HospitalInspections.org

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the 2-hour separation between the licensed hospital portion of the building and the portion leased to another licensed facility. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The facility failed to provide a 2-hour separation between the occupancies within the hospital building. A review of the facility floor plans, indicated there was no 2-hour separation provided on the third floor between the hospital health care occupancy and the business occupancy licensed as the Orthopaedic Assoc. When the staff was questioned as to whether this space was part of the licensed hospital, they answered NO.

19.1.2.1
Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:

(1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours.

Each of the hazardous area deficiency items were discussed with the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the fire-resistance rating of the structure as required by 19.1.6 (Minimum Construction Requirements). This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The building structure protective assemblies were not maintained, as follows:

a. Sections of unprotected steel beams were observed in the fifth floor mechanical room in the NE corner where the protective spray-on fire proofing was removed.

Life Safety Code Section 19.1.6.2 outlines allowed construction types. The original building is classified as Type II (222), which must be maintained and not diminished.

2. There was an unsealed opening in the ceiling of the first floor housekeeping room, which may prevent the fire sprinkler head from operating as designed by the manufacturer.

Each of the hazardous area deficiency items were discussed with the Facility Director during a tour of the facility.

It was determined by observation, during the course of the survey on January 10-13, 2012, that the facility failed to provide the egress corridor of the healthcare occupancy with interior finish materials having a flame spread rating of Class A or Class B in accordance with Life Safety Code section 19.3.3.2 and NFPA 255. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The ceiling interior finish, located in the 4th floor elevator lobby/egress corridor area and near the entry to the Critical Care Unit, consisted of a non-structural build-up of exposed false beams and inset panels of solid wood and/or composite wood materials, inherently having a Class C flame spread rating. The built-up wooden ceiling was estimated by the facility staff to amount to approximately 50% of the ceiling space within this approximately 30 x 35 feet lobby area.

This interior finish deficiency item was discussed with the Facility Director during a tour of the facility.

It was determined by observation, during the course of the survey on January 10-13, 2012, that the smoke resistant corridor doors and their frames were not maintained to be smoke resistive in accordance with section 19.3.6.3.1 of the Life Safety Code. The smoke resistance of the corridor door is dependent upon proper closing and latching with a sealed fit between the door and door frame with a gap not to exceed a maximum of ? inch in a sprinkler protected building. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The corridor door to Critical Care Unit (CCU) rooms #1, #2, #3, #4 and room #6 were each provided with a 12 foot wide, three panel sliding door. Within each 12 foot door arrangement there were two locations between the three sliding door panels, near the door header, each having an unsealed hole up to 0.825 inch wide and up to 3.75 inch long that was not considered to be smoke resistive.

2. Emergency Department was provided with a 70/30 corridor door system at room #4. The 70 door did not latch into the 30 door.

The corridor door deficiency items were discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain an 1-hour fire resistance rating as required by 19.3.1.1. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The facility failed to protect vertical openings in accordance with Life Safety Code 101, Section 19.3.1.1 and Section 8.2.5. This was evidenced by the following:

Unprotected vertical openings did not meet the design requirements for an atrium, as required. The findings include:

a. The dining room vertical opening was open between the third and fourth floors to a height of approximately 36 feet.
b. The occupancies within the atrium space had ordinary hazard contents and consisted primarily of dining room and the kitchen, which was open to the dining room.
c. Patient sleeping and treatment areas were not open to the vertical opening; however, there was no rated wall separating the sleeping areas and corridors on the fourth floor.
d. The facility had no record of a smoke control engineering analysis as required by Life Safety Code Section 8.2.5.6 (5). An engineering analysis shall be performed that demonstrates that the building is designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft. (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater.
e. The Director of Plant Operations confirmed that an engineered smoke control system was not installed in the atrium area as required by Life Safety Code Section 8.2.5.6 (6). There were no manual controls for a smoke control system in the main entrance area that would be readily accessible to the fire department as required in Section 8.2.5.6 (6).
f. The floor plans indicated a non-rated wall separating the vertical opening and the fourth floor corridor.

2. The facility failed to provide at least 90 minute fire rated construction to vertical openings between floors. This was evidenced by the following:

a. Stairway door "C" on the 3rd floor level was equipped with a non-listed or 20 minute equivalent fire rated door in lieu of the required 90 minute fire rated door.
b. Additionally, the hardware provided for this door was listed panic door hardware (and may be capable of being "dogged down" and thereby not latch within the frame) and was not the required listed "fire exit hardware".

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

It was determined by observation, during the survey on January 10-13, 2012, that the facility failed to properly protect the hazardous areas with construction that was smoke-resisting in accordance with section 19.3.2.1 of the Life Safety Code. This was evidenced by the following hazardous areas that were sprinkler protected, but were not maintained to be smoke-resistive:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The door to the Soiled Linen Room, located within the 1st floor Imaging Suite #S1, was without a means of self-closing.

2. The corridor door to the ground level Laundry Clean Linen Room, did not latch into the frame. This item was corrected during the survey.

3. The corridor double door set to the ground level Laundry Room, hit on the frame and obstructed the doors from closing into the frame. This item was corrected during the survey.

Each of the hazardous area deficiency items were discussed with the Facility Director during a tour of the facility.

It was determined by observation, testing, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the exits in accordance with NFPA 7.1. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The facility failed to maintain an unobstructed egress pathway from the corridor on the fourth floor, near the critical care cath lab. There were locked cross corridor doors, which obstructed the egress pathway to the stairway exit and which also created a dead-end corridor that exceeded 30-feet in length. The cross corridor doors were equipped with electro-magnetic locking devices, which failed to open from the egress side of the corridor without the use of a badge card to unlock the doors.

NFPA 101, 19.2 MEANS OF EGRESS REQUIREMENTS
19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

2. The facility failed to maintain the egress corridors from the second floor, Family Birth Place and the Labor and Delivery area. The two (2) corridor doors were locked against egress and the stairway A exit was locked.

The Life Safety Code Section 19.2.1 requires that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.9 requires that any device or alarm installed to restrict the improper use of a means of egress be designed and installed so that it cannot, even in the case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 (Special Locking Arrangements).

The Life Safety Code Section 19.2.2.2.4 Exception #2 allows delayed-egress locks that comply with Section 7.2.1.6.1 provided that not more than one such device is installed in any egress path.

Door locks shall not require the use of a key, chain, tool, special knowledge or effort for operation from the inside, or egress side, of the building.

3. The delayed egress door locking system, located at the stairway door from the 2nd floor Youth Recovery Center, was incorrectly arranged to sound a pre-alarm during the first three seconds of grasping the egress panic bar. Once the egress bar is held for up to three seconds, an irreversible process is to occur that incorporates an alarm and allows the lock to release within 15 - 30 seconds.

The special door locking arrangements deficiency items were discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by document review, during the survey on January 10-13, 2012, that the facility exceeded the number of intervening rooms permitted within a sleeping suite of rooms, in accordance with the Life Safety Code section 19.2.5.1. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. Based on information provided by the facility, a construction drawing identified as Life Safety Plan LS-2 depicted:

a) The 2nd floor Nursery Suite #S2, had two intervening rooms from the room identified as "Isolation" to the exit access door.
b) In addition, this "Isolation" room was only partially visible from the Nurse Station.

Staff stated that the isolation room was used as needed to isolate a sick baby from other more healthy babies. This room was not provided with a sleeping crib during the time of survey.

LSC section 19.2.5.1 exception #3 permits to have one intervening room in a special nursing suite having direct and constant supervision.

2. Based on information provided by the facility, construction drawing identified as Life Safety Plan LS-4 depicted:

The 4th floor Critical Care Unit (CCU)/Recovery Suite #S1, had three intervening rooms from each of the rooms identified as Recovery 1, Recovery 2, Recovery 3, and Recovery 4.

The intervening room deficiency items were discussed with the Life Safety Officer, during a review of the provided floor plans and during a tour of the facility.

It was determined by observation and record review, during the course of the survey conducted on January 10-13, 2012, that the facility failed to install battery powered emergency lights in accordance with NFPA 7.9. This was evidenced by the following:

Building B3: Pediatric Partners of Glenwood/A Women's Place, 1905 Blake Avenue, Glenwood Springs, CO

1. The battery powered emergency light, located above the fire extinguisher in the hall near the nurses' area of the Pediatric Partners of Glenwood, second level failed to illuminate when the test button was depressed.

2. The battery powered emergency light, located in the hall near exam room #8 of the Pediatric Partners of Glenwood, second level failed to illuminate when the test button was depressed.

3. A review of the maintenance reports for the facility, failed to document the battery powered emergency lighting system had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

It was determined by observation and record review, during the course of the survey on January 10-13, 2012, that the facility failed to provide and maintain a reliable power supply for the emergency lighting system in accordance with section 19.2.9 of the Life Safety Code. This was evidenced by the following:

Building B7: Valley View Rehab at New Castle, 820 Castle Valley Blvd., New Castle, CO

1. The facility was provided with battery operated emergency lighting units did not operate when tested with a button identified as "push to test" in two locations.

This emergency lighting deficiency item was discussed with the Life Safety Officer during a tour of the facility.

It was determined by observation, during the course of the survey conducted on January 10-13, 2012, that the facility failed to install battery powered emergency lights in accordance with NFPA 7.9. This was evidenced by the following:

B9: Eagle Valley Medical Center (Speciality Clinic/Family Practice Clinic/Rehab Center), 377 Sylvan Lake Road, Eagle, CO

1. The battery powered emergency light, located in the waiting room of the Family Practice Clinic, second floor failed to illuminate when the test button was depressed.

2. The battery powered emergency light, located in the hall near exam room #3 of the Family Practice Clinic, second floor failed to illuminate when the test button was depressed.

3. A review of the maintenance reports for the facility, failed to document the battery powered emergency lighting system had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

It was determined by observation, during the course of the survey conducted on January 10-13, 2012, that the facility failed to install battery powered emergency lights in accordance with NFPA 7.9. This was evidenced by the following:

Building B8: Willits Medical Center, 711 East Valley Road, Suite 201A, Basalt, CO

1. The battery powered emergency light, located at the entrance door of the clinic, second floor failed to illuminate when the test button was depressed.

39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

It was determined by observation, during the course of the survey on January 10-13, 2012, that the facility failed to provide emergency power in accordance with Life Safety Code section 7.9 and referenced NFPA 110, Standard for Emergency and Standby Power Systems (section 5-3). This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. Emergency lighting for task illumination, had not been provided at one of two generator locations within the Generator Power House, in the event the generator failed to start.

NOTE: The battery operated lights are required to be on the load side of the transfer switch and powered from the emergency panel branch circuit.

This emergency lighting deficiency item was discussed with the Facility Director during a tour of the facility.

It was determined by record review and observation, during the course of the survey conducted on January 10-13, 2012, that the facility failed to install battery powered emergency lights in accordance with NFPA 7.9. This was evidenced by the following:

Building B2: Medical Office Building 2, Rocky Mountain Urology/Women's Health/High Mountain Brain and Spinal Surgery, 1830 Blake Avenue, Glenwood Springs, CO

1. The battery powered emergency light, located in the office area of the Medical Office Building 2, second floor, Women's Health failed to illuminate when the test button was depressed.

2. A review of the maintenance reports for the facility failed to document the battery powered emergency lighting system had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

It was determined by observation and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the exit and directional signs as required by 19.2.10.1. This was evidenced by the following:

B9: Eagle Valley Medical Center (Speciality Clinic/Family Practice Clinic/Rehab Center), 377 Sylvan Lake Road, Eagle, CO

1. The battery powered exit sign, located above the entrance door of the Speciality Clinic, first floor failed to illuminate when the test button was depressed.

2. The battery powered exit sign, located near the reception desk of the Speciality Clinic, first floor failed to illuminate when the test button was depressed.

3. The seven (7) battery powered exit signs, located inside of the back exam area of the Speciality Clinic, first floor failed to illuminate when the test button was depressed.

4. A review of the maintenance reports for the facility, failed to document the battery powered exit signs had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.10 Marking of Means of Egress.
Means of egress shall have signs in accordance with Section 7.10.

It was determined by observation and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the exit and directional signs as required by 19.2.10.1. This was evidenced by the following:

Building B3: Pediatric Partners of Glenwood/A Women's Place, 1905 Blake Avenue, Glenwood Springs, CO

1. A review of the maintenance reports for the facility, failed to document the battery powered exit signs had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.10 Marking of Means of Egress.
Means of egress shall have signs in accordance with Section 7.10.

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the exit and directional signs as required by 19.2.10.1. This was evidenced by the following:

Building B2: Medical Office Building 2, Rocky Mountain Urology/Women's Health/High Mountain Brain and Spinal Surgery, 1830 Blake Avenue, Glenwood Springs, CO

1. The battery powered exit sign, located in the egress hall of the Medical Office Building 2, second floor, Rocky Mountain Urology failed to illuminate when the test button was depressed.

2. A review of the maintenance reports for the facility, failed to document the battery powered exit signs had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.10 Marking of Means of Egress.
Means of egress shall have signs in accordance with Section 7.10.

It was determined by record review, during the course of the survey on January 10-13, 2012, that the facility failed to maintain the fire alarm system to assure reliable operation in accordance with section 19.3.4 of the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

Building B6: Silt Medical Center, 2001 Horseshoe Trail, Silt, CO

1. View of the manual alarm pull station in the employee entry/exit area of the facility, was obstructed by a sign on a stand that was located near the exit door.

The location of the manual alarm pull station must remain conspicuous, unobstructed and accessible.

This alarm system deficiency item was discussed with the Life Safety Officer during a tour of the facility.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the fire alarm system in accordance to NFPA 70 and 72. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. A review of the facility's records, failed to document the deficiencies noted on the fire alarm inspection report had been corrected. The report completed by an independent contractor on September 13, 2011, indicated the following:

a. Duct detectors L10D106, 109, 100, 126, fourth floor north were not tested "cannot locate".
b. L5D106 remote test, third floor work room doesn't work.
c. L5D119 remote test light does not work.
d. L4M70-75 loading dock supply area, up high, batteries appear damaged.

2. The facility failed to install fire alarm visual notification within OR #3. In lieu of a fire alarm notification strobe not being provided within the operating room, it was determined the flash/reflection of a strobe light outside the OR was not clearly visible and located within direct line of sight from the OR table or situated to be clearly visible to see the reflection.

NFPA 101, 19.3.4.3.1 Occupant Notification; Chapter 9.6.3 Occupant Notification; NFPA 72 4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the fire alarm system in accordance to NFPA 70 and 72. This was evidenced by the following:

Building B2: Medical Office Building 2, Rocky Mountain Urology/Women's Health/High Mountain Brain and Spinal Surgery, 1830 Blake Avenue, Glenwood Springs, CO

1. A review of the facility's records, failed to document the fire alarm system had been inspected and tested annually.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the fire alarm system in accordance to NFPA 70 and 72. This was evidenced by the following:

Building B8: Willits Medical Center, 711 East Valley Road, Suite 201A, Basalt, CO

1. A review of the facility's records, failed to document the fire alarm system had been inspected and tested annually. There were no records available for review.

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by the following:

Building B8: Willits Medical Center, 711 East Valley Road, Suite 201A, Basalt, CO

1. There were two (2) escutcheon rings missing from the fire sprinkler heads, located in the clinic.

2. A review of the facility's records, failed to document the deficiencies noted on the inspection report dated August 23, 2011, for the fire sprinkler system had been corrected. An independent contractor indicated on the report that the antifreeze was tested at +25 degrees and that two (2) escutcheons were missing from the fire sprinkler heads in the lobby and an office.

3. The sprinkler system tamper switches were not tested semi-annually as required.

NFPA 25 Section 9-3.4.3 requires valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

4. A review of the facility's records, failed to document the sprinkler system water flow alarms were tested quarterly as required.

NFPA 25 Section 9-2.7 requires all waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

5. A review of the facility's records, failed to document the backflow prevention device installed on the fire sprinkler system had been inspected and tested annually.

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. One of the two fire sprinkler heads, located in the fourth floor family room, had physical damage to the deflector. The deflector was bent and may not function as designed by the manufacturer.

NFPA 25, 2-2.1 Sprinklers.
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2. There were glass bulb type fire sprinkler heads that failed to have the appropriate color coding, located in the second floor customer service area and two of four heads in the first floor copy/workstation of the imaging area. These heads had a clear fluid in the bulb and were Viking, M04, QR 135 degree, VK302LPC.

NFPA 13, 3-2.5.2 The liquid in bulb-type sprinklers shall be color coded in accordance with Table 3-2.5.1.

3. The escutcheon plates were missing from the fire sprinkler heads in the following locations:

a. The fourth floor custodian closet, near the nurses' station (north wing).
b. The fourth floor, cv lab control room.
c. The second floor, respiratory suite, linen storage room near the sleep lab.
d. The second floor, customer service area.
e. The second floor, room #255.
f. The bathroom, near the nurses' station in the Youth Recovery Area.

3-2.7 Escutcheon Plates.
3-2.7.1 Nonmetallic escutcheon plates shall be listed.

4. The facility failed to provide fire sprinkler coverage to the following areas:

a. The third floor, kitchen electrical room.
b. The third floor, physical therapy closet.
c. The first floor, X-Ray A and B dressing rooms.
d. The first floor, electrical room in the IT area.

5. The fire sprinkler coverage was obstructed by the ceiling mounted equipment in the first floor, X-Ray A and B rooms.

6. A review of the facility's records, failed to document the deficiencies noted on the fire sprinkler inspection report had been corrected. The report completed by an independent contractor on November 28, 2011, indicated the following:

a. First floor north wing by elevator, machine room above ceiling, 4-inch BFV tamper reports to fire alarm panel as a trouble open circuit signal.
b. Second floor closet, behind laundry in the Youth Recovery Center, tamper reports as phone L02M045.
c. First floor north wing janitor's closet, dry system low air switch is not tied in with the fire alarm system.
d. Second floor north wing janitor's closet, dry system low air switch is not tied in with the fire alarm system.

The inspection report from August 24, 2011, also indicated the following that had not been corrected:

a. First floor engineer/administration pre-action system 1 1/2 - inch BFV tamper reports to fire alarm panel as a trouble open circuit signal L03M060.
b. Velocity check on the first floor dry valve, does not close when the valve is tripped.

7. Pendent style sprinkler heads were observed to be covered with a build-up layer of lint that may effect the thermal properties of the sprinkler head being activated, in accordance with 1999 NFPA 13 section 3-2.6.
Sprinkler heads with a build-up of lint were observed in:

a) 2nd floor Nursery at the Nurse Station,
b) 2nd floor L&D room #251, #256 and #259,
c) 4th floor Patient room #426.

8. Air/water pressure gauges were not replaced, or recalibrated, every five (5) years in accordance with (1998) NFPA 25, section 2-3.2. The facility was observed with water pressure gauges that were dated 2004 located:

a) in Stairway "A" at 1st floor level,
b) in Stairway "A" between 3rd and 4th floor levels,
c) in Stairway "B" at 1st floor level,
d) in Stairway "C" between 3rd and 4th floor levels,
e) in the Janitor Closet of the 1st floor Imaging Department,
f) in the Generator Room of the Power House,
g) in the Fire Sprinkler Pump Room.

9. The deflector of a sidewall mounted sprinkler head, was observed to be incorrectly oriented at an angle that was other than parallel (approximately 45 degrees) to the flat ceiling, located in the 2nd floor egress corridor near Stairway #9, in accordance with (1999) NFPA 13, section 5-7.4.2 Deflector Orientation.

These fire sprinkler system deficiency items were discussed with either the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13. This was evidenced by the following:

Building B2: Medical Office Building 2, Rocky Mountain Urology/Women's Health/High Mountain Brain and Spinal Surgery, 1830 Blake Avenue, Glenwood Springs, CO

1. A review of the facility's records, failed to document the fire sprinkler system had been inspected and tested annually.

2. The sprinkler system tamper switches were not tested semi-annually as required.

NFPA 25 Section 9-3.4.3 requires valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

3. A review of the facility's records, failed to document the sprinkler system water flow alarms were tested quarterly as required.

NFPA 25 Section 9-2.7 requires all waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

4. A review of the facility's records, failed to document the backflow prevention device installed on the fire sprinkler system had been inspected and tested annually.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the cooking facility in accordance with 9.2.3, 19.3.2.6, NFPA 96. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. A review of the facility's records, failed to document the deficiencies noted on the inspection report for the fixed kitchen suppression system had been corrected. The report completed by an independent contractor on September 30, 2011, indicated the following:

a. Findings: Entire system interior accessible. Marked as "No" on the form.
b. Findings: Entire system cleaned to applicable codes. Marked as "No" on the form.
c. Fan/Roof: Requires fan hinge kit.
d. Comments: There are three (3) areas needing attention with your exhaust system:

i. We were unable to remove your exhaust vent fans. This makes it nearly impossible to properly clean the interior of them.
ii. The access panel on the west end of your north system is very difficult to get to. This limits our ability to properly reach all areas of the exhaust ductwork when cleaning it.
iii. When we came to bid this work, we noted a filter was missing from your south system while it was in use.

2. The facility failed to properly maintain the kitchen exhaust hood and duct system in accordance with (1998) NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. This was evidenced by the following:

a. Cleaning documentation in the form of the required sticker provided and affixed to the kitchen hood exhaust system stated that "inaccessible areas exist". This sticker stated that the last cleaning occurred on September 2011.
b. Visible grease accumulations were observed in the exhaust duct above the filters and appeared ready to drip.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations section 1-3.1.3 states "All interior surfaces of the exhaust system shall be reasonably accessible for cleaning and inspection purposes." Section 4-3.1 states "Openings shall be provided at the sides or at the top of the duct, whichever is more accessible, and at changes of direction. Openings shall be protected by approved access panels that comply with 4-3.4.4."

This hood cleaning deficiency item was discussed with the Life Safety Officer and the Facility Director during a tour of the facility.

It was determined by record review and staff interview, during the course of the survey on January 10-13, 2012, that the facility failed to maintain draperies, curtains and other loosely hanging fabrics serving as furnishings or decorations in accordance with section 10.3.1 of the Life Safety Code. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. Loose hanging fabrics could not be identified as being flame retardant or meeting the requirements of NFPA 701. During the walk-through of the facility with a staff member, a gunny sack beige colored fabric drapery was observed located six times at three windows in the Main Entry/Exit Lobby of the facility.

This flame retardant deficiency item was discussed with the Life Safety Officer and the Facility Director during a tour of the facility.

It was determined by observation, during the survey on January 10-13, 2012, that the facility failed to provide proper oxygen storage in accordance with NFPA 99 for all portions of the facility. This was evidenced by the following:

Building B6: Silt Medical Center, 2001 Horseshoe Trail, Silt, CO

1. Two series "E" style oxygen cylinder, was observed laying down on their side within an open shelf/cabinet, located in the Clean Storage Room.

This cylinder storage deficiency item was discussed with the Life Safety Officer during a tour of the facility.

It was determined by observation, during the survey on January 10-13, 2012, that the facility failed to provide a piped-in medical gas system meeting the requirements of (1999) NFPA 99, Health Care Facilities. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. A review of the medical gas system's annual inspection, test and maintenance records, provided by an independent medical gas system contractor to the facility, and dated October 2011, documented deficiency items that had not yet been corrected at the time of this survey, to include:

a. There was no intervening wall between the zone valve box and outlets served, in accordance with NFPA 99, section 4-3.1.2.3(d), and located in:

a) 1st floor Emergency Department for rooms #5-#13.
b) 1st floor Imaging, for the Bay 11 and 12 holding area.

b. The zone valve box is not located properly for the areas served, in accordance with NFPA 99, section 4-3.1.2.3, and located in:

a) 1st floor Emergency Department for rooms #5-#13.
b) 1st floor Imaging, for the Bay 11 and 12 holding area.
c) 2nd floor L&D/PACU and identified as Recovery.

c. The zone valve box is located behind normally open or normally closed door, in accordance with NFPA 99, section 4-3.1.2.3(i), and located in:

a) 2nd floor L&D / PACU and identified as Recovery.

These medical gas system deficiency items were confirmed during the survey and discussed with either the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the relative humidity in accordance with NFPA 99 4.3.1.2.3(n); 5.4.1.1; and 19.3.2.3. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. A review of the facility's records, failed to document the humidity levels were being maintained in accordance with NFPA 99. The facility only had records for November and December 2011. Staff stated there were no other records available, as the information had been removed from the check sheet.

NFPA 99 Section 5-4.1.1 requires that the mechanical ventilation system supplying anesthetizing locations have the capability of controlling relative humidity at a level of 35% or greater.

2. The ventilating system serving anesthetizing locations was not installed in accordance with NFPA 99 Section 5-4.1.2 and 5-4.1.3, as required. There was no smoke evacuation system installed in the existing C-Section operating room on the second floor.

a. The sequence of operation supplied by the facility for the ventilation system serving the anesthetizing locations for the four (4) operating rooms, failed to provide verification that the system was compliant with NFPA 99.

NFPA 99 Section 5-4.1.2: Supply and exhaust systems for anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

3. The wet locations within the patient care areas, are provided with special protection against electrical shock, however, Life Safety staff stated that documentation of the required monthly testing of the Line Isolation Monitor circuitry located in OR's #1, #2, #3 and #4, as well as in the L&D C-section OR, was not available, in accordance with NFPA 99 section 3-3.3.4.2.

4. It was observed that the L&D C-section OR was not provided with at least one battery-powered emergency lighting unit in accordance with NFPA 99 section 3-3.2.1.2.(a).5.

The deficiency items regarding anesthetizing locations were discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by document review, during the survey on January 10-13, 2012, that the facility exceeded the 10,000 square foot limitation of floor space permitted within a non-sleeping suite of rooms, in accordance with the Life Safety Code section 19.2.5.7. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. Based on information provided by the facility, construction drawing LS-1 states that 1st floor OR Suite #S4 consisted of a 10,841 square foot non-sleeping area and thereby exceeding the 10,000 square foot limitation.

These deficiency items were discussed with the Life Safety Officer during a review of the facility's floor plan documentation.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

B9: Eagle Valley Medical Center (Speciality Clinic/Family Practice Clinic/Rehab Center), 377 Sylvan Lake Road, Eagle, CO

1. The facility failed to provide a 1-hour separation between the occupancies within the building. The Eagle Valley Medical Center is a business occupancy licensed under the hospitals provider number and occupied a portion of the 2-story building. A 1-hour rated fire separation, both horizontally and vertically, between the licensed healthcare and non-healthcare occupancies could not be identified.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B2: Medical Office Building 2, Rocky Mountain Urology/Women's Health/High Mountain Brain and Spinal Surgery, 1830 Blake Avenue, Glenwood Springs, CO

1. The facility failed to provide a 1-hour separation between the occupancies within the building. The Medical Office Building #2 is a business occupancy licensed under the hospitals provider number and occupied a portion of the 2-story building. A one-hour rated fire separation, both horizontally and vertically, between the licensed healthcare and non-healthcare occupancies could not be identified.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B3: Pediatric Partners of Glenwood/A Women's Place, 1905 Blake Avenue, Glenwood Springs, CO

1. The facility failed to provide a 1-hour separation between the occupancies within the building. This facility is a business occupancy licensed under the hospitals provider number and occupied the upper level of the 2-story building. A one-hour rated fire separation, both horizontally and vertically, between the licensed healthcare and non-healthcare occupancies could not be identified.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B6: Silt Medical Center, 2001 Horseshoe Trail, Silt, CO

1. Silt Medical Center is a business occupancy licensed under the hospitals provider number and occupied a portion of the 1st floor within a one story Type II (111) structure. A one-hour rated fire separation could not be identified or failed to be complete, as required, when the structure was observed above the suspended ceiling grid located between spaces licensed and certified under the Hospital and the adjacent spaces not licensed or certified under the Hospital.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B7: Valley View Rehab at New Castle, 820 Castle Valley Blvd., New Castle, CO

1. The facility failed to provide a one-hour fire-rated separation wall between the off campus location, identified as Valley View Rehab at New Castle and the adjacent business occupancy.

Valley View Rehab at New Castle is a business occupancy licensed under the hospitals provider number and occupied a portion of the 2nd floor within a 2 story Type V(000) structure. A one-hour rated fire separation, both horizontally and vertically, could not be identified or failed to be complete, as required, when the structure was observed above the suspended ceiling grid located between spaces licensed and certified under the Hospital and the adjacent spaces not licensed or certified under the Hospital.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B8: Willits Medical Center, 711 East Valley Road, Suite 201A, Basalt, CO

1. The facility failed to provide a 1-hour separation between the occupancies within the building. The Willits Medical Center is a business occupancy licensed under the hospitals provider number and occupied a portion of the 2-story building. A 1-hour rated fire separation, both horizontally and vertically, between the licensed healthcare and non-healthcare occupancies could not be identified.

This occupancy separation deficiency item was discussed with the Facility Director during a tour of the facility.

2. There was an unsecured oxygen cylinder standing in exam room #6.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B4: HMR, 410 20th Street, Glenwood Springs, CO

1. Health Management Resources (HMR) is a business occupancy licensed under the hospitals provider number and occupied a portion of the 1st floor within a 2 story Type V(000) structure. A one-hour rated fire separation, both horizontally and vertically, could not be identified or failed to be complete, as required, when the structure was observed above the suspended ceiling grid located between spaces licensed and certified under the Hospital and the adjacent spaces not licensed or certified under the Hospital.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70. This was evidenced by the following:

Building B3: Pediatric Partners/A Women's Place, 1905 Blake Avenue, Glenwood Springs, CO

1. The approved coverplate was missing from the electrical wiring junction box, located in the boiler room at the fire sprinkler riser of the Pediatric Partners of Glenwood on the second level.

2. There were open spaces (x2) in the main electrical panel, located in the boiler room of the Pediatric Partners of Glenwood on the second level. These spaces were labeled as "Exhaust Unit E-3".

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the 2-hour separation between the licensed hospital portion of the building and the portion leased to another licensed facility. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The facility failed to provide a 2-hour separation between the occupancies within the hospital building. A review of the facility floor plans, indicated there was no 2-hour separation provided on the third floor between the hospital health care occupancy and the business occupancy licensed as the Orthopaedic Assoc. When the staff was questioned as to whether this space was part of the licensed hospital, they answered NO.

19.1.2.1
Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:

(1) They are not intended to serve health care occupants for purposes of housing, treatment, or customary access by patients incapable of self-preservation.
(2) They are separated from areas of health care occupancies by construction having a fire resistance rating of not less than 2 hours.

Each of the hazardous area deficiency items were discussed with the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the fire-resistance rating of the structure as required by 19.1.6 (Minimum Construction Requirements). This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The building structure protective assemblies were not maintained, as follows:

a. Sections of unprotected steel beams were observed in the fifth floor mechanical room in the NE corner where the protective spray-on fire proofing was removed.

Life Safety Code Section 19.1.6.2 outlines allowed construction types. The original building is classified as Type II (222), which must be maintained and not diminished.

2. There was an unsealed opening in the ceiling of the first floor housekeeping room, which may prevent the fire sprinkler head from operating as designed by the manufacturer.

Each of the hazardous area deficiency items were discussed with the Facility Director during a tour of the facility.

It was determined by observation, during the course of the survey on January 10-13, 2012, that the facility failed to provide the egress corridor of the healthcare occupancy with interior finish materials having a flame spread rating of Class A or Class B in accordance with Life Safety Code section 19.3.3.2 and NFPA 255. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The ceiling interior finish, located in the 4th floor elevator lobby/egress corridor area and near the entry to the Critical Care Unit, consisted of a non-structural build-up of exposed false beams and inset panels of solid wood and/or composite wood materials, inherently having a Class C flame spread rating. The built-up wooden ceiling was estimated by the facility staff to amount to approximately 50% of the ceiling space within this approximately 30 x 35 feet lobby area.

This interior finish deficiency item was discussed with the Facility Director during a tour of the facility.

It was determined by observation, during the course of the survey on January 10-13, 2012, that the smoke resistant corridor doors and their frames were not maintained to be smoke resistive in accordance with section 19.3.6.3.1 of the Life Safety Code. The smoke resistance of the corridor door is dependent upon proper closing and latching with a sealed fit between the door and door frame with a gap not to exceed a maximum of ? inch in a sprinkler protected building. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The corridor door to Critical Care Unit (CCU) rooms #1, #2, #3, #4 and room #6 were each provided with a 12 foot wide, three panel sliding door. Within each 12 foot door arrangement there were two locations between the three sliding door panels, near the door header, each having an unsealed hole up to 0.825 inch wide and up to 3.75 inch long that was not considered to be smoke resistive.

2. Emergency Department was provided with a 70/30 corridor door system at room #4. The 70 door did not latch into the 30 door.

The corridor door deficiency items were discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain an 1-hour fire resistance rating as required by 19.3.1.1. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The facility failed to protect vertical openings in accordance with Life Safety Code 101, Section 19.3.1.1 and Section 8.2.5. This was evidenced by the following:

Unprotected vertical openings did not meet the design requirements for an atrium, as required. The findings include:

a. The dining room vertical opening was open between the third and fourth floors to a height of approximately 36 feet.
b. The occupancies within the atrium space had ordinary hazard contents and consisted primarily of dining room and the kitchen, which was open to the dining room.
c. Patient sleeping and treatment areas were not open to the vertical opening; however, there was no rated wall separating the sleeping areas and corridors on the fourth floor.
d. The facility had no record of a smoke control engineering analysis as required by Life Safety Code Section 8.2.5.6 (5). An engineering analysis shall be performed that demonstrates that the building is designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft. (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater.
e. The Director of Plant Operations confirmed that an engineered smoke control system was not installed in the atrium area as required by Life Safety Code Section 8.2.5.6 (6). There were no manual controls for a smoke control system in the main entrance area that would be readily accessible to the fire department as required in Section 8.2.5.6 (6).
f. The floor plans indicated a non-rated wall separating the vertical opening and the fourth floor corridor.

2. The facility failed to provide at least 90 minute fire rated construction to vertical openings between floors. This was evidenced by the following:

a. Stairway door "C" on the 3rd floor level was equipped with a non-listed or 20 minute equivalent fire rated door in lieu of the required 90 minute fire rated door.
b. Additionally, the hardware provided for this door was listed panic door hardware (and may be capable of being "dogged down" and thereby not latch within the frame) and was not the required listed "fire exit hardware".

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

It was determined by observation, during the survey on January 10-13, 2012, that the facility failed to properly protect the hazardous areas with construction that was smoke-resisting in accordance with section 19.3.2.1 of the Life Safety Code. This was evidenced by the following hazardous areas that were sprinkler protected, but were not maintained to be smoke-resistive:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The door to the Soiled Linen Room, located within the 1st floor Imaging Suite #S1, was without a means of self-closing.

2. The corridor door to the ground level Laundry Clean Linen Room, did not latch into the frame. This item was corrected during the survey.

3. The corridor double door set to the ground level Laundry Room, hit on the frame and obstructed the doors from closing into the frame. This item was corrected during the survey.

Each of the hazardous area deficiency items were discussed with the Facility Director during a tour of the facility.

It was determined by observation, testing, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the exits in accordance with NFPA 7.1. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. The facility failed to maintain an unobstructed egress pathway from the corridor on the fourth floor, near the critical care cath lab. There were locked cross corridor doors, which obstructed the egress pathway to the stairway exit and which also created a dead-end corridor that exceeded 30-feet in length. The cross corridor doors were equipped with electro-magnetic locking devices, which failed to open from the egress side of the corridor without the use of a badge card to unlock the doors.

NFPA 101, 19.2 MEANS OF EGRESS REQUIREMENTS
19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

2. The facility failed to maintain the egress corridors from the second floor, Family Birth Place and the Labor and Delivery area. The two (2) corridor doors were locked against egress and the stairway A exit was locked.

The Life Safety Code Section 19.2.1 requires that every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.9 requires that any device or alarm installed to restrict the improper use of a means of egress be designed and installed so that it cannot, even in the case of failure, impede or prevent emergency use of such means of egress unless otherwise provided in 7.2.1.6 (Special Locking Arrangements).

The Life Safety Code Section 19.2.2.2.4 Exception #2 allows delayed-egress locks that comply with Section 7.2.1.6.1 provided that not more than one such device is installed in any egress path.

Door locks shall not require the use of a key, chain, tool, special knowledge or effort for operation from the inside, or egress side, of the building.

3. The delayed egress door locking system, located at the stairway door from the 2nd floor Youth Recovery Center, was incorrectly arranged to sound a pre-alarm during the first three seconds of grasping the egress panic bar. Once the egress bar is held for up to three seconds, an irreversible process is to occur that incorporates an alarm and allows the lock to release within 15 - 30 seconds.

The special door locking arrangements deficiency items were discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by document review, during the survey on January 10-13, 2012, that the facility exceeded the number of intervening rooms permitted within a sleeping suite of rooms, in accordance with the Life Safety Code section 19.2.5.1. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. Based on information provided by the facility, a construction drawing identified as Life Safety Plan LS-2 depicted:

a) The 2nd floor Nursery Suite #S2, had two intervening rooms from the room identified as "Isolation" to the exit access door.
b) In addition, this "Isolation" room was only partially visible from the Nurse Station.

Staff stated that the isolation room was used as needed to isolate a sick baby from other more healthy babies. This room was not provided with a sleeping crib during the time of survey.

LSC section 19.2.5.1 exception #3 permits to have one intervening room in a special nursing suite having direct and constant supervision.

2. Based on information provided by the facility, construction drawing identified as Life Safety Plan LS-4 depicted:

The 4th floor Critical Care Unit (CCU)/Recovery Suite #S1, had three intervening rooms from each of the rooms identified as Recovery 1, Recovery 2, Recovery 3, and Recovery 4.

The intervening room deficiency items were discussed with the Life Safety Officer, during a review of the provided floor plans and during a tour of the facility.

It was determined by observation and record review, during the course of the survey conducted on January 10-13, 2012, that the facility failed to install battery powered emergency lights in accordance with NFPA 7.9. This was evidenced by the following:

Building B3: Pediatric Partners of Glenwood/A Women's Place, 1905 Blake Avenue, Glenwood Springs, CO

1. The battery powered emergency light, located above the fire extinguisher in the hall near the nurses' area of the Pediatric Partners of Glenwood, second level failed to illuminate when the test button was depressed.

2. The battery powered emergency light, located in the hall near exam room #8 of the Pediatric Partners of Glenwood, second level failed to illuminate when the test button was depressed.

3. A review of the maintenance reports for the facility, failed to document the battery powered emergency lighting system had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

It was determined by observation and record review, during the course of the survey on January 10-13, 2012, that the facility failed to provide and maintain a reliable power supply for the emergency lighting system in accordance with section 19.2.9 of the Life Safety Code. This was evidenced by the following:

Building B7: Valley View Rehab at New Castle, 820 Castle Valley Blvd., New Castle, CO

1. The facility was provided with battery operated emergency lighting units did not operate when tested with a button identified as "push to test" in two locations.

This emergency lighting deficiency item was discussed with the Life Safety Officer during a tour of the facility.

It was determined by observation, during the course of the survey conducted on January 10-13, 2012, that the facility failed to install battery powered emergency lights in accordance with NFPA 7.9. This was evidenced by the following:

B9: Eagle Valley Medical Center (Speciality Clinic/Family Practice Clinic/Rehab Center), 377 Sylvan Lake Road, Eagle, CO

1. The battery powered emergency light, located in the waiting room of the Family Practice Clinic, second floor failed to illuminate when the test button was depressed.

2. The battery powered emergency light, located in the hall near exam room #3 of the Family Practice Clinic, second floor failed to illuminate when the test button was depressed.

3. A review of the maintenance reports for the facility, failed to document the battery powered emergency lighting system had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

It was determined by observation, during the course of the survey conducted on January 10-13, 2012, that the facility failed to install battery powered emergency lights in accordance with NFPA 7.9. This was evidenced by the following:

Building B8: Willits Medical Center, 711 East Valley Road, Suite 201A, Basalt, CO

1. The battery powered emergency light, located at the entrance door of the clinic, second floor failed to illuminate when the test button was depressed.

39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

It was determined by observation, during the course of the survey on January 10-13, 2012, that the facility failed to provide emergency power in accordance with Life Safety Code section 7.9 and referenced NFPA 110, Standard for Emergency and Standby Power Systems (section 5-3). This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. Emergency lighting for task illumination, had not been provided at one of two generator locations within the Generator Power House, in the event the generator failed to start.

NOTE: The battery operated lights are required to be on the load side of the transfer switch and powered from the emergency panel branch circuit.

This emergency lighting deficiency item was discussed with the Facility Director during a tour of the facility.

It was determined by record review and observation, during the course of the survey conducted on January 10-13, 2012, that the facility failed to install battery powered emergency lights in accordance with NFPA 7.9. This was evidenced by the following:

Building B2: Medical Office Building 2, Rocky Mountain Urology/Women's Health/High Mountain Brain and Spinal Surgery, 1830 Blake Avenue, Glenwood Springs, CO

1. The battery powered emergency light, located in the office area of the Medical Office Building 2, second floor, Women's Health failed to illuminate when the test button was depressed.

2. A review of the maintenance reports for the facility failed to document the battery powered emergency lighting system had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

It was determined by observation and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the exit and directional signs as required by 19.2.10.1. This was evidenced by the following:

B9: Eagle Valley Medical Center (Speciality Clinic/Family Practice Clinic/Rehab Center), 377 Sylvan Lake Road, Eagle, CO

1. The battery powered exit sign, located above the entrance door of the Speciality Clinic, first floor failed to illuminate when the test button was depressed.

2. The battery powered exit sign, located near the reception desk of the Speciality Clinic, first floor failed to illuminate when the test button was depressed.

3. The seven (7) battery powered exit signs, located inside of the back exam area of the Speciality Clinic, first floor failed to illuminate when the test button was depressed.

4. A review of the maintenance reports for the facility, failed to document the battery powered exit signs had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.10 Marking of Means of Egress.
Means of egress shall have signs in accordance with Section 7.10.

It was determined by observation and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the exit and directional signs as required by 19.2.10.1. This was evidenced by the following:

Building B3: Pediatric Partners of Glenwood/A Women's Place, 1905 Blake Avenue, Glenwood Springs, CO

1. A review of the maintenance reports for the facility, failed to document the battery powered exit signs had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.10 Marking of Means of Egress.
Means of egress shall have signs in accordance with Section 7.10.

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the exit and directional signs as required by 19.2.10.1. This was evidenced by the following:

Building B2: Medical Office Building 2, Rocky Mountain Urology/Women's Health/High Mountain Brain and Spinal Surgery, 1830 Blake Avenue, Glenwood Springs, CO

1. The battery powered exit sign, located in the egress hall of the Medical Office Building 2, second floor, Rocky Mountain Urology failed to illuminate when the test button was depressed.

2. A review of the maintenance reports for the facility, failed to document the battery powered exit signs had been functionally tested at 30-day intervals for 30 seconds and for a period of 1 1/2 hours annually.

39.2.10 Marking of Means of Egress.
Means of egress shall have signs in accordance with Section 7.10.

It was determined by record review, during the course of the survey on January 10-13, 2012, that the facility failed to maintain the fire alarm system to assure reliable operation in accordance with section 19.3.4 of the Life Safety Code and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

Building B6: Silt Medical Center, 2001 Horseshoe Trail, Silt, CO

1. View of the manual alarm pull station in the employee entry/exit area of the facility, was obstructed by a sign on a stand that was located near the exit door.

The location of the manual alarm pull station must remain conspicuous, unobstructed and accessible.

This alarm system deficiency item was discussed with the Life Safety Officer during a tour of the facility.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the fire alarm system in accordance to NFPA 70 and 72. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. A review of the facility's records, failed to document the deficiencies noted on the fire alarm inspection report had been corrected. The report completed by an independent contractor on September 13, 2011, indicated the following:

a. Duct detectors L10D106, 109, 100, 126, fourth floor north were not tested "cannot locate".
b. L5D106 remote test, third floor work room doesn't work.
c. L5D119 remote test light does not work.
d. L4M70-75 loading dock supply area, up high, batteries appear damaged.

2. The facility failed to install fire alarm visual notification within OR #3. In lieu of a fire alarm notification strobe not being provided within the operating room, it was determined the flash/reflection of a strobe light outside the OR was not clearly visible and located within direct line of sight from the OR table or situated to be clearly visible to see the reflection.

NFPA 101, 19.3.4.3.1 Occupant Notification; Chapter 9.6.3 Occupant Notification; NFPA 72 4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the fire alarm system in accordance to NFPA 70 and 72. This was evidenced by the following:

Building B2: Medical Office Building 2, Rocky Mountain Urology/Women's Health/High Mountain Brain and Spinal Surgery, 1830 Blake Avenue, Glenwood Springs, CO

1. A review of the facility's records, failed to document the fire alarm system had been inspected and tested annually.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the fire alarm system in accordance to NFPA 70 and 72. This was evidenced by the following:

Building B8: Willits Medical Center, 711 East Valley Road, Suite 201A, Basalt, CO

1. A review of the facility's records, failed to document the fire alarm system had been inspected and tested annually. There were no records available for review.

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by the following:

Building B8: Willits Medical Center, 711 East Valley Road, Suite 201A, Basalt, CO

1. There were two (2) escutcheon rings missing from the fire sprinkler heads, located in the clinic.

2. A review of the facility's records, failed to document the deficiencies noted on the inspection report dated August 23, 2011, for the fire sprinkler system had been corrected. An independent contractor indicated on the report that the antifreeze was tested at +25 degrees and that two (2) escutcheons were missing from the fire sprinkler heads in the lobby and an office.

3. The sprinkler system tamper switches were not tested semi-annually as required.

NFPA 25 Section 9-3.4.3 requires valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

4. A review of the facility's records, failed to document the sprinkler system water flow alarms were tested quarterly as required.

NFPA 25 Section 9-2.7 requires all waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

5. A review of the facility's records, failed to document the backflow prevention device installed on the fire sprinkler system had been inspected and tested annually.

It was determined by observation, record review, and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. One of the two fire sprinkler heads, located in the fourth floor family room, had physical damage to the deflector. The deflector was bent and may not function as designed by the manufacturer.

NFPA 25, 2-2.1 Sprinklers.
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2. There were glass bulb type fire sprinkler heads that failed to have the appropriate color coding, located in the second floor customer service area and two of four heads in the first floor copy/workstation of the imaging area. These heads had a clear fluid in the bulb and were Viking, M04, QR 135 degree, VK302LPC.

NFPA 13, 3-2.5.2 The liquid in bulb-type sprinklers shall be color coded in accordance with Table 3-2.5.1.

3. The escutcheon plates were missing from the fire sprinkler heads in the following locations:

a. The fourth floor custodian closet, near the nurses' station (north wing).
b. The fourth floor, cv lab control room.
c. The second floor, respiratory suite, linen storage room near the sleep lab.
d. The second floor, customer service area.
e. The second floor, room #255.
f. The bathroom, near the nurses' station in the Youth Recovery Area.

3-2.7 Escutcheon Plates.
3-2.7.1 Nonmetallic escutcheon plates shall be listed.

4. The facility failed to provide fire sprinkler coverage to the following areas:

a. The third floor, kitchen electrical room.
b. The third floor, physical therapy closet.
c. The first floor, X-Ray A and B dressing rooms.
d. The first floor, electrical room in the IT area.

5. The fire sprinkler coverage was obstructed by the ceiling mounted equipment in the first floor, X-Ray A and B rooms.

6. A review of the facility's records, failed to document the deficiencies noted on the fire sprinkler inspection report had been corrected. The report completed by an independent contractor on November 28, 2011, indicated the following:

a. First floor north wing by elevator, machine room above ceiling, 4-inch BFV tamper reports to fire alarm panel as a trouble open circuit signal.
b. Second floor closet, behind laundry in the Youth Recovery Center, tamper reports as phone L02M045.
c. First floor north wing janitor's closet, dry system low air switch is not tied in with the fire alarm system.
d. Second floor north wing janitor's closet, dry system low air switch is not tied in with the fire alarm system.

The inspection report from August 24, 2011, also indicated the following that had not been corrected:

a. First floor engineer/administration pre-action system 1 1/2 - inch BFV tamper reports to fire alarm panel as a trouble open circuit signal L03M060.
b. Velocity check on the first floor dry valve, does not close when the valve is tripped.

7. Pendent style sprinkler heads were observed to be covered with a build-up layer of lint that may effect the thermal properties of the sprinkler head being activated, in accordance with 1999 NFPA 13 section 3-2.6.
Sprinkler heads with a build-up of lint were observed in:

a) 2nd floor Nursery at the Nurse Station,
b) 2nd floor L&D room #251, #256 and #259,
c) 4th floor Patient room #426.

8. Air/water pressure gauges were not replaced, or recalibrated, every five (5) years in accordance with (1998) NFPA 25, section 2-3.2. The facility was observed with water pressure gauges that were dated 2004 located:

a) in Stairway "A" at 1st floor level,
b) in Stairway "A" between 3rd and 4th floor levels,
c) in Stairway "B" at 1st floor level,
d) in Stairway "C" between 3rd and 4th floor levels,
e) in the Janitor Closet of the 1st floor Imaging Department,
f) in the Generator Room of the Power House,
g) in the Fire Sprinkler Pump Room.

9. The deflector of a sidewall mounted sprinkler head, was observed to be incorrectly oriented at an angle that was other than parallel (approximately 45 degrees) to the flat ceiling, located in the 2nd floor egress corridor near Stairway #9, in accordance with (1999) NFPA 13, section 5-7.4.2 Deflector Orientation.

These fire sprinkler system deficiency items were discussed with either the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 13. This was evidenced by the following:

Building B2: Medical Office Building 2, Rocky Mountain Urology/Women's Health/High Mountain Brain and Spinal Surgery, 1830 Blake Avenue, Glenwood Springs, CO

1. A review of the facility's records, failed to document the fire sprinkler system had been inspected and tested annually.

2. The sprinkler system tamper switches were not tested semi-annually as required.

NFPA 25 Section 9-3.4.3 requires valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

3. A review of the facility's records, failed to document the sprinkler system water flow alarms were tested quarterly as required.

NFPA 25 Section 9-2.7 requires all waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

4. A review of the facility's records, failed to document the backflow prevention device installed on the fire sprinkler system had been inspected and tested annually.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the cooking facility in accordance with 9.2.3, 19.3.2.6, NFPA 96. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. A review of the facility's records, failed to document the deficiencies noted on the inspection report for the fixed kitchen suppression system had been corrected. The report completed by an independent contractor on September 30, 2011, indicated the following:

a. Findings: Entire system interior accessible. Marked as "No" on the form.
b. Findings: Entire system cleaned to applicable codes. Marked as "No" on the form.
c. Fan/Roof: Requires fan hinge kit.
d. Comments: There are three (3) areas needing attention with your exhaust system:

i. We were unable to remove your exhaust vent fans. This makes it nearly impossible to properly clean the interior of them.
ii. The access panel on the west end of your north system is very difficult to get to. This limits our ability to properly reach all areas of the exhaust ductwork when cleaning it.
iii. When we came to bid this work, we noted a filter was missing from your south system while it was in use.

2. The facility failed to properly maintain the kitchen exhaust hood and duct system in accordance with (1998) NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. This was evidenced by the following:

a. Cleaning documentation in the form of the required sticker provided and affixed to the kitchen hood exhaust system stated that "inaccessible areas exist". This sticker stated that the last cleaning occurred on September 2011.
b. Visible grease accumulations were observed in the exhaust duct above the filters and appeared ready to drip.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations section 1-3.1.3 states "All interior surfaces of the exhaust system shall be reasonably accessible for cleaning and inspection purposes." Section 4-3.1 states "Openings shall be provided at the sides or at the top of the duct, whichever is more accessible, and at changes of direction. Openings shall be protected by approved access panels that comply with 4-3.4.4."

This hood cleaning deficiency item was discussed with the Life Safety Officer and the Facility Director during a tour of the facility.

It was determined by record review and staff interview, during the course of the survey on January 10-13, 2012, that the facility failed to maintain draperies, curtains and other loosely hanging fabrics serving as furnishings or decorations in accordance with section 10.3.1 of the Life Safety Code. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. Loose hanging fabrics could not be identified as being flame retardant or meeting the requirements of NFPA 701. During the walk-through of the facility with a staff member, a gunny sack beige colored fabric drapery was observed located six times at three windows in the Main Entry/Exit Lobby of the facility.

This flame retardant deficiency item was discussed with the Life Safety Officer and the Facility Director during a tour of the facility.

It was determined by observation, during the survey on January 10-13, 2012, that the facility failed to provide proper oxygen storage in accordance with NFPA 99 for all portions of the facility. This was evidenced by the following:

Building B6: Silt Medical Center, 2001 Horseshoe Trail, Silt, CO

1. Two series "E" style oxygen cylinder, was observed laying down on their side within an open shelf/cabinet, located in the Clean Storage Room.

This cylinder storage deficiency item was discussed with the Life Safety Officer during a tour of the facility.

It was determined by observation, during the survey on January 10-13, 2012, that the facility failed to provide a piped-in medical gas system meeting the requirements of (1999) NFPA 99, Health Care Facilities. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. A review of the medical gas system's annual inspection, test and maintenance records, provided by an independent medical gas system contractor to the facility, and dated October 2011, documented deficiency items that had not yet been corrected at the time of this survey, to include:

a. There was no intervening wall between the zone valve box and outlets served, in accordance with NFPA 99, section 4-3.1.2.3(d), and located in:

a) 1st floor Emergency Department for rooms #5-#13.
b) 1st floor Imaging, for the Bay 11 and 12 holding area.

b. The zone valve box is not located properly for the areas served, in accordance with NFPA 99, section 4-3.1.2.3, and located in:

a) 1st floor Emergency Department for rooms #5-#13.
b) 1st floor Imaging, for the Bay 11 and 12 holding area.
c) 2nd floor L&D/PACU and identified as Recovery.

c. The zone valve box is located behind normally open or normally closed door, in accordance with NFPA 99, section 4-3.1.2.3(i), and located in:

a) 2nd floor L&D / PACU and identified as Recovery.

These medical gas system deficiency items were confirmed during the survey and discussed with either the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by record review and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the relative humidity in accordance with NFPA 99 4.3.1.2.3(n); 5.4.1.1; and 19.3.2.3. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. A review of the facility's records, failed to document the humidity levels were being maintained in accordance with NFPA 99. The facility only had records for November and December 2011. Staff stated there were no other records available, as the information had been removed from the check sheet.

NFPA 99 Section 5-4.1.1 requires that the mechanical ventilation system supplying anesthetizing locations have the capability of controlling relative humidity at a level of 35% or greater.

2. The ventilating system serving anesthetizing locations was not installed in accordance with NFPA 99 Section 5-4.1.2 and 5-4.1.3, as required. There was no smoke evacuation system installed in the existing C-Section operating room on the second floor.

a. The sequence of operation supplied by the facility for the ventilation system serving the anesthetizing locations for the four (4) operating rooms, failed to provide verification that the system was compliant with NFPA 99.

NFPA 99 Section 5-4.1.2: Supply and exhaust systems for anesthetizing locations shall be arranged to automatically vent smoke and products of combustion. Section 5-4.1.3: Ventilating systems for anesthetizing locations shall be provided that automatically (a) prevent recirculation of smoke originating within the surgical suite and (b) prevent the circulation of smoke entering the system intake, without in either case interfering with the exhaust function of the system.

3. The wet locations within the patient care areas, are provided with special protection against electrical shock, however, Life Safety staff stated that documentation of the required monthly testing of the Line Isolation Monitor circuitry located in OR's #1, #2, #3 and #4, as well as in the L&D C-section OR, was not available, in accordance with NFPA 99 section 3-3.3.4.2.

4. It was observed that the L&D C-section OR was not provided with at least one battery-powered emergency lighting unit in accordance with NFPA 99 section 3-3.2.1.2.(a).5.

The deficiency items regarding anesthetizing locations were discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by document review, during the survey on January 10-13, 2012, that the facility exceeded the 10,000 square foot limitation of floor space permitted within a non-sleeping suite of rooms, in accordance with the Life Safety Code section 19.2.5.7. This was evidenced by the following:

Building B1: Main Hospital, 1906 Blake Avenue, Glenwood Springs, CO

1. Based on information provided by the facility, construction drawing LS-1 states that 1st floor OR Suite #S4 consisted of a 10,841 square foot non-sleeping area and thereby exceeding the 10,000 square foot limitation.

These deficiency items were discussed with the Life Safety Officer during a review of the facility's floor plan documentation.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

B9: Eagle Valley Medical Center (Speciality Clinic/Family Practice Clinic/Rehab Center), 377 Sylvan Lake Road, Eagle, CO

1. The facility failed to provide a 1-hour separation between the occupancies within the building. The Eagle Valley Medical Center is a business occupancy licensed under the hospitals provider number and occupied a portion of the 2-story building. A 1-hour rated fire separation, both horizontally and vertically, between the licensed healthcare and non-healthcare occupancies could not be identified.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B2: Medical Office Building 2, Rocky Mountain Urology/Women's Health/High Mountain Brain and Spinal Surgery, 1830 Blake Avenue, Glenwood Springs, CO

1. The facility failed to provide a 1-hour separation between the occupancies within the building. The Medical Office Building #2 is a business occupancy licensed under the hospitals provider number and occupied a portion of the 2-story building. A one-hour rated fire separation, both horizontally and vertically, between the licensed healthcare and non-healthcare occupancies could not be identified.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B3: Pediatric Partners of Glenwood/A Women's Place, 1905 Blake Avenue, Glenwood Springs, CO

1. The facility failed to provide a 1-hour separation between the occupancies within the building. This facility is a business occupancy licensed under the hospitals provider number and occupied the upper level of the 2-story building. A one-hour rated fire separation, both horizontally and vertically, between the licensed healthcare and non-healthcare occupancies could not be identified.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B6: Silt Medical Center, 2001 Horseshoe Trail, Silt, CO

1. Silt Medical Center is a business occupancy licensed under the hospitals provider number and occupied a portion of the 1st floor within a one story Type II (111) structure. A one-hour rated fire separation could not be identified or failed to be complete, as required, when the structure was observed above the suspended ceiling grid located between spaces licensed and certified under the Hospital and the adjacent spaces not licensed or certified under the Hospital.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B7: Valley View Rehab at New Castle, 820 Castle Valley Blvd., New Castle, CO

1. The facility failed to provide a one-hour fire-rated separation wall between the off campus location, identified as Valley View Rehab at New Castle and the adjacent business occupancy.

Valley View Rehab at New Castle is a business occupancy licensed under the hospitals provider number and occupied a portion of the 2nd floor within a 2 story Type V(000) structure. A one-hour rated fire separation, both horizontally and vertically, could not be identified or failed to be complete, as required, when the structure was observed above the suspended ceiling grid located between spaces licensed and certified under the Hospital and the adjacent spaces not licensed or certified under the Hospital.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B8: Willits Medical Center, 711 East Valley Road, Suite 201A, Basalt, CO

1. The facility failed to provide a 1-hour separation between the occupancies within the building. The Willits Medical Center is a business occupancy licensed under the hospitals provider number and occupied a portion of the 2-story building. A 1-hour rated fire separation, both horizontally and vertically, between the licensed healthcare and non-healthcare occupancies could not be identified.

This occupancy separation deficiency item was discussed with the Facility Director during a tour of the facility.

2. There was an unsecured oxygen cylinder standing in exam room #6.

It was determined by observation, record review, and staff interview, during the course of the survey conducted January 10-13, 2012, the facility failed 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:

Building B4: HMR, 410 20th Street, Glenwood Springs, CO

1. Health Management Resources (HMR) is a business occupancy licensed under the hospitals provider number and occupied a portion of the 1st floor within a 2 story Type V(000) structure. A one-hour rated fire separation, both horizontally and vertically, could not be identified or failed to be complete, as required, when the structure was observed above the suspended ceiling grid located between spaces licensed and certified under the Hospital and the adjacent spaces not licensed or certified under the Hospital.

This occupancy separation deficiency item was discussed with the Life Safety Officer or the Facility Director during a tour of the facility.

It was determined by observation and staff interview, during the course of the survey conducted on January 10-13, 2012, that the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70. This was evidenced by the following:

Building B3: Pediatric Partners/A Women's Place, 1905 Blake Avenue, Glenwood Springs, CO

1. The approved coverplate was missing from the electrical wiring junction box, located in the boiler room at the fire sprinkler riser of the Pediatric Partners of Glenwood on the second level.

2. There were open spaces (x2) in the main electrical panel, located in the boiler room of the Pediatric Partners of Glenwood on the second level. These spaces were labeled as "Exhaust Unit E-3".