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A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

The following deficiencies were recited as a result of the revisit onsite:

During this revisit survey, the remainder of the building was surveyed in accordance with the facility's plan of correction for Tag 130. The surveyors were denied access to these portions of the building during the original survey; and now the facility had access to these portions for the walk through inspection and will correct deficiencies in these portions in accordance with their plan of correction.

The following items were cited as deficiencies as a result of surveying this additional area of the building:

1. The self-closing doors in the following locations in the first floor radiology area were held open with a wedge, a foot stop or kick stand installed at the bottom of the door, or held open with other materials:
a. radiology
b. staff office
c. door to the staff corridor
d. the door from waiting area to radiology
e. conference room

A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

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

The following deficiencies were recited as a result of the revisit onsite:

1. A review of the facility's documentation for the fire alarm system presented for review during the revisit survey failed to document the smoke detectors had been sensitivity tested.

A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

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

The following deficiencies were recited as a result of the revisit onsite:

1. There was an escutcheon rings missing from the fire sprinkler heads located in the second floor hospital office lobby.

2. There were two (2) fire sprinkler heads with excutcheon rings extending down too low below the level of the ceiling exposing the hole around the piping.

3. The sprinkler system tamper switches were not tested semi-annually as required. The documentation presented during the revisit for review indicated that the last test had been conducted on August 23, 2011.

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. The documentation presented during the revisit for review indicated that the last test had been conducted on August 23, 2011.

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

A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

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

The following deficiencies were recited as a result of the revisit onsite:

1. A review of the facility's records presented for review during the revisit survey for the annual inspection of the fire sprinkler system failed to document the deficiencies noted on the report had been corrected. The report completed by an independent contractor on November 29, 2011 documented the following deficiencies:
a. The first floor conference room lacked total coverage.
b. The hair salon on the second floor was missing an escutcheon ring on the fire sprinkler head.


During this revisit survey, the remainder of the building was surveyed in accordance with the facility's plan of correction for Tag 130. The surveyors were denied access to these portions of the building during the original survey; and now the facility had access to these portions for the walk through inspection and will correct deficiencies in these portions in accordance with their plan of correction.

The following items were cited as deficiencies as a result of surveying this additional area of the building:

1. The fire sprinkler head located in the nurses' station of radiology was loaded with foreign matter and may not function as designed by the manufacturer.

2. The fire sprinkler head at the nurses' station on the second level dermatology area was loaded with foreign matter 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.

A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

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

During this revisit survey, the remainder of the building was surveyed in accordance with the facility's plan of correction for Tag 130. The surveyors were denied access to these portions of the building during the original survey; and now the facility had access to these portions for the walk through inspection and will correct deficiencies in these portions in accordance with their plan of correction. (Access to exam rooms #4, 7, and 9 was still not permitted during this revisit survey.)

The following items were cited as deficiencies in this portion of the building:

1. There were sixteen (16) fire sprinkler heads throughout the building which were loaded with foreign matter:
a. Four (4) heads in the waiting area
b. Lab
c. Break room

2. The fire sprinkler system failed to provide coverage to the room next to the elevator machine room-stairs leading to the upper level, that was walled off since 1998 and contained storage.

3. There were two (2) missing fire sprinkler escutcheon plates in the building in the following locations:
a. Lab
b. Break Room

4. The fire sprinkler heads in the following locations were installed too far off the wall as the lintel was less than 8-inches and the "small room rule" does not apply where sprinkler heads can be up to 9-feet off of one wall:
a. Exam rooms #3, 5, 6, and 10.

5. There were ordinary temperature fire sprinkler heads located within 1-foot of the ceiling diffuser. The heads that are within 12-inches need to be replaced with an intermediate temperature head in Exam rooms #2, 8, main copier area, executives office, and call center or relocated.

6. There was no tag installed on the fire systems backflow device located on the lower level.

A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

During this revisit survey, the remainder of the building was surveyed in accordance with the facility's plan of correction for Tag 130. The surveyors were denied access to these portions of the building during the original survey; and now the facility had access to these portions for the walk through inspection and will correct deficiencies in these portions in accordance with their plan of correction.

The following items were cited as deficiencies as a result of surveying this additional area of the building:

1. The exit corridor leading from Exam room #12 down the exit discharge to the public way was obstructed and contained storage of medical equipment and office equipment. (wheel chairs, oxygen bottles, copier, and boxes) Egress pathways shall be maintain for instant use during emergencies.

NFPA 101, 7.1.10 Means of Egress Reliability.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

During this revisit survey, the remainder of the building was surveyed in accordance with the facility's plan of correction for tag 130. The surveyors were denied access to these portions of the building during the original survey; and now the facility had access to these portions for the walk through inspection and will correct deficiencies in these portions in accordance with their plan of correction.

The following items were cited as deficiencies as a result of surveying this additional area of the building:

1. The egress from the radiology area on the first floor was being used for a combustible storage area. The area had shelves with paper products and office paper storage, trash bins, cases of supplies, a book shelf with paper back books, five (5) trash bags of shredded documents, one (1) bag of clothing items, two (2) wooden easels, and other miscellaneous items.

2. The exit pathway on the exterior from the egress from the radiology area was obstructed with two (2) carts and a metal rolling shelving unit.

3. The exit stairs was being used for storage. There were two (2) chairs and boxes in the stair tower.

NFPA 101, 7.1.10 Means of Egress Reliability.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

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

During this revisit survey, the remainder of the building was surveyed in accordance with the facility's plan of correction for tag 130. The surveyors were denied access to these portions of the building during the original survey; and now the facility had access to these portions for the walk through inspection and will correct deficiencies in these portions in accordance with their plan of correction. (Access to exam rooms #4, 7, and 9 was still not permitted during this revisit survey.)

The following items were cited as deficiencies in this portion of the building:

1. There was an alcohol hand cleaning dispenser located directly above an electrical outlet in the hall by the med prep room. The alcohol cleaner is a flammable product.

2. The Surveyor was denied access to exam rooms 4,7, and 9 during the revisit survey.

Originally cited:
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. When the staff was questioned as to whether this space was part of the licensed hospital, they answered NO.

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

A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

The following deficiencies were recited as a result of the revisit onsite:

During this revisit survey, the remainder of the building was surveyed in accordance with the facility's plan of correction for tag 130. The surveyors were denied access to these portions of the building during the original survey; and now the facility had access to these portions for the walk through inspection and will correct deficiencies in these portions in accordance with their plan of correction.

The following items were cited as deficiencies as a result of surveying this additional area of the building:

1. There was an unsecured oxygen cylinder and two (2) unsecured nitrous tanks located in procedure room #101 for the first floor radiology.

2. There were two (2) unsecured oxygen cylinders located in the waiting area for radiology.

3. There was an unsecured oxygen cylinder located in the west exam desk area of the first floor radiology.

NFPA 99, 4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers: 25. When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to therapy apparatus of sufficient size to render the entire assembly stable. Individual cylinder storage associated with patient care areas are not required to be stored in enclosures. 26. Cylinders and containers shall not be dropped, dragged, or rolled. 27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

4. There was an open flame to a decorative combustible candle being used in the hair salon on the second level.

A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

During this revisit survey, the remainder of the building was surveyed in accordance with the facility's plan of correction for tag 130. The surveyors were denied access to these portions of the building during the original survey; and now the facility had access to these portions for the walk through inspection and will correct deficiencies in these portions in accordance with their plan of correction.

The following items were cited as deficiencies as a result of surveying this additional area of the building:


1. There was an electrical cord extending through the doorway from the billing office on the first floor radiology to an outlet outside of the room.

NFPA 70, National Electrical Code, 400-8. Uses Not Permitted:
Flexible cords and cables shall not be used for the following:
a) As a substitute for the fixed wiring of a structure.
b) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
c) Where run through doorways, windows, or similar openings.
d) Where attached to building surfaces.
e) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.

A revisit onsite survey was conducted on June 27, 2012 to verify corrective actions of specific allegations outlined in the deficiency list for the life safety code inspection of January 10-13, 2012.

During this revisit survey, the remainder of the building was surveyed in accordance with the facility's plan of correction for Tag 130. The surveyors were denied access to these portions of the building during the original survey; and now the facility had access to these portions for the walk through inspection and will correct deficiencies in these portions in accordance with their plan of correction.

The following items were cited as deficiencies as a result of surveying this additional area of the building:

1. The exit corridor leading from Exam room #12 down the exit discharge to the public way was obstructed and contained storage of medical equipment and office equipment. (wheel chairs, oxygen bottles, copier, and boxes) Egress pathways shall be maintain for instant use during emergencies.

NFPA 101, 7.1.10 Means of Egress Reliability.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.