the Hospital and an adjacent space that is not licensed or certified under the Hospital failed to be complete, as evidenced by:
a. The separation doors were found to be a 20-minute fire rated doors, rather than the required ¾ hour fire rated doors.
b. The separation wall on the corridor side of the facility was found to have several unsealed penetrations.

The maintenance of the fire-rated occupancy separation deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

1. Through record review during the survey, November 10, 2011, it was determined that the facility failed to conduct fire drills at least quarterly on each shift.

During the review of records, documentation could not be provided showing that fire drills have been conducted.

2. Through a review of the records during the survey, November 10, 2011, it was determined that the facility failed to maintain the fire alarm system.

During the review of records, documentation could not be provided showing that the smoke detectors have been sensitivity tested.

3. Through record review during the survey, November 10, 2011, it was determined that the facility failed to document the generator testing every month.

Documentation could not be provided:
a) showing that the generator has been run under load monthly or that a load bank test has been performed annually.
b) showing that the generator has been annually tested.

4. Through observation, during the survey November 10, 2011, it was determined that the facility failed to provide emergency lighting of 1-1/2 hour duration as required by NFPA 110, Chapter 5, Section 5-3.

During the walk through of the facility with the Director of Plant Operations, no emergency lighting was provided in the immediate area of the emergency generator.

5. Through observation during the survey, November 10, 2011, it was determined that the facility failed to maintain the one-hour fire resistance rating of the common wall.

During the walk through of the facility with the Director of Plant Operations, the South Denver Heart Center did not have a complete one (1) hour separation from the remainder of the building.

6. Through observation during the survey, November 10, 2011, it was determined that the facility failed to provide curtains that comply with NFPA 701 in all areas.

During the walk through of the facility with the Director of Plant Operations, no documentation could be provided showing that the curtains in all six (6) patient rooms in the Cath Lab and three (3) curtains in the ECP room are inherently flame resistant.

7. Through observation and record review during the survey, November 10, 2011, it was determined that the facility failed to maintain the sprinkler system in a reliable operating condition.

During the walk through of the facility with the Director of Plant Operations, one (1) fire sprinkler head in the pump room was missing an escutcheon (diagnostic area).

8. Through observation during the survey, November 10, 2011, it was determined the facility failed to maintain the door to the hazardous areas.

During the walk through of the facility with the Director of Plant Operations, the door to the oxygen storage room did not latch into the frame (diagnostic area).

9. Through observation during the survey, November 10, 2011, it was determined that the facility failed to maintain the sprinkler system in a reliable operating condition.

During the walk through of the facility with the Director of Plant Operations, several ceiling tile were missing in the video room (CT area).

Through observation during the survey, November 8 through November 15, 2011, it was determined that the facility failed to maintain environments as free from combustible materials.

During the walk through of the facility with the Director of Plant Operations, one (1) tree is located 6 feet from the liquid oxygen tanks. Combustible materials shall not be within 25 of the tanks.

This portion applies to Building AA, known as the Castle Rock Adventist Health Campus.

It was determined through observation during the survey, that the facility failed to maintain the generator and related equipment in accordance with the Life Safety Code, NFPA 99, Healthcare Facilities, and NFPA 110, Standard for Emergency and Standby Power Equipment. This was evidenced by:

Documentation not provided to reflect the emergency generator had been inspected weekly, as required.

The generator deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A1, known as the Main Hospital.

It was determined through observation, staff interview and document review, that the facility failed to install and maintain the essential electrical system in accordance with the Life Safety Code and NFPA 99, Healthcare Facilities. This was evidenced by:

1) Panel LEMPA on the eighth floor penthouse, found to be connected via the Equipment Branch, supplied power to an exit sign (circuit #17) and the elevator shunt trip controller (circuit #12). All portions of the fire alarm system and all exit signs shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

2) Panel LEC3C1 on the third floor, found to be connected via the Critical Branch, supplied power to the Fire Alarm Control Panel (circuit #75) and a Fire Alarm Panel (circuit #77). All portions of the fire alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

3) Panel LEC3D on the third floor, found to be connected via the Critical Branch, supplied power to Fire Alarm Pad 3 (circuit #23). All portions of the fire alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

4) Panel HEC3A on the third floor, found to be connected via the Critical Branch, supplied power to the wing's corridor emergency lights (circuits #1, #3, and #5). All lights utilized for emergency egress lighting shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

5) The following panels were missing their schedules and it could not be determined if all circuits were correctly placed:
a. Panel LEC3C3 on the third floor.
Note: this item was corrected during the survey.
b. Panel LEC4A on the fourth floor.
c. Panel HEC4A on the fourth floor.

The essential electrical system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation during the survey, November 8 through November 15, 2011, it was determined that facility failed to divide the essential electrical system onto the correct branches per NFPA 99.

During the walk through of the facility with the Director of Plant Operations:
1) Ground floor - Panel LELSBB, circuit #16 was found to be connected via the Life Safety Branch, supplying power to the morgue cooler. The Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2. allows only systems essential for life safety systems to be powered by this branch.
2) Ground floor - Panel LEMBA2:
a. Relocate circuit #3 and #5 (dust machine) from the critical branch to the equipment branch.
b. Relocate circuit #16 (pre-action compressor) from the critical branch to the life safety branch (corrected onsite).
3) Ground floor - panel HEMBB has a jockey pump being powered by the critical branch. The jockey pump shall be powered by the life safety branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.
4) Ground floor - LEMBB, circuit #6 is being powered by the critical branch, supplied power to the Fire Control Panel (FCP). The FCP shall be powered by the Life Safety Branch.
5) 1st floor - panel LEC1CA-Critical branch.
a. Remove the following circuits from this branch (corrected onsite).
i. Circuit #8 - water fall healing garden.
ii. Circuit #11 - Court yard sign.
iii. Circuit #12 - Ball fountain.
6) Ground floor - panel LECBA1, circuit #19, #21, #23, #25, and #29 was found to be connected via the critical branch, supplied power to the E.R. televisions.
7) First floor lab- panel LEC1CA - Critical branch, circuit #10 was found to be connected via the critical branch, supplied power to the fire alarm chime and strobes. Functions of the life safety systems shall be powered by the life safety branch.
8) Second floor - panel LEC2C, circuit #2 was found to be connected via the electrical branch, supplied power to the fire alarm NAC panel, fire alarm components shall be connected via the life safety branch.
9) Second floor - panel HEC2A, circuit #8 was found to be connected to the electrical branch, supplied power to the Southeast emergency lighting. Emergency lighting shall be connected via the Life Safety Branch.

This portion applies to Building A1, known as the Main Hospital.

It was determined by observation during the course of the survey, that the facility failed to provide and maintain the electrical systems in accordance with the NFPA 70, National Electric Code. This was evidenced by:

Television equipment in the eighth floor penthouse had a surge protected power strip plugged into a second multiple outlet electrical power strip.

The electrical system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.


30095


Through observation during the survey during the survey November 8 through November 15, 2011, it was determined that the facility failed to maintain and install electrical wiring in accordance with NFPA 70, National Electrical Code.

During the walk through of the facility with the Director of Plant Operations, the cafe service line had an extension cord powering the Panini maker (corrected onsite).

This portion applies to Building A2, known as the 4th and 5th Floors of the South Tower.

It was determined by observation during the course of the survey, that the facility failed to provide and maintain the electrical systems in accordance with the NFPA 70, National Electric Code. This was evidenced by:

The respiratory supply room on the fourth floor had an extension cord in place of permanent wiring to provide power to a computer station.
Note: this item corrected during the survey.

The electrical system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.

This portion applies to Building A4, known as Outpatient Rehabilitation Physical Medicine.

It was determined by observation during the course of the survey, that the facility failed to provide and maintain the electrical systems in accordance with the NFPA 70, National Electric Code. This was evidenced by:

The front desk was found to have a surge protected power strip plugged into a second multiple outlet electrical power strip.
Note: this item corrected during the survey.

The electrical system deficiency items were discussed during the survey and again during the exit conference on November 15, 2011.