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This portion applies to Building A2, known as Select Specialty hospital - Denver South Campus.

It was determined by observation and through record review, during the course of the survey on July 21, 2011, the facility failed to perform fire drills in accordance with Life Safety Code section 19.7.1.2. This was evidenced by the following:

Documentation was not provided at the time of the survey to show the following drills had been completed:

1) One (1) during the second shift in the first quarter of 2011.
2) One (1) during the first shift in the fourth quarter of 2010.
3) One (1) during the second shift in the fourth quarter of 2010.

Note: The facility provided documentation at the time of the survey to reflect several drills had taken place over the course of the last year; however, many of these drills were documented during a false or actual alarm of the fire and smoke detection system. Fire drills must be pre-planned events and the facility may not utilize false alarms of the fire and smoke detection system or real events in lieu of these pre-planned events.

The fire drill deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building A2, known as Select Specialty Hospital - Denver South Campus.

It was determined through observation, during the survey July 21, 2011, the facility failed to install and maintain the automatic fire sprinkler system in accordance with NFPA 13, Installation of Sprinkler Systems. This was evidenced by:

1) The following compartments contained Quick Response (QR) sprinkler heads and standard response (SR) sprinkler heads:

a) all patient rooms #3127 through #3134 in the north wing, and
b) all patient rooms #3102 through #3107 in the north wing.

Note: Per NFPA 13 1999 Edition, section 5-4.5.3 "Where residential sprinklers are installed in a compartment as defined in 1-4.2, all sprinklers within the compartment shall be of the fast-response type that meets the criteria of 1-4.5.1(a)1."

2) The central storage room on the south wing had an extended coverage sprinkler head that was located approximately six feet, two inches from another sprinkler head and within approximately seven feet of a third sprinkler head.

Note: Per NFPA 13 1999 Edition, section 5-8.3.4 "Sprinklers shall not be spaced less than 8 feet on center."

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

This portion applies to Building A2, known as Select Specialty Hospital - Denver South Campus.

It was determined through observation, during the survey July 21, 2011, the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency, as required by the Life Safety Code. This was evidenced by:

Located on the corridor wall, at the door of each resident room, on the east wing is a nurse charting station that, when in the open position, protrudes into the corridor approximately two and a half feet. These charting stations failed to have self-closure devices that would ensure the stations do not obstruct the clear width of the corridor when not in use.

NOTE: All items above were corrected during the survey.

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

This portion applies to Building A2, known as Select Specialty Hospital - Denver South Campus.

It was determined by observation and record review, during the survey on July 21, 2011, the facility failed to prohibit combustible draperies in accordance with Life Safety Code section 10.3.1. This was evidenced by the following:

At the time of the survey, the facility failed to provide documentation that the shower curtain for the gurney shower, which is open to the corridor, met the requirements set forth in NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films, as required.

Note: The above item was corrected during the survey.

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

This portion applies to building A2, known as Select Specialty Hospital - Denver South Campus.

It was determined through observation and document review, during the survey July 21, 2011, the facility failed to divide the essential electrical system onto the correct branches per NFPA 99. This was evidenced by:

1) Panel ER3A in the south wing on the third floor, found to be connected via the Critical Branch, supplied power to a duct detector (circuit 20). All portions of the fire alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

2) Panel ERGA3 in the south wing on the third floor, found to be connected via the Critical Branch, supplied power to the Fire Alarm Control Panel. All portions of the fire alarm system shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

3) Panel EH3B in the north wing on the third floor, found to be connected via the Critical Branch, supplied power to the wing's emergency lights. All lights utilized for emergency egress lighting shall be connected to the Life Safety Branch per NFPA 1999 Edition of NFPA 99, section 3-4.2.2.2.

The Essential Electrical System deficiency item was discussed during the survey and again during the exit conference.