HospitalInspections.org

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation and record review during the course of the survey, it was determined that the facility failed to provide a two-hour fire rated separation to non-healthcare occupancies in accordance with Life Safety Code Section 18.1.2.3. This was evidenced by the following:

The healthcare occupancy was not separated from connected non-healthcare occupancies by two-hour rated construction and protected openings, as required. The second floor elevated sky bridge (non-combustible construction-partially sprinkler protected) communicated with the healthcare occupancy via a wall of undermined fire resistance rating and 20 minute fire rated double doors. The sky bridge communicated with the parking structure to the north via unprotected glass doors. Facility life safety plan page G-LS02 did not indicate any rated fire walls in the area of Bridge 2.C2344 or Corridor 2.C2344.

Life Safety Code Section 18.1.2.3: Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 18.1.1.4.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation, it was determined that the facility failed to maintain the fire protection rating of the building structure in accordance with Life Safety Code Section 19.1.6.2. This was evidenced by the following:

Building structure fire protection systems were not maintained, as required. Structural steel spray on fire-proofing material was not maintained at the original thickness on a structural support beam (room OP-0029). The spray-on fire-proofing had been removed to install two welded plates for a lift/hoist I rail. Facility architectural plans classified the building as construction Type I (332).
Life Safety Code Section 19.1.6.2 outlines allowed construction types. The original building classification of Type I (332) must be maintained and not diminished.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation, it was determined that the facility failed to install and maintain the fire protection rating of the building structure in accordance with Life Safety Code Section 18.1.6.2 and Section 8.2. This was evidenced by the following:

Building structure protective assemblies were not maintained, as required.
A) A structural steel cross-brace was observed to have the original spray-on fire-proofing removed in three areas along the length of the brace. The structural brace was located on the west side of the emergency generator room.

B) Building structural steel was not protected to meet the minimum building fire protection rating, as required. Facility records documented the building construction type to be NFPA Type I (332). Egress stair #3 and #4 were both observed to have non-combustible stair assemblies supported by unprotected steel columns and beams.
Life Safety Code Section 18.1.6.2 outlines allowed construction types. The building was classified as Type I (332) which must be provided and maintained. Section 8.2.1: Construction.
Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided
Section 8.2.3.1.1: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2.
Exception No. 1: Structural elements shall be required to have only the fire resistance rating required for the construction classification of the building where such elements support nonbearing wall or partition assemblies having a required fire resistance rating of 1 hour or less and where such elements do not serve as exit enclosures or protection for vertical openings.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, record review and staff interview during the course of the survey, it was determined that the facility failed to maintain the separation between egress corridors and all other areas in accordance with Life Safety Code Section 18.3.6.1 and 18.3.6.2. This was evidenced by the following:

Egress corridors were not separated from patient treatment areas by non-fire rated smoke resistive partitions, as required. The Emergency Department Manager reported that the department utilized 21 "hall beds" for emergency patient care. The hall beds were used on a daily basis, depending upon patient census. Hall beds located within the emergency department core areas were utilized first with additional "disaster beds" utilized last. 3 of 21 hall beds were located in the Outpatient Pavilion Radiology egress corridor (see AOP building deficiency list). A review of facility plans determined that the core area of the emergency department was arranged as three separate non-sleeping suites all within AIP-Anschutz Inpatient Pavilion, Building A-1, as follows:
South suite-ambulance entrance area- 2015 square feet.
Core area suite - 6289 square feet.
North area suite- 6167 square feet.
The plan review verified that 3 of the 21 hall beds were located within designated 8 ft. wide egress corridors and not within an internal suite passageway. The patient care beds, located within the designated egress corridors, were observed in the pharmacy egress corridor (1D0403).

The Life Safety Code Section 18.3.6.1 requires that corridors be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5. Exception #1 to 18.3.6.1 allows some areas to be open to the egress corridor, however, the allowed areas exclude patient sleeping rooms, patient treatment rooms and hazardous areas. Section 18.3.6.2 requires that corridor walls separating use areas from the egress corridor form a barrier to limit the transfer of smoke.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the separation between egress corridors and all other areas in accordance with Life Safety Code Section 19.3.6.1 and 19.3.6.2. This was evidenced by the following:

Egress corridors were not separated from patient treatment areas by non-fire rated smoke resistive partitions, as required. The Emergency Department Manager reported that the department utilized 21 "hall beds" for emergency patient care. The hall beds were used on a daily basis, depending upon patient census. Hall beds located within the emergency department core areas (AIP-Bldg. A-1) were utilized first with additional "disaster beds" utilized last. 3 of 21 hall beds were located in the Outpatient Pavilion (AOP) Radiology 8 ft. egress corridor.

The Life Safety Code Section 19.3.6.1 requires that corridors be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. Exception #1 to 19.3.6.1 allows some areas to be open to the egress corridor, however, the allowed areas exclude patient sleeping rooms, patient treatment rooms and hazardous areas. Section 19.3.6.2 requires that corridor walls separating use areas from the egress corridor form a barrier to limit the transfer of smoke.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3. This was evidenced by the following:

A) Corridor doors would not positively latch, as required. The following room doors would not positively latch when tested:
1) Room #902
2) Room #7125
3) Room #604
4) Linen closet adjacent to room #503
5) West chute service room double doors were not arranged with positive latching hardware (1st floor and 4th floor).
Life Safety Code Section 18.3.6.3.2: Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

B) Corridor doors were not arranged to automatically latch into the door frame, as required. Two linen closets (6th floor) were equipped with double doors. One of two leafs was not equipped with automatic latching hardware. The leaf equipped with the latchset was arranged to latch into the " fixed " door leaf that was equipped with manual latching hardware. If the manual latching hardware was not engaged, neither leaf would be positively latched.

C) Corridor doors were not maintained to be smoke resistive, as required. Room 1204 and 1001 were observed to have gaps between the door and door frame that exceeded 1/2 inch in width. Life Safety Code Section 18.3.6.3.1 requires that corridor doors be constructed to resist the passage of smoke.

D) The Cystology/Hystology Lab pass-through double doors (40" x 35") were obstructed from closing by plastic tubs, a metal bell and a clipboard.

Most of the K-18 items were reported to be corrected at the exit conference.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation during the survey, it was determined that the facility failed to protect vertical openings in accordance with Life Safety Code Section 19.3.1.1 and 8.2.5. This was evidenced by the following:
A) Vertical openings were not protected in accordance with Life Safety Code Section 8.2.5, as required. The ACP main entrance area was observed to have a 3 story vertical opening that was not one-hour rated.
1) The first floor area is not separated from the unprotected vertical opening.
2) The second floor area is not separated from the unprotected vertical opening.
3) The third floor is separated from the unprotected vertical opening by a glass wall with no apparent fire rating.

B) Two hour rated vertical opening enclosures were not maintained, as required.
1. Stair #2, 5th floor was observed to have unsealed pipe penetrations through the wall.
2. Stair #2, 3rd floor was observed to have approximately 8 feet of missing fire stop between the 2 hour wall and the floor deck.

Life Safety Code Section 19.3.1.1 requires that any vertical opening between stories shall be enclosed in accordance with Section 8.2.5 with construction having a one-hour fire resistance rating. Section 8-2.3.2.4.2 requires, in part, that the space between cable or pipe penetrations and the fire barrier be filled with a material capable of maintaining the fire resistance rating of the barrier.

RMLEI-Rocky Mountain Lions Eye Institute-Aspen ID: Building A-4
Based on observation during the survey, it was determined that the facility failed to protect vertical openings in accordance with Life Safety Code Section 39.3.1.1 and 8.2.5. This was evidenced by the following:
Vertical openings were not protected in accordance with Life Safety Code Section 8.2.5, as required. The RMLEI main entrance area was observed to have a 3 story vertical opening that was not one-hour rated.
1) The first floor area is not separated from the unprotected vertical opening.
2) The second floor area is not separated from the unprotected vertical opening.
3) The third floor is separated from the unprotected vertical opening by a glass wall with no apparent fire rating.
Life Safety Code Section 39.3.1.1 requires that any vertical opening between stories shall be enclosed in accordance with Section 8.2.5 with construction having a one-hour fire resistance rating. Section 8-2.3.2.4.2 requires, in part, that the space between cable or pipe penetrations and the fire barrier be filled with a material capable of maintaining the fire resistance rating of the barrier.

This portion applies to Building AC, known as University Family Medicine - Boulder.

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

The building is served by two open stairways that extend from the ground floor to the second floor (three stories). These stairways are connected by open corridors on both the ground floor and the second floor, thus creating a three-story vertical opening affected in the entire facility. This vertical opening fails to meet any of the conditions set forth in NFPA 101 (2000), section 8.2.5, Vertical Openings.

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

This portion applies to Building AD, known as Boulder Physical Therapy Clinic.

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

The building is served by two open stairways that extend from the ground floor to the second floor (three stories). These stairways are connected by open corridors on both the ground floor and the second floor, thus creating a three-story vertical opening affected in the entire facility. This vertical opening fails to meet any of the conditions set forth in NFPA 101 (2000), section 8.2.5, Vertical Openings.

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

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

The building has an open stairway and an open atrium that extend from the ground floor to the second floor (two stories). This stairway and open atrium creates a two-story vertical opening. This vertical opening does not appear to meet any of the conditions set forth in NFPA 101 (2000), section 8.2.5, Vertical Openings. Note: Patrons of the facility must enter the facility through this vertical opening and the vertical opening is not separated by fire-rated construction from the facility.

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

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the survey, it was determined that the facility failed to mark access to exits in areas where the way to reach the exit was not readily apparent to occupants. This was evidenced by the following:

A) The PACU suite did not have an exit sign installed near the nurse's station to direct occupants to the suite exit.

B) The outpatient radiology area exit path was marked by an exit sign that did not have the required directional indicator.

Life Safety Code Section 7.10.1.4 requires that access to exits be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, it was determined that the facility failed to maintain the fire resistance rating of smoke barrier walls in accordance with the Life Safety Code Section 18-3.7.3 and Section 8.3. This was evidenced by the following:

One hour rated smoke barrier walls were not maintained, as required. The second floor one hour rated wall (at Cardio Lab 3.2302) was observed to have a cable tray penetration without a complete fire stop system. An intumescent fire stop brick was observed to be missing.

Life Safety Code Section 18.3.7.3 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than 1 hour. Section 8-3.6.1 requires, in part, that the space between cable and pipe penetrations and the smoke barrier wall be filled with a material capable of maintaining the 1 hour fire resistance rating of the barrier.
The deficiency was reported to be corrected at the exit conference.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation, it was determined that the facility failed to maintain the fire resistance rating of smoke barrier walls in accordance with the Life Safety Code Section 19-3.7.3 and Section 8.3. This was evidenced by the following:

Smoke barrier wall (second floor corridor near laser room) was observed to have two unsealed pipe penetrations.
Life Safety Code Section 8-2.3.2.4.2 requires, in part, that the space between cable or pipe penetrations and the fire barrier be filled with a material capable of maintaining the fire resistance rating of the barrier.
The deficiency was reported to be corrected at the exit conference.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the course of the survey, it was determined that the facility failed to install smoke barrier doors in accordance with the Life Safety Code Section 18.3.7.8. This was evidenced by the following:

One set of smoke barrier cross-corridor doors (10th floor) were not equipped with rabbets, bevels or astragals on the meeting edges of the doors, as required.
Life Safety Code Section 18.3.7.8 requires that the meeting edges on smoke barrier doors be equipped with rabbets, bevels or astragals.
The deficiency was reported to be corrected at the exit conference.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation during the course of the survey, it was determined that the facility failed to install smoke barrier doors in accordance with the Life Safety Code Section 19.3.7.6 and Section 8.3.4.
This was evidenced by the following:
Second floor smoke barrier doors were observed to have a gap between the door leafs that exceeded 1/8 inch.
Life Safety Code Section 8.3.4 requires that doors in smoke barriers close the opening leaving only the minimum clearance necessary for proper operation.
The deficiency was reported to be corrected at the exit conference.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the survey, it was determined that the facility failed to enclose hazardous areas in accordance with the Life Safety Code Section 18.3.2.1 and Section 8.4. This was evidenced by the following:

Storage rooms, greater than 100 square feet in area, were not provided with 45 minute (minimum) rated doors, as required. Pharmacy storage room 1C0501 was equipped with a 20 minute rated door.
The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 18.3.2.1 and Section 8.4. Section 8.4.1.3 requires that doors in fire rated barriers have a minimum ? hour fire resistance rating and that the doors be self-closing or automatic closing.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the survey, it was determined that the facility failed to maintain hazardous area enclosures in accordance with the Life Safety Code Section 18.3.2.1 and Section 8.4. This was evidenced by the following:

Hazardous area enclosure doors were not self-closing and positively latching, as required. The O/R area equipment storage room door (outside OR 3 and OR 4), would not positively latch into the door frame.
The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 18.3.2.1 and Section 8.4. Section 8.4.1.3 requires that doors in fire rated barriers have a minimum ? hour fire resistance rating and that the doors be self-closing or automatic closing. Rated fire doors must positively latch into the door frame in accordance with NFPA 80.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on record review during the survey, it was determined that the facility failed to conduct laboratory fire drills in accordance with NFPA 99, Health Care Facilities. This was evidenced by the following:

Laboratory fire drills were not conducted quarterly, as required. Records documented two fire drills during the prior 12 month period. Drills were conducted on September 28, 2012 and October 12, 2012.
NFPA 99 Section 10-2.1.4.3 requires that fire drills in laboratories be conducted quarterly.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:
A) Corridor doors were not installed in accordance with Section 7.2.1.4.4, as required. Doors opening into the corridor exceeded the allowed maximum of 7 inches from the wall when in the fully opened position. The following doors were observed to project 12 inches to 14 inches into the corridor clearwidth when in the fully open position:
1) electric room #1127
2) electric room #2127
3) janitor closet #2125
Life Safety Code Section 7.2.1.4.4: During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open.

B) Discharge from exits was not arranged in accordance with Life Safety Code Section 7.7.2, as required. Greater than 50% of the required number of exits and greater than 50% of the required egress capacity (exits from floors 5 through 12) discharged through areas on the level of exit discharge. Stair #1 and Stair #2 both discharged inside the building on the level of exit discharge. Neither stair discharge was arranged as an exit passageway in accordance with Life Safety Code Section 7.2.6.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 18.2.1 and Chapter 7. This was evidenced by the following:

A) Corridor doors were not arranged in accordance with Life Safety Code Section 7..1.4.4, as required. Doors opening into the corridor exceeded the allowed maximum of 7 inches from the wall, when in the full open position, in the following locations:
1) Room #B-2314 corridor door obstructed from fully opening, hits cross corridor door-approx
12 inch projection into the corridor
2) Room B-2305.19 electric room door, when fully open projects approximately 14 inches into
the corridor.

B) Penetrations in egress stair enclosures were not in accordance with Life Safety Code Section 7.1, as required. Egress stairs #3 and #4 were observed to have supply and return air duct penetrations throughout the stair enclosure. The duct penetrations were part of the HVAC system for normal heating and cooling of the egress stair enclosure and did not appear to be related to an independent stair pressurization system.
Life Safety Code Section 7.1.3.2.1 (e): Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.

This portion applies to Building AM, known as University Family Medicine - Park Meadows.

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

The northeast exit door, which serves an occupant load greater than 50 persons, was found to swing against the direction of egress travel.

The means of egress deficiency item was discussed during the survey and again during the exit conference.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, it was determined that the facility failed to arrange special door locking in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:
A) Egress doors equipped with delayed-egress locking devices were not programmed to start the irreversible unlocking sequence upon activation of an audible signal in the vicinity of the door, as required. The following doors were equipped with delayed-egress special locking that were programmed to sound a pre-alarm signal in the vicinity of the door:
1. Door 4.C134 (cross corridor door)
2. Door 4.B0704 (cross corridor door)
3. Door 4.C1302 (Stair 1)
4. Door 4.C0302 (Stair 2)
5. Stair 1 and stair 2 doors, 5th floor.
Upon sounding of the pre-alarm signal, the unlocking sequence did not start. Life Safety Code Section 7.2.1.6.1(c) requires, in part, that the initiation of the release process activate an audible signal in the vicinity of the door.
The pre-alarm signals were removed prior to the exit conference on February 4, 2013.

B) Doors equipped with delayed-egress special locking were not arranged in accordance with Life Safety Code Section 18.2.2.2.4, as required. 4th floor cross-corridor doors and stair exit doors were equipped with delayed egress special locking. The door arrangement resulted in more than one such devices located in an egress path.
Life Safety Code Section 18.2.2.2.4, Exception No. 2: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation, it was determined that the facility failed to arrange special door locking in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:
A) Egress doors equipped with delayed-egress locking devices were not programmed to sound an audible signal, in the vicinity of the door, at the start of the irreversible unlocking sequence, as required. The 4th floor NICU suite corridor door was equipped with delayed egress special locking. When tested during a tour of the facility, the locking device failed to sound an alarm at the start of the unlocking sequence.
Life Safety Code Section 7.2.1.6.1(c) requires, in part, that the initiation of the release process activate an audible signal in the vicinity of the door.

B) Doors equipped with delayed-egress special locking were not arranged in accordance with Life Safety Code Section 18.2.2.2.4, as required. The 4th floor NICU exit door and Stair #3door were equipped with delayed egress special locking. The door arrangement resulted in more than one such devices located in an egress path.
Life Safety Code Section 18.2.2.2.4, Exception No. 2: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
The stair 3 delayed egress hardware was disabled during the survey, and the alarm was restored on the NICU delayed egress hardware.

This portion applies to Building AC, known as University Family Medicine - Boulder.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AD, known as Boulder Physical Therapy Clinic.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AE, known as University Family Medicine - Westminster.

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

1) The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

2) The facility provides battery backed-up emergency lighting in all exam rooms; however, that the time of the survey, two (2) of these lights failed to operate when the button marked as "push to test" was depressed. Note: This item was corrected during the survey.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AF, known as University Physical Therapy at Stapleton.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AG, known as University Family Medicine - A.F. Williams.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AI, known as University of Colorado Hospital Imaging.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AJ, known as CU Sports Physical Therapy and Rehabilitation.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AK, known as CU Sports Medicine.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AL, known as Eye Center at Park Meadows.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AM, known as University Family Medicine - Park Meadows.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AN, known as ToMo Therapy Cancer Treatment Center.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code Section 18.3.4.3. This was evidenced by the following:

Visual fire alarm system notification appliances were not installed inside critical care areas, as required. The following critical care areas were not provided with visual notification appliances:
1. 5th floor C Section room.
2. Labor and Delivery suite, 4th floor.
3. NICU O/R, 4th floor.

Life Safety Code Section 18.3.4.3.1: Occupant notification shall be accomplished automatically in accordance with Section 9.6.3. Exception: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code Section 19.3.4.3. This was evidenced by the following:

Visual fire alarm system notification appliances were not installed inside critical care areas, as required. Operating rooms (#1 through #8) were not provided with visual notification appliances.

Life Safety Code Section 19.3.4.3.1: Occupant notification shall be accomplished automatically in accordance with Section 9.6.3. Exception: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code Section 18.3.4.3. This was evidenced by the following:

Visual fire alarm system notification appliances were not installed inside critical care areas, as required. Windowless operating rooms (#1 through #16) were not provided with visual notification appliances.

Life Safety Code Section 18.3.4.3.1: Occupant notification shall be accomplished automatically in accordance with Section 9.6.3. Exception: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A) Fire pump supervisory signals were not tested quarterly, as required. The facility Electronic Systems Technician reported that fire pump loss of power supervision was tested annually during the pump flow test and any time a section of the system was drained and refilled. There was no documentation of this test situation. The facility Electronic Systems Technician was not aware of any testing of the pump power supply phase reversal supervision.
NFPA 72 Section 7-3.2 requires supervisory signal devices be tested quarterly. Section 7.5.2.2 requires, in part, that a permanent record of all inspections, testing and maintenance be maintained.

B) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

C) Fire alarm system secondary power supply sealed lead-acid batteries were not discharge tested annually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years. NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to an annual discharge test (30 minutes).

D) Fire alarm system sealed lead acid batteries were not replaced every four years, as required. The facility Electronic Systems Technician reported that all fire alarm system batteries were replaced every five years.
NFPA 72 Section 7.3.2 requires that sealed lead-acid type batteries be replaced every 4 years or when the recharged battery voltage or current falls below the manufacturer's recommendations.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A) Fire pump supervisory signals were not tested quarterly, as required. The facility Electronic Systems Technician reported that fire pump loss of power supervision was tested annually during the pump flow test and any time a section of the system was drained and refilled. There was no documentation of this test situation. The facility Electronic Systems Technician was not aware of any testing of the pump power supply phase reversal supervision.
NFPA 72 Section 7-3.2 requires supervisory signal devices be tested quarterly. Section 7.5.2.2 requires, in part, that a permanent record of all inspections, testing and maintenance be maintained.

B) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

C) Fire alarm system secondary power supply sealed lead-acid batteries were not discharge tested annually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years. NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to an annual discharge test (30 minutes).

D) Fire alarm system sealed lead acid batteries were not replaced every four years, as required. The facility Electronic Systems Technician reported that all fire alarm system batteries were replaced every five years.
NFPA 72 Section 7.3.2 requires that sealed lead-acid type batteries be replaced every 4 years or when the recharged battery voltage or current falls below the manufacturer's recommendations.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A) Fire pump supervisory signals were not tested quarterly, as required. The facility Electronic Systems Technician reported that fire pump loss of power supervision was tested annually during the pump flow test and any time a section of the system was drained and refilled. There was no documentation of this test situation. The facility Electronic Systems Technician was not aware of any testing of the pump power supply phase reversal supervision.
NFPA 72 Section 7-3.2 requires supervisory signal devices be tested quarterly. Section 7.5.2.2 requires, in part, that a permanent record of all inspections, testing and maintenance be maintained.

B) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

C) Fire alarm system secondary power supply sealed lead-acid batteries were not discharge tested annually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years. NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to an annual discharge test (30 minutes).

D) Fire alarm system sealed lead acid batteries were not replaced every four years, as required. The facility Electronic Systems Technician reported that all fire alarm system batteries were replaced every five years.
NFPA 72 Section 7.3.2 requires that sealed lead-acid type batteries be replaced every 4 years or when the recharged battery voltage or current falls below the manufacturer's recommendations.

E) First floor carbon dioxide room was observed to have a smoke detector detached from the junction box. The detector was supported only by the fire alarm system wiring.

RMLEI-Rocky Mountain Lions Eye Institute-Aspen ID: Building A-4:
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

B) Fire alarm system secondary power supply sealed lead-acid batteries were not discharge tested annually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years. NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to an annual discharge test (30 minutes).

C) Fire alarm system sealed lead acid batteries were not replaced every four years, as required. The facility Electronic Systems Technician reported that all fire alarm system batteries were replaced every five years.
NFPA 72 Section 7.3.2 requires that sealed lead-acid type batteries be replaced every 4 years or when the recharged battery voltage or current falls below the manufacturer's recommendations.

This portion applies to Building AE, known as University Family Medicine - Westminster.

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

During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

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

This portion applies to Building AF, known as University Physical Therapy at Stapleton.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AG, known as University Family Medicine - A.F. Williams.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AI, known as University of Colorado Hospital Imaging.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AJ, known as CU Sports Physical Therapy and Rehabilitation.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AK, known as CU Sports Medicine.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AL, known as Eye Center at Park Meadows.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AM, known as University Family Medicine - Park Meadows.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AN, known as ToMo Therapy Cancer Treatment Center.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with National Fire Protection Association (NFPA) Standard 13, for all portions of the facility. This was evidenced by the following:

A) Single interlock pre-action sprinkler systems were not installed with fire/smoke detection systems throughout the protected area, as required. The east pre-action sprinkler system protected numerous building areas including the AOP generator room, AIP generator room, generator air supply "breezeway", chiller/storage room and the entire covered loading dock area (including the oxygen cylinder storage vault). Fire/smoke detection systems were not installed in the chiller/storage room, the breezeway air supply area in front of the AOP generators, or throughout the loading dock area, including the oxygen cylinder storage vault. The facility Electronic Systems Technician acknowledged the absence of fire/smoke detection in these areas during a tour of the facility and confirmed the installation of detection devices in the other protected rooms. Pre-action sprinkler design plans specified a single-interlock style system. As arranged without detection systems, the chiller/storage room (approximately 30 ft. x 42 ft.), the 15 ft. x 30 ft. air supply area in front of the AOP generators and the entire loading dock area (approximately 4000 sq.ft.) are not sprinkler protected. The facility Manager of Support Services confirmed the single interlock design specified on the sprinkler plans.
NFPA 13 Section 4-3.2.1: Single Interlock System- A single interlock system admits water to sprinkler piping upon operation of detection devices.

B) Sprinkler protection was not provided below ductwork (greater than 4 ft. wide), as required.
The 3rd floor mechanical room had four areas with ductwork that was 8 ft. wide. Sprinkler protection was not provided below the ductwork.
NFPA 13 Section 5-5.5.3.1: Sprinklers shall be installed under fixed obstructions over 4 ft. wide such as ducts, decks, open grate flooring, cutting tables and overhead doors.

AOP-Anschutz Outpatient Pavilion & ACP- Anschutz Cancer Pavilion-Aspen ID: Building A-3
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with National Fire Protection Association (NFPA) Standard 13, for all portions of the facility. This was evidenced by the following:

Single interlock pre-action sprinkler systems were not installed with fire/smoke detection systems throughout the protected area, as required. The east pre-action sprinkler system protected numerous building areas including the AOP generator room, AIP generator room, generator air supply "breezeway", chiller/storage room and the entire covered loading dock area (including the oxygen cylinder storage vault). Fire/smoke detection systems were not installed in the chiller/storage room, the breezeway air supply area in front of the AOP generators, or throughout the loading dock area, including the oxygen cylinder storage vault. The facility Electronic Systems Technician acknowledged the absence of fire/smoke detection in these areas during a tour of the facility and confirmed the installation of detection devices in the other protected rooms. Pre-action sprinkler design plans specified a single-interlock style system. As arranged without detection systems, the chiller/storage room (approximately 30 ft. x 42 ft.), the 15 ft. x 30 ft. air supply area in front of the AOP generators and the entire loading dock area (approximately 4000 sq.ft.) are not sprinkler protected.
The facility Manager of Support Services confirmed the single interlock design specified on the sprinkler plans.
NFPA 13 Section 4-3.2.1: Single Interlock System- A single interlock system admits water to sprinkler piping upon operation of detection devices.

This portion applies to Building AC, known as University Family Medicine - Boulder.

It was determined through observation during the survey, that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

The facility failed to extend the sprinkler protection to the following areas:
a. CNC desk area,
b. Biohazard closet, and
c. the acoustical room.

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

This portion applies to Building AD, known as Boulder Physical Therapy Clinic.

It was determined through observation during the survey, that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

There were two pendant sprinkler heads within approximately two-feet of one another in the core gym room. Note: In accordance with NFPA 13 (1999), 5-6.3.4, the heads shall be no less than six-feet apart.

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

It was determined through observation during the survey, that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

The fire sprinkler heads in X-ray room 113 were obstructed by the ceiling mounted X-ray equipment.

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

This portion applies to Building AK, known as CU Sports Medicine.

It was determined through observation during the survey, that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

Seven (7) of eight (8) standard pendant style sprinkler heads in the storage area shell space were installed incorrectly. These heads were installed in the cavity created for flush-mount sprinkler heads, resulting in the sprinkler head being located above the plane of the ceiling and lacking the required escutcheon.

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

K-61
AOP-Anschutz Outpatient Pavilion & ACP- Anschutz Cancer Pavilion-Aspen ID: Building A-3
Sprinkler system valve tamper supervisory equipment (ACP- Anschutz Cancer Pavilion) was not tested semi-annually, as required. Valve tamper testing was documented once in 2012 on August 31, 2012. There were no other documented tests during calendar year 2012.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on record review, observation and staff interview, it was determined that the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This was evidenced by the following:
A) Sprinkler system pressure reducing valves were not:
1. Inspected quarterly in accordance with NFPA 25 Section 9-5.2.1.
2. Tested every 5 years with a full flow in accordance with NFPA 25 Section 9-5.2.2.
Sprinkler system pressure reducing valves were installed on floors basement through 8th.

B) Sprinkler system water supply check valves were not internally inspected every 5 years, as required. Numerous check valves were installed in the fire pump room and dry-pipe system risers. The facility Electronic Systems Technician was not aware of any five year inspection records. NFPA 25 Section 9-4.2.1 requires that check valves be inspected internally every 5 years to verify that all components operate properly, move freely and are in good condition.

C) Dry-pipe sprinkler systems were not trip tested annually, as required. The building was equipped with four dry-pipe systems partially protecting mechanical areas and the ambulance canopy. The facility Electronic Systems Technician was not aware of any records documenting annual trip tests on the dry pipe systems.
NFPA 25 Section 9.4.4.2 requires that the dry pipe valve be trip tested annually during warm weather. Every three years and whenever the system is altered, the dry pipe valve must be trip tested with the control valve fully open and the quick-opening device, if provided, in service. During those years when full flow testing is not required, each dry pipe valve must be trip tested with the control valve partially open. During the annual trip test, the interior of the dry pipe valve shall be cleaned thoroughly and parts replaced or repaired as necessary. A tag or card showing the date on which the dry pipe valve was last tripped and showing the name of the person and organization conducting the test shall be attached to the valve. Separate records of initial air and water pressure, tripping air pressure, and dry pipe valve operating condition shall be maintained on the premises for comparison with previous test results. Records of tripping time also shall be maintained for full flow trip tests.

D) Sprinkler system piping was not maintained free of external loads, as required. Approximately 50 feet of 1 inch copper pipe was observed to be suspended from the pre-action system sprinkler piping in the "breezeway" air supply room. The facility Manager of Support Services acknowledged the suspended piping during a tour of the facility.
NFPA 25 Section 2-2.2: Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

E) Sprinkler system pressure gauges were not recalibrated or replaced every 5 years, as required. Gauges in the Stair #1 first floor foyer were greater than 5 years old. The facility Electronic Systems Technician reported that a gauge replacement program was in progress and awaiting an additional shipment of replacement gauges.

F) Sprinkler system control valves were not equipped with signage indicting the building and/or area served, as required. The pump room 6 inch control valves, installed at the backflow preventer, were not equipped with signs.
NFPA 25 Section 9-3.2: Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

G) Pre-action system sprinkler piping and valves were not protected from physical damage and were not maintained in operable condition, as required. The two drum-drip/drain valve assemblies (east and west side of loading dock area) were both observed to be damaged with piping support units broken. The one of two west drain valves was missing the operating wheel.
NFPA 25 Section 2-2.2: Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment.

H) A hydraulic sprinkler system design information placard was not installed on the ambulance canopy dry-pipe sprinkler riser, as required.
NFPA 13 Section 10-5 requires that the installing contractor identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. The sign shall include the following information:
(1) Location of the design area or areas
(2) Discharge densities over the design area or areas
(3) Required flow and residual pressure demand at the base of the riser
(4) Occupancy classification or commodity classification and maximum permitted storage height and configuration
(5) Hose stream demand included in addition to the sprinkler demand

I) dry-pipe sprinkler system low air supervisory alarms were not tested quarterly, as required. Facility records documented annual testing of the low air alarms.
NFPA 25 Section 9-4.4.2.6 requires that dry-pipe system low air pressure alarms be tested quarterly in accordance with manufacturer's instructions.

J) Sprinkler heads were not maintained free of paint overspray, as required. Room 524 (bathroom) was observed to have paint on the automatic sprinkler head.
(Corrected during the survey)

K) Sprinkler heads were observed to be loaded with foreign materials in the following rooms:
417, 609, 908-3, 910 and 929.
(Corrected during the survey)

AOP-Anschutz Outpatient Pavilion & ACP- Anschutz Cancer Pavilion-Aspen ID: Building A-3
Based on record review, observation and staff interview, it was determined that the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This was evidenced by the following:
A) Pre-action sprinkler system waterflow alarms were not tested quarterly, as required. Facility records documented pre-action waterflow alarm tests on 02-07-12 and 07-12-12. Facility records did not document a test of the ACP wet system waterflow alarm during the 4th quarter of 2012.
NFPA 25 Section 9-2.7 requires quarterly testing of all waterflow alarms.

B) Sprinkler system pressure reducing valves were not inspected quarterly in accordance with NFPA 25 Section 9-5.2.1.

C) Fire pump pressure relief valves were not documented to be inspected weekly in accordance with NFPA 25 Section 9-5.5.2

D) Sprinkler system pressure gauges were not recalibrated or replaced every 5 years, as required. Gauges in the AOP fire pump room were labeled "B89". Gauges at the ACP main sprinkler riser appeared to be dated 1998 and 1999.The facility Electronic Systems Technician reported that a gauge replacement program was in progress and awaiting an additional shipment of replacement gauges.

E) Sprinkler system water supply check valves were not internally inspected every 5 years, as required. Numerous check valves were installed in the fire pump room. The facility Electronic Systems Technician was not aware of any fire year inspection records. NFPA 25 Section 9-4.2.1 requires that check valves be inspected internally every 5 years to verify that all components operate properly, move freely and are in good condition.

F) The elevator shaft pre-action system was not equipped with a listed air maintenance device, as required. NFPA 13 Section 3-1.1: All materials and devices essential to successful system operation shall be listed.

G) Sprinkler system control valves did not indicate the system or portion of the system controlled by the valve, as required. Sprinkler system control valves provide with "Control Valve" signs, but the area served by the valve was not indicated.
NFPA 25 Section 9-3.2: Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

H) Pre-action sprinkler systems were not trip tested annually, as required. The building was equipped with two pre-action systems partially protecting the elevator shaft, generator rooms, generator air supply "breezeway", chiller room and the entire open loading dock area (approximately 4000 square feet).The facility Electronic Systems Technician was not aware of any records documenting annual trip tests on the pre-action systems.
NFPA 25 Section 9.4.3.2.2 requires that each deluge or preaction valve be trip tested annually at full flow in warm weather and in accordance with the manufacturer ' s instructions. Where testing deluge systems, care shall be taken to prevent water damage by verifying that there is adequate drainage. Protection shall be provided for any devices or equipment subject to damage by system discharge during tests.

I) Pre-action sprinkler system low air supervisory alarms were not tested quarterly, as required. Facility records documented annual testing.

J) A pressure gauge was not provided on the city side of the ACP sprinkler system backflow preventor, as required.

K) A standard pendant sprinkler head was missing the required escutcheon plate in the AOP kitchen walk in freezer.

CCW-Critical Care Wing-Aspen ID: Building A-2
A) Sprinkler system pressure reducing valves were not inspected quarterly in accordance with NFPA 25 Section 9-5.2.1.

B) Sprinkler system water supply check valves were not internally inspected every 5 years, as required. Numerous check valves were installed in the fire pump room and the dry pipe system riser. The facility Electronic Systems Technician was not aware of any five year inspection records. NFPA 25 Section 9-4.2.1 requires that check valves be inspected internally every 5 years to verify that all components operate properly, move freely and are in good condition.

C) Dry-pipe sprinkler systems were not trip tested annually, as required. The building was equipped with one dry-pipe system partially protecting the north open storage area (first floor) and a portion of the 2nd floor elevated walkway. The facility Electronic Systems Technician was not aware of any records documenting annual trip tests on the dry pipe systems. During the survey, the dry-pipe system was trip tested by the facility outside fire protection vendor on January 22, 2013.
NFPA 25 Section 9.4.4.2 requires that the dry pipe valve be trip tested annually during warm weather. Every three years and whenever the system is altered, the dry pipe valve must be trip tested with the control valve fully open and the quick-opening device, if provided, in service. During those years when full flow testing is not required, each dry pipe valve must be trip tested with the control valve partially open. During the annual trip test, the interior of the dry pipe valve shall be cleaned thoroughly and parts replaced or repaired as necessary. A tag or card showing the date on which the dry pipe valve was last tripped and showing the name of the person and organization conducting the test shall be attached to the valve. Separate records of initial air and water pressure, tripping air pressure, and dry pipe valve operating condition shall be maintained on the premises for comparison with previous test results. Records of tripping time also shall be maintained for full flow trip tests.

D) A hydraulic sprinkler system design information placard was not installed on the sprinkler riser, as required. The facility Fire Prevention Officer confirmed that the hydraulic design information was not posted in the sprinkler riser area during a tour of the facility.
NFPA 13 Section 10-5 requires that the installing contractor identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. The sign shall include the following information:
(1) Location of the design area or areas
(2) Discharge densities over the design area or areas
(3) Required flow and residual pressure demand at the base of the riser
(4) Occupancy classification or commodity classification and maximum permitted storage height and configuration
(5) Hose stream demand included in addition to the sprinkler demand

E) Sprinkler system pressure gauges were not recalibrated or replaced every 5 years, as required. Gauges installed at the dry-pipe sprinkler riser were dated 2005 and 2006. The facility Electronic Systems Technician reported that a gauge replacement program was in progress and awaiting an additional shipment of replacement gauges.

F) Room B-2314 was protected by one standard upright sprinkler head with a distance to the rear room wall of 14 ft. 7 inches which exceeds the allowed spacing.

G) Room B-2305.19 was protected by a standard pendant sprinkler head installed approximately 60 inches below the floor deck above. The installation exceeded the allowed maximum of 12 inches.

H) dry-pipe sprinkler system low air supervisory alarms were not tested quarterly, as required. Facility records documented annual testing of the low air alarms.
NFPA 25 Section 9-4.4.2.6 requires that dry-pipe system low air pressure alarms be tested quarterly in accordance with manufacturer's instructions.

I) Sprinkler heads were not maintained to be free of paint overspray, as required. One sprinkler head was observed to be painted at the entrance to the morgue.

RMLEI-Rocky Mountain Lions Eye Institute-Aspen ID: Building A-4:
Based on record review and staff interview, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25. This was evidenced by the following:
A) Sprinkler system waterflow alarms were not tested quarterly, as required. Facility records did not document a test of the waterflow alarm during the 2nd and 4th quarters of 2012. NFPA 25 Section 9-2.7 requires quarterly testing of all waterflow alarms.

B) Sprinkler system water supply check valves were not internally inspected every 5 years, as required. The facility Electronic Systems Technician was not aware of any five year inspection records. NFPA 25 Section 9-4.2.1 requires that check valves be inspected internally every 5 years to verify that all components operate properly, move freely and are in good condition.

This portion applies to Building AC, known as University Family Medicine - Boulder.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) There were no less than five (5) of the required escutcheon plates missing in the north portion of the facility, which houses the audiology department.

2) At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25, and
b) an annual test of the backflow preventer serving the fire sprinkler system.

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

This portion applies to Building AD, known as Boulder Physical Therapy Clinic.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25, and
b) an annual test of the backflow preventer serving the fire sprinkler system.

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

This portion applies to Building AE, known as University Family Medicine - Westminster.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) The required escutcheon plate for the pendant style sprinkler head located in the breakroom closet was missing at the time of the survey.

2) At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first half of 2012, conducted in accordance with NFPA 25, and
b) an annual test of the backflow preventer serving the fire sprinkler system, and
c) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012, and
iii) third quarter 2012.

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

This portion applies to Building AF, known as University Physical Therapy at Stapleton.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) The required escutcheon plate for the pendant style sprinkler head located in the lobby over the front desk was missing at the time of the survey.

2) At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.

3) At the time of the survey, the facility failed to provide documentation that the pendant style sprinkler heads, designed for corrosive atmospheres, located in the room housing the therapy pool, had been replaced or tested in the past five years, as required by NFPA 25 (2002), section 5.3.1.1.2.

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

This portion applies to Building AG, known as University Family Medicine - A.F. Williams.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) The required escutcheon plate for the pendant style sprinkler head located in the east store room was missing at the time of the survey.

2) At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.

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

This portion applies to Building AI, known as University of Colorado Hospital Imaging.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.

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

This portion applies to Building AJ, known as CU Sports Physical Therapy and Rehabilitation.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.
e) Treatment room #4 was missing a required escutcheon for the pendant style sprinkler head located therein.

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

This portion applies to Building AK, known as CU Sports Medicine.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.
e) A ceiling tile was missing in the storage area shell space, creating a void in the required smooth, flat ceiling needed for the associated sprinkler heads to operate as intended.

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

This portion applies to Building AL, known as Eye Center at Park Meadows.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.
e) A ceiling tile was missing in the data room, creating a void in the required smooth, flat ceiling needed for the associated sprinkler heads to operate as intended.


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

This portion applies to Building AM, known as University Family Medicine - Park Meadows.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.
e) The ceiling in the electrical closet has unsealed penetrations, creating a void in the required smooth, flat ceiling needed for the associated sprinkler heads to operate as intended.

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

This portion applies to Building AN, known as ToMo Therapy Cancer Treatment Center.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.

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

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to insure that the automatic sprinkler system has an adequate and reliable water supply in accordance with NFPA 20, Standard for the Installation of Stationary Fire Pumps for Fire Protection Service (1999) and NFPA 25. This was evidenced by the following:

A) Fire pump weekly churn tests are not documented in accordance with NFPA 25 Section 5-3.2.4. The printed work order specifies recording suction and discharge pressures, pump starting pressure, and pump run time. The required recordings are not documented during the weekly tests.

B) Battery operated emergency lighting was not provided in the pump room, as required. The room was not equipped with fixed or portable battery operated lights.
NFPA 20 Section 2-7.4: Emergency lighting shall be provided by fixed or portable battery-operated lights, including flashlights. Emergency lights shall not be connected to an engine-starting battery.

C) The fire pump room enclosure was not a one-hour fire rated assembly, as required. The pump room north wall was not fire rated per the facility Life Safety Plan. The facility Electronic Systems Technician confirmed that the north wall was a partition wall with gypsum board on one side only. The fire rating of the east pump room wall, adjacent to the stair #1 void space, could not be determined during the survey.
NFPA 20 Section 2-7.1.1 requires that indoor fire pump units be separated from all other areas of the building by 2-hour fire-rated construction.
Exception No. 2: In buildings protected with an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, the separation requirement shall be reduced to 1-hour fire-rated construction.

D) Fire pump supervisory signals were not displayed at a location within the protected building that was constantly attended by qualified personnel or at an approved, remotely located receiving facility. The facility Electronic Systems Technician reported that the fire pump supervisory annunciator panel was located in the fire command center which was not constantly attended and the annunciator was not connected to the building fire alarm system.

E) Fire pump power supplies did not appear to be monitored to transmit an alarm when the controller was connected to the alternate power source, as required. This function did not appear to have an indicator lamp on the main annunciator in the fire command center.

NFPA 20 Section 7-4.7 Alarm and Signal Devices Remote from Controller.
Where the pump room is not constantly attended, audible or visible alarms powered by a source not exceeding 125 V shall be provided at a point of constant attendance. These alarms shall indicate the following.
(a) Pump or Motor Running. The alarm shall actuate whenever the controller has operated into a motor-running condition. This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(b) Loss of Phase. The loss of any phase at the line terminals of the motor contactor shall be monitored. All phases shall be monitored.
Exception: When power is supplied from multiple power sources, monitoring of each power source for phase loss shall be permitted at any point electrically upstream of the line terminals of the contactor provided all sources are monitored.
(c) Phase Reversal. (See 7-4.6.2.) This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(d) Controller Connected to Alternate Source. Where two sources of power are supplied to meet the requirements of 6-2.3, this alarm circuit shall indicate whenever the alternate source is the source supplying power to the controller. This alarm circuit shall be energized by a separate reliable, supervised power source, reduced to not more than 125 V.

AOP-Anschutz Outpatient Pavilion & ACP- Anschutz Cancer Pavilion-Aspen ID: Building A-3
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to insure that the automatic sprinkler system has an adequate and reliable water supply in accordance with NFPA 20, Standard for the Installation of Stationary Fire Pumps for Fire Protection Service (1999) and NFPA 25. This was evidenced by the following:

A) Fire pump weekly churn tests are not documented in accordance with NFPA 25 Section 5-3.2.4. The printed work order specifies recording suction and discharge pressures, pump starting pressure, and pump run time. The required recordings are not documented during the weekly tests.

B) Fire pump components were not maintained, as required. The 10-27-12 fire pump test report noted that the pump should have new packing installed and adjusted. During the survey, the packing was noted to be leaking water steadily. NFPA 25 Section 5-5.1: A preventive maintenance program shall be established on all components of the pump assembly in accordance with the manufacturer ' s recommendations. Records shall be maintained on all work performed on the pump, driver, controller, and auxiliary equipment. In the absence of manufacturer ' s recommendations for preventive maintenance, Table 5-5.1 provides alternative requirements.

C) The fire pump room enclosure was not maintained to be a one-hour fire rated assembly, as required. The gypsum board enclosure wall was observed to have an 8" x 12" cut out in the wall which voided the one hour rating. The cutout appeared to be from a recent DWV plumbing modification. NFPA 20 Section 2-7.1.1 requires that indoor fire pump units be separated from all other areas of the building by 2-hour fire-rated construction.
Exception No. 2: In buildings protected with an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, the separation requirement shall be reduced to 1-hour fire-rated construction.

D) Battery operated emergency lighting was not provided in the pump room, as required. The room was not equipped with fixed or portable battery operated lights.
NFPA 20 Section 2-7.4: Emergency lighting shall be provided by fixed or portable battery-operated lights, including flashlights. Emergency lights shall not be connected to an engine-starting battery.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to insure that the automatic sprinkler system has an adequate and reliable water supply in accordance with NFPA 20, Standard for the Installation of Stationary Fire Pumps for Fire Protection Service (1999) and NFPA 25. This was evidenced by the following:

A) Fire pump weekly churn tests are not documented in accordance with NFPA 25 Section 5-3.2.4. The printed work order specifies recording suction and discharge pressures, pump starting pressure, and pump run time. The required recordings were not documented during the weekly tests.

B) Battery operated emergency lighting was not provided in the pump room, as required. The room was not equipped with fixed or portable battery operated lights.
NFPA 20 Section 2-7.4: Emergency lighting shall be provided by fixed or portable battery-operated lights, including flashlights. Emergency lights shall not be connected to an engine-starting battery.

C) The fire pump room enclosure was not a one-hour fire rated assembly, as required. The pump room north wall was not fire rated per the facility Life Safety Plan. The facility Electronic Systems Technician confirmed that the north wall was a partition wall with gypsum board on one side only. The fire rating of the east pump room wall, adjacent to the stair #1 void space, could not be determined during the survey.
NFPA 20 Section 2-7.1.1 requires that indoor fire pump units be separated from all other areas of the building by 2-hour fire-rated construction.
Exception No. 2: In buildings protected with an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, the separation requirement shall be reduced to 1-hour fire-rated construction.

D) Fire pump supervisory signals were not displayed at a location within the protected building that was constantly attended by qualified personnel or at an approved, remotely located receiving facility. The facility Electronic Systems Technician reported that the fire pump supervisory annunciator panel was located in the fire command center which was not constantly attended and the annunciator was not connected to the building fire alarm system.

E) Fire pump power supplies did not appear to be monitored to transmit an alarm when the controller was connected to the alternate power source, as required. This function did not appear to have an indicator lamp on the main annunciator in the fire command center.

NFPA 20 Section 7-4.7 Alarm and Signal Devices Remote from Controller.
Where the pump room is not constantly attended, audible or visible alarms powered by a source not exceeding 125 V shall be provided at a point of constant attendance. These alarms shall indicate the following.
(a) Pump or Motor Running. The alarm shall actuate whenever the controller has operated into a motor-running condition. This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(b) Loss of Phase. The loss of any phase at the line terminals of the motor contactor shall be monitored. All phases shall be monitored.
Exception: When power is supplied from multiple power sources, monitoring of each power source for phase loss shall be permitted at any point electrically upstream of the line terminals of the contactor provided all sources are monitored.
(c) Phase Reversal. (See 7-4.6.2.) This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(d) Controller Connected to Alternate Source. Where two sources of power are supplied to meet the requirements of 6-2.3, this alarm circuit shall indicate whenever the alternate source is the source supplying power to the controller. This alarm circuit shall be energized by a separate reliable, supervised power source, reduced to not more than 125 V.

This portion applies to Building AK, known as CU Sports Medicine.

It was determined through observation during the survey that the facility failed to maintain the Fire Extinguishers in accordance with the Life Safety Code and NFPA 10. This was evidenced by:

The fire extinguishers were last annually inspected in February of 2011.

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

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation and staff interview, it was determined that the facility failed to maintain air plenum rooms in accordance with National Fire Protection Association (NFPA) Standard 90A. This was evidenced by the following:

Air handling system plenum/air mixing rooms were not maintained free of combustible storage, as required. Filter storage (cardboard boxes on wood pallets) was observed inside the 3rd floor and penthouse mechanical areas. The storage was inside rooms utilized as return/fresh air plenum rooms.
NFPA 90A Section 2-3.10.1: Plenums shall not be used for occupancy or storage.

The condition was reported to be corrected at the exit conference.

This portion applies to Building AF, known as University Physical Therapy at Stapleton.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AG, known as University Family Medicine - A.F. Williams.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AI, known as University of colorado Hospital Imaging.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AJ, known as CU Sports Physical Therapy and Rehabilitation.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AK, known as CU Sports Medicine.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AL, known as Eye Center at Park Meadows.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AM, known as University Family Medicine - Park Meadows.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AN, known as ToMo Therapy Cancer Treatment Center.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation and staff interview, it was determined that the facility failed to prohibit the use of portable space heating devices in accordance with Life Safety Code Section 18.7.8. This was evidenced by the following:

A portable electric space heater was observed inside office 1066.1. The maximum heating element temperature could not be determined during the survey. Facility staff removed the employee provided heater during a tour of the facility.

Life Safety Code Section 19.7.8 (Portable Space-Heating Devices): Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the course of the survey, it was determined that the facility failed to arrange chute service rooms in accordance with National Fire Protection Association (NFPA) Life Safety Code Section 18.5.4 and Section 9.5. This was evidenced by the following:

A) Rubbish and linen chute inlet opening doors were not arranged to open to a room that was designed and used exclusively for accessing the chute opening, as required. The West rubbish and linen chute service inlet doors (1st floor through 12th floor) opened to the elevator access lobby on each floor. The access lobby/chute service room was separated from the egress corridor, on the north and south side, by double door sets.
Life Safety Code Section 9.5.1: Rubbish chutes and laundry chutes shall be separately enclosed by walls or partitions in accordance with the provisions of Section 8.2. Inlet openings serving chutes shall be protected in accordance with Section 8.2. Doors of such chutes shall open only to a room that is designed and used exclusively for accessing the chute opening. The room shall be separated from other spaces in accordance with Section 8.4.

B) Laundry chute doors would not close and positively latch into the frame, as required.
1) 3rd floor east chute door.
2) 11th floor chute door near elevator #1.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10 and 7.3.2. This was evidenced by the following:

Designated egress corridors were not continuously maintained free of obstructions and impediments to full instant use, as required. Egress corridors were observed to be obstructed in the following locations:
A) The pharmacy egress corridor (1D0403) was obstructed by 3 patient care beds and associated equipment including ceiling mounted cubicle curtains, 3 ft. wide wheeled cloth privacy screens and open folding chairs.

B) The Emergency Department waiting room exit access (1.CO41) was obstructed by patient bed and computer cart.

C) The Emergency Department waiting room exit vestibule (1.048.50) was obstructed by storage that included a computer cart, isolation cart, IV stands, blood pressure monitor and a chair.

The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10 and 7.3.2. This was evidenced by the following:

Designated egress corridors were not continuously maintained free of obstructions and impediments to full instant use, as required. Egress corridors were observed to be obstructed in the following locations:

1. The Outpatient Pavilion Radiology egress corridor (1E0001 and 1G0001) was obstructed by 3 patient care beds and 4 beds in storage. The patient care and stored beds reduced the corridor clearwidth to approximately 4 ft.

2. The corridor (AOP-2nd floor O/R area) was obstructed by 12 large wheeled carts utilized during various surgical procedures.

The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10 and 7.3.2. This was evidenced by the following:

Designated egress corridors were not continuously maintained free of obstructions and impediments to full instant use, as required. Egress corridors were observed to be obstructed in the following locations:
A) An x-ray machine was stored in the corridor outside room 4.22231.

B) Surgery equipment carts, x-ray machines and patient beds were stored in corridor C2300a (outside of the operating rooms).

C) X-ray machine was stored in the corridor outside of the NICU suite.

D) Materials Management supplies were stored in the corridor outside of the CMB office.

The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the survey, it was determined that the facility failed to protect medical gas administration and storage areas in accordance with Life Safety Code Section 18.3.2.4 and NFPA 99. This was evidence by the following:

Electric fixtures were not installed at least 5 ft. above the floor in medical gas storage areas, as required. Carbon dioxide room 2.035 had a light switch installed less than 5 ft. above the floor.
NFPA 99 Section 8-3.1.11.2 (f): Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11(d): Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. above the floor to avoid physical damage.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the survey, it was determined that the facility failed to protect medical gas administration and storage areas in accordance with Life Safety Code Section 18.3.2.4 and NFPA 99. This was evidence by the following:

A) Electric fixtures were not installed at least 5 ft. above the floor in medical gas storage areas, as required. Medical gas storage room 1.2324 had a light switch installed less than 5 ft. above the floor and a duplex receptacle approximately 18 inches above the floor.
NFPA 99 Section 8-3.1.11.2 (f): Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11(d): Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. above the floor to avoid physical damage.

B) Oxygen cylinders were not racked or chained, as required. Unsecured oxygen cylinders were observed in room 1.2327.1 and in the radiology area.
NFPA 99 Section 8-3.1.11.2 (Storage for nonflammable gases less than 3000 cubic feet) requires, in part, that cylinder protection from mechanical shock meet the requirements of Section 4-3.5.2.1(b) 13, and cylinder or container restraint meet the requirements of Section 4-3.5.2.1(b)27.
The cylinder support deficiencies were corrected during the survey.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the course of the survey, it was determined that the facility failed to install the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This was evidenced by the following:

Zone Valves were not installed with a wall and door intervening between the valve and the outlet(s), as required. The MRI patient holding area medical gas zone valve box was not separated from the outlets controlled by the valves. An unprotected door opening, full ceiling height with no lintel, and approximately 6 feet wide, was observed between the room and the zone valve box.

NFPA 99 Section 4-3.1.2.3(d) requires, in part, that station outlets not be supplied directly from a riser unless a manual shutoff valve (located in the same story) is installed between the riser and the outlet with a wall intervening between the valve and the outlet. This valve shall be readily operable from a standing position in the corridor on the same floor it serves.
The NFPA Health Care Facilities Handbook (1999) offers background information on the installation of the zone valve. The purpose of the "wall" between the valves and outlets is to allow someone to shut off the flow of gas to a fire scene without being directly exposed to the fire and any products of combustion. NFPA Technical Assistance offered an opinion (not a Formal Interpretation) that the wall should also include any door assemblies with the objective to provide some degree of protection to someone trying to close the valve if the fire is in the room with the outlet. Having an opening in the wall without a door negates that protection, therefore, a wall includes doors to protect the opening.

This portion applies to Building AB, known as University of Colorado Hospital Lone tree Health Center.

It was determined through observation during the survey that the facility failed to maintain the MedGas storage location in accordance with the Life Safety Code (2000) and NFPA 99 (1999), Healthcare Facilities. This was evidenced by:

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

The MedGas storage location deficiency items were discussed during the survey and again during the exit conference.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on staff interview during the course of the survey, it was determined that the facility failed to protect anesthetizing locations in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This was evidenced by the following:
Operating room relative humidity levels were not maintained at a level of 35%, or greater, as required. Relative humidity levels in the operating rooms were reported to be automatically controlled to maintain relative humidity at 26%.
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.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 99-Health Care Facilities and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

A) Level 1 Emergency Power Supplies were not installed within a room having a minimum 2 hour fire rating, as required.
1) The main generator room was observed to have an unprotected pipe penetration through a two-hour rated wall. The original fire caulking had been dislodged.

2) The generator room communicated to the air supply "breezeway" room via a non-fire rated single door, and a sheet metal covered air intake opening for a future generator. The two existing generators did not have fire dampers on the air intakes from the "breezeway" air supply room. Note: the "breezeway" air supply room also communicated via unprotected openings with the high-voltage switch vault, the mechanical room (exhaust fan opening) and the AOP generator room via non-dampered air intake openings and sheet metal wall sections. The "breezeway" air supply room also communicated with the covered loading dock area via double doors that were not fire rated.
NFPA 99 Section 3-4.1.1.6 requires, in part, that energy converters be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or be located in an adequate enclosure outside of the building. NFPA 110 Section 5-2.1 requires, in part, that Level 1 installations be installed in a separate room and shall be separated by a minimum of 2 hour fire rated construction.

B) Generator rooms were not maintained free of storage, as required. The main generator room was being used for storage of electrical supplies on storage racks and empty plastic 5 gallon motor oil containers. The communicating "breezeway" air supply room was observed to have 13 empty plastic 55 gallon drums in storage and two plastic pallets with cardboard boxes stored in the room. The Facility Manager of Support Services acknowledged the storage during a tour of the facility.
NFPA 110, Section 5-11.1 requires that the room in which Emergency Power Supply (EPS) is located not be used for storage purposes.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

A) Level 1 Emergency Power Supplies were not installed within a room having a minimum 2 hour fire rating, as required.
The generator room communicated to the air supply "breezeway" room via a non-fire rated sheet metal wall section. The two existing generators did not have fire dampers on the air intakes from the "breezeway" air supply room. Note: the "breezeway" air supply room also communicated via unprotected openings with the high-voltage switch vault, the mechanical room exhaust fan and the AIP generator room via non-dampered air intake openings, sheet metal wall sections and door opening with a non-fire rated door. The "breezeway" air supply room also communicated with the covered loading dock area via double doors that were not fire rated.

B) Generator rooms were not maintained free of storage, as required. The communicating "breezeway" air supply room was observed to have 13 empty plastic 55 gallon drums in storage and two plastic pallets with cardboard boxes stored in the room.
The facility Manager of Support Services acknowledged the storage during a tour of the facility.
NFPA 99 Section 3-4.1.1.6 requires, in part, that energy converters be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or be located in an adequate enclosure outside of the building. NFPA 110 Section 5-2.1 requires, in part, that Level 1 installations be installed in a separate room and shall be separated by a minimum of 2 hour fire rated construction.
NFPA 110, Section 5-11.1 requires that the room in which Emergency Power Supply (EPS) is located not be used for storage purposes.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 99-Health Care Facilities and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

A) Level 1 Emergency Power Supplies were not installed within a room having a minimum 2 hour fire rating, as required.
1) The main generator room was observed to have an unprotected duct penetration on the south side two-hour rated wall. The facility Master Electrician confirmed the absence of a fire damper in the duct penetration during a tour of the facility.

2) The main generator room was observed to have a one inch unsealed hole in the south 2 hour rated gypsum board wall. Gaps were also observed around emergency lighting unit junction boxes mounted in the gypsum board wall.

NFPA 99 Section 3-4.1.1.6 requires, in part, that energy converters be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or be located in an adequate enclosure outside of the building. NFPA 110 Section 5-2.1 requires, in part, that Level 1 installations be installed in a separate room and shall be separated by a minimum of 2 hour fire rated construction.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
A) Based on observation and record review during the survey, it was determined that the building standpipe system was not installed and maintained in accordance with NFPA 14-Standard for the Installation of Standpipe, Private Hydrant and Hose Systems, and NFPA 25. This was evidenced by the following:

a) Hose connection pressure reducing valves were not:
1. Inspected quarterly in accordance with NFPA 25 Section 9-5.2.1.
2. Tested annually with a partial flow in accordance with NFPA 25 Section 9-5.2.3.
3. Tested every 5 years with a full flow in accordance with NFPA 25 Section 9-5.2.2.

b) 2.5 inch hose connections were not provided, as required, in the following locations:
1. On each side of the wall adjacent to the exit openings of horizontal exits. Horizontal exits are provided on the upper patient floors.
2. In each exit passageway at the entrance from the building areas into the passageway. Currently, the east stair discharges into a non-compliant exit passageway (see K-38). A standpipe hose outlet will have to be provided if this exit passageway is modified to be compliant, or at the west stair discharge if the facility upgrades this discharge to an exit passageway.
NFPA 14 Section 5-3.2- Class I Systems.
Class I systems shall be provided with 2.5 inch hose connections in the following locations:
(a) At each intermediate landing between floor levels in every required exit stairway.
Exception: Hose connections shall be permitted to be located at the main floor landings in exit stairways where approved by the authority having jurisdiction.
(b) On each side of the wall adjacent to the exit openings of horizontal exits.
(c) In each exit passageway at the entrance from the building areas into the passageway.
(d) In covered mall buildings, at the entrance to each exit passageway or exit corridor, and at exterior public entrances to the mall.
(e) At the highest landing of stairways with stairway access to a roof, and on the roof where stairways do not access the roof. An additional 21/2-in. (63.5-mm) hose connection shall be provided at the hydraulically most remote riser to facilitate testing of the system.
(f) Where the most remote portion of a nonsprinklered floor or story is located in excess of 150 ft (45.7 m) of travel distance from a required exit containing or adjacent to a hose connection, or the most remote portion of a sprinklered floor or story is located in excess of 200 ft (61 m) of travel distance from a required exit containing or adjacent to a hose connection, additional hose connections shall be provided, in approved locations, where required by the local fire department or the authority having jurisdiction.

B) Based on record review during the survey, it was determined that suites of sleeping rooms were not arranged in accordance with Life Safety Code Section 18.2.5.6, as required. This was evidenced by the following:

Suites of sleeping rooms were not limited to 5000 square feet or less in area, as required.
a) The 2nd floor INCU suite was labeled on the facility life safety plan as a sleeping suite of rooms. The plan indicated the suite area as 5109 square feet which exceeds the maximum sleeping suite area.

b) The Emergency Department central core suite was designated on the facility life safety plan as a non-sleeping suite of rooms, 6289 square feet in size. The facility was utilizing rooms within the suite as inpatient sleeping rooms. The suite of sleeping rooms exceeds the allowed maximum of 5000 square feet.
Life Safety Code Section 18.2.5.6: Suites of sleeping rooms shall not exceed 5000 square feet.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3
Based on staff interview during the course of the survey, it was determined that the facility failed to install mechanical ventilation systems in anesthetizing locations in accordance with National Fire Protection Association Standard 99, Health Care Facilities, Section 5-4.1. This was evidenced by the following:
Anesthetizing locations (2nd floor O/Rs) were not arranged to automatically vent smoke and products of combustion in accordance with NFPA 99 Section 5-4.1.2. Facility staff reported that operating rooms did not have any type of automatic smoke venting system.
NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless 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.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on record review and observation during the survey, it was determined that non-sleeping suites were not arranged in accordance with Life Safety Code Section 18.2.5.8, as required. This was evidenced by the following:

Suites with two intervening rooms in the path of egress, were not arranged such that travel distance within the suite to an exit access door was less than 50 feet, as required. The Electrophysiology suite had 2 intervening rooms in the path of travel to the suite exit access door. The travel distance within the suite, via the two intervening rooms, was 75 feet.

Life Safety Code Section 18.2.5.8: Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 feet and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 feet.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

Weekly inspections of emergency generators were not documented, as required. The facility Master Electrician reported that the generators were inspected weekly, but documentation of inspections was not maintained.
NFPA 110 Section 6-4.1 requires Level 1 and Level 2 Emergency Power Supply Systems (EPSS) including all appurtenant components, be inspected weekly and exercised under load at least monthly. Section 6-3.4 requires, in part, that a written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

Weekly inspections of emergency generators were not documented, as required. The facility Master Electrician reported that the generators were inspected weekly, but documentation of inspections was not maintained.
NFPA 110 Section 6-4.1 requires Level 1 and Level 2 Emergency Power Supply Systems (EPSS) including all appurtenant components, be inspected weekly and exercised under load at least monthly. Section 6-3.4 requires, in part, that a written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

Weekly inspections of emergency generators were not documented, as required. The facility Master Electrician reported that the generators were inspected weekly, but documentation of inspections was not maintained.
NFPA 110 Section 6-4.1 requires Level 1 and Level 2 Emergency Power Supply Systems (EPSS) including all appurtenant components, be inspected weekly and exercised under load at least monthly. Section 6-3.4 requires, in part, that a written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on record review during the course of the survey, it was determined that the facility failed to install and maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This was evidenced by the following:

A review of panelboard branch circuit index cards noted the following deficiencies:

A) The Life Safety Branch of the essential electrical system was supplying branch circuits that were not considered essential to life safety nor specifically allowed on the Life Safety Branch in accordance with Section 3-4.2.2.2 (b).
1) Panelboard IP-L4LE circuit #14: 4th floor mag doors (magnetic door hold open devices)

2) Panelboard IP-L6LE circuit #39: 7th floor mag doors (magnetic door hold open devices)

3) Panelboard IP-L8LE: 8th and 9th floor mag doors (magnetic door hold open devices)

4) Panelboard LBLE circuit #2, #4 and #7: mag door holds

5) Panelboard LBLE circuit #9: 1st floor door security

6) Panelboard LBLE circuit #33: Triatek Panel (undetermined-possible room lighting)

7) Panelboard LBLE circuit #34: Basement security west

NFPA 99 Section 3-4.2.2.2 (b) Life Safety Branch: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as
specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

B) The Critical Branch of the essential electrical system was supplying branch circuits that were not related to patient care in accordance with Section 3-4.2.2.2 (c).

1) Panelboard IP-C1LE1-S2, circuit #61 was powering heat tape installed on the front canopy
downspouts.

2) Panelboard IP-C1LW-S1, circuit #35 was powering heat tape installed on the front canopy
downspouts.

3) Panelboard IP-C3L-S2, circuit #72 was powering heat tape.

4) Panelboard IP-C3L-S3, circuit #94 was powering the east dry-pipe sprinkler system air
compressor.

5) Panelboard IP-C3L-S3, circuit #96 was powering the west dry-pipe sprinkler system air
compressor.

6) Panelboard IP-C1LE, circuit #100 was powering the ambulance canopy dry sprinkler system riser room unit heater blower motor.

7) Panelboard IP-CBLE circuit #27: CM-2 (unidentified load)

8) Panelboard IP-CBLE circuit #2: DWP-3 (unidentified load)

9) Panelboard IP-CBLE circuit #33: EF-23 (motor size unknown), UH-0-4 (unidentified load)

10) Panelboard IP-CBLE circuit #18: EF-9 (motor size unknown)

11) Panelboard IP-CBLE circuit #20: RD-1 (unidentified load)

12) Panelboard IP-CBLE circuit #22: DWH-1/DWH-2 &CM-4 (unidentified load)

NFPA 99 Section 3-4.2.2.2 (c) Critical Branch.: The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on record review during the course of the survey, it was determined that the facility failed to install and maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This was evidenced by the following:

A review of panelboard branch circuit index cards noted the following deficiencies:

A) The Life Safety Branch of the essential electrical system was supplying branch circuits that were not considered essential to life safety nor specifically allowed on the Life Safety Branch in accordance with Section 3-4.2.2.2 (b).

1) Panelboard B-LBLSE circuit #17: LL mag door holds

2) Panelboard B-LBLSE circuit #29: LL Security Doors

3) Panelboard B-LBLSE circuit #31 and #33: LL Roll Up Door

4) Panelboard B-LBLSE circuit #10: 1st floor mag holds

5) Panelboard B-LBLSE circuit #18 and #20: first floor security doors

6) Panelboard B-LBLNW circuit #11 and #12: LL and first floor mag hold opens

7) Panelboard B-LBLNW circuit #18: Roll up door control module

8) Panelboard B-L2LNW circuits #3 and #10: 2nd and 3rd floor mag holds

9) Panelboard B-L2LNW circuits #29: second floor security doors

10) Panelboard B-L2LNW circuits #31, #33 and #37: various roll up doors

11) Panelboard B-L4LSW circuits #9: 4th floor security doors

12) Panelboard B-L4LSW circuits #11: 4th floor mag holds

NFPA 99 Section 3-4.2.2.2 (b) Life Safety Branch: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as
specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

B) The Critical Branch of the essential electrical system was supplying branch circuits that were not related to patient care in accordance with Section 3-4.2.2.2 (c).
The following circuit breakers, as identified on the panelboard index card, were not related to patient care and/or exceeded the allowed motor size:

1) Panelboard CBLNW-S1 circuit #32: MRI #2 door compressor (1 ? horsepower motor)

2) Panelboard CBHNW circuit #32 and #33: MRI chiller pumps (1 horsepower each)


NFPA 99 Section 3-4.2.2.2 (c) Critical Branch.: The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association Standard 70, National Electric Code. This was evidenced by the following:

Flexible cords were being used as a substitute for permanent wiring in the following locations:
1. One extension cord in the Cytology office.
2. Multi-outlet power strips were linked together in office #1008.
NFPA 70, National Electric Code Section 400-8 requires, in part, that flexible cords and cables not be used a substitute for the fixed wiring of a structure, and that they not be attached to a building surface.
The extension cords and power strips were removed from use during a tour of the facility.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association Standard 70, National Electric Code. This was evidenced by the following:

Flexible cords were being used as a substitute for permanent wiring in the following locations:
1. One extension cord was plugged into a multi-outlet power strip in room 4.2219.
2. One extension cord was plugged into a multi-outlet power strip in room 4.2215.
3. One extension cord was plugged into a multi-outlet power strip in the Materials Management storage room.
4. Extension cords and a multi-outlet power strip plugged into a 3 way outlet extender.
NFPA 70, National Electric Code Section 400-8 requires, in part, that flexible cords and cables not be used a substitute for the fixed wiring of a structure, and that they not be attached to a building surface.
The extension cords and power strips were removed from use during a tour of the facility.

This portion applies to Building AC, known as University Family Medicine - Boulder.

It was determined through observation during the survey that the facility failed to utilize the building's electrical system in accordance with the Life Safety Code. This was evidenced by:

1) A flexible cord was routed through the ceiling in the IT Closet. Note: In accordance with 1999 NFPA 70 Article 400-8, flexible cords may not be routed through ceilings.

2) A surge protected power strip was plugged into a second surge protected power strip in exam room #5.

3) A surge protected power strip was plugged into a second surge protected power strip in the doctor's office across from the linen closet.

4) The facility was utilizing an extension cord in place of the permanent wiring of the building in the audiology consult office.

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

This portion applies to Building AG, known as University Family Medicine - A.F. Williams.

It was determined through observation during the survey that the facility failed to utilize the building's electrical system in accordance with the Life Safety Code. This was evidenced by:

1) A surge protected power strip was plugged into a second surge protected power strip in gold pod.

2) A surge protected power strip was plugged into a second surge protected power strip at the front desk.

Note: The above items were corrected during the survey.

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

This portion applies to Building AD, known as Boulder Physical Therapy Clinic.

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

At the time of the survey the facility failed to provide documentation reflecting that the elevator had been inspected annually, as required. Note: The elevator is utilized by the facility's patrons for access to the floor on which the facility is located.

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

It was determined through observation during the survey that the facility failed to install Alcohol Based Hand Rub Dispensers in a safe and appropriate manner. This was evidenced by:

The following alcohol-based hand sanitizer dispensers were located above an electrical device:
a. one in room #110, and
b. one in room 106.

The alcohol based hand rub dispenser deficiency items were discussed during the survey and again during the exit conference.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation and record review during the course of the survey, it was determined that the facility failed to provide a two-hour fire rated separation to non-healthcare occupancies in accordance with Life Safety Code Section 18.1.2.3. This was evidenced by the following:

The healthcare occupancy was not separated from connected non-healthcare occupancies by two-hour rated construction and protected openings, as required. The second floor elevated sky bridge (non-combustible construction-partially sprinkler protected) communicated with the healthcare occupancy via a wall of undermined fire resistance rating and 20 minute fire rated double doors. The sky bridge communicated with the parking structure to the north via unprotected glass doors. Facility life safety plan page G-LS02 did not indicate any rated fire walls in the area of Bridge 2.C2344 or Corridor 2.C2344.

Life Safety Code Section 18.1.2.3: Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours as provided for additions in 18.1.1.4.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation, it was determined that the facility failed to maintain the fire protection rating of the building structure in accordance with Life Safety Code Section 19.1.6.2. This was evidenced by the following:

Building structure fire protection systems were not maintained, as required. Structural steel spray on fire-proofing material was not maintained at the original thickness on a structural support beam (room OP-0029). The spray-on fire-proofing had been removed to install two welded plates for a lift/hoist I rail. Facility architectural plans classified the building as construction Type I (332).
Life Safety Code Section 19.1.6.2 outlines allowed construction types. The original building classification of Type I (332) must be maintained and not diminished.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation, it was determined that the facility failed to install and maintain the fire protection rating of the building structure in accordance with Life Safety Code Section 18.1.6.2 and Section 8.2. This was evidenced by the following:

Building structure protective assemblies were not maintained, as required.
A) A structural steel cross-brace was observed to have the original spray-on fire-proofing removed in three areas along the length of the brace. The structural brace was located on the west side of the emergency generator room.

B) Building structural steel was not protected to meet the minimum building fire protection rating, as required. Facility records documented the building construction type to be NFPA Type I (332). Egress stair #3 and #4 were both observed to have non-combustible stair assemblies supported by unprotected steel columns and beams.
Life Safety Code Section 18.1.6.2 outlines allowed construction types. The building was classified as Type I (332) which must be provided and maintained. Section 8.2.1: Construction.
Buildings or structures occupied or used in accordance with the individual occupancy chapters (Chapters 12 through 42) shall meet the minimum construction requirements of those chapters. NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on either of the following:
(1) Separate buildings if a 2-hour or greater vertically-aligned fire barrier wall in accordance with NFPA 221, Standard for Fire Walls and Fire Barrier Walls, exists between the portions of the building
Exception: The requirement of 8.2.1(1) shall not apply to previously approved separations between buildings.
(2) The least fire-resistive type of construction of the connected portions, if no such separation is provided
Section 8.2.3.1.1: Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2.
Exception No. 1: Structural elements shall be required to have only the fire resistance rating required for the construction classification of the building where such elements support nonbearing wall or partition assemblies having a required fire resistance rating of 1 hour or less and where such elements do not serve as exit enclosures or protection for vertical openings.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, record review and staff interview during the course of the survey, it was determined that the facility failed to maintain the separation between egress corridors and all other areas in accordance with Life Safety Code Section 18.3.6.1 and 18.3.6.2. This was evidenced by the following:

Egress corridors were not separated from patient treatment areas by non-fire rated smoke resistive partitions, as required. The Emergency Department Manager reported that the department utilized 21 "hall beds" for emergency patient care. The hall beds were used on a daily basis, depending upon patient census. Hall beds located within the emergency department core areas were utilized first with additional "disaster beds" utilized last. 3 of 21 hall beds were located in the Outpatient Pavilion Radiology egress corridor (see AOP building deficiency list). A review of facility plans determined that the core area of the emergency department was arranged as three separate non-sleeping suites all within AIP-Anschutz Inpatient Pavilion, Building A-1, as follows:
South suite-ambulance entrance area- 2015 square feet.
Core area suite - 6289 square feet.
North area suite- 6167 square feet.
The plan review verified that 3 of the 21 hall beds were located within designated 8 ft. wide egress corridors and not within an internal suite passageway. The patient care beds, located within the designated egress corridors, were observed in the pharmacy egress corridor (1D0403).

The Life Safety Code Section 18.3.6.1 requires that corridors be separated from all other areas by partitions complying with 18.3.6.2 through 18.3.6.5. Exception #1 to 18.3.6.1 allows some areas to be open to the egress corridor, however, the allowed areas exclude patient sleeping rooms, patient treatment rooms and hazardous areas. Section 18.3.6.2 requires that corridor walls separating use areas from the egress corridor form a barrier to limit the transfer of smoke.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the separation between egress corridors and all other areas in accordance with Life Safety Code Section 19.3.6.1 and 19.3.6.2. This was evidenced by the following:

Egress corridors were not separated from patient treatment areas by non-fire rated smoke resistive partitions, as required. The Emergency Department Manager reported that the department utilized 21 "hall beds" for emergency patient care. The hall beds were used on a daily basis, depending upon patient census. Hall beds located within the emergency department core areas (AIP-Bldg. A-1) were utilized first with additional "disaster beds" utilized last. 3 of 21 hall beds were located in the Outpatient Pavilion (AOP) Radiology 8 ft. egress corridor.

The Life Safety Code Section 19.3.6.1 requires that corridors be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. Exception #1 to 19.3.6.1 allows some areas to be open to the egress corridor, however, the allowed areas exclude patient sleeping rooms, patient treatment rooms and hazardous areas. Section 19.3.6.2 requires that corridor walls separating use areas from the egress corridor form a barrier to limit the transfer of smoke.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the survey, it was determined that the facility failed to install corridor doors in accordance with Life Safety Code Section 18.3.6.3. This was evidenced by the following:

A) Corridor doors would not positively latch, as required. The following room doors would not positively latch when tested:
1) Room #902
2) Room #7125
3) Room #604
4) Linen closet adjacent to room #503
5) West chute service room double doors were not arranged with positive latching hardware (1st floor and 4th floor).
Life Safety Code Section 18.3.6.3.2: Doors shall be provided with positive latching hardware. Roller latches shall be prohibited.

B) Corridor doors were not arranged to automatically latch into the door frame, as required. Two linen closets (6th floor) were equipped with double doors. One of two leafs was not equipped with automatic latching hardware. The leaf equipped with the latchset was arranged to latch into the " fixed " door leaf that was equipped with manual latching hardware. If the manual latching hardware was not engaged, neither leaf would be positively latched.

C) Corridor doors were not maintained to be smoke resistive, as required. Room 1204 and 1001 were observed to have gaps between the door and door frame that exceeded 1/2 inch in width. Life Safety Code Section 18.3.6.3.1 requires that corridor doors be constructed to resist the passage of smoke.

D) The Cystology/Hystology Lab pass-through double doors (40" x 35") were obstructed from closing by plastic tubs, a metal bell and a clipboard.

Most of the K-18 items were reported to be corrected at the exit conference.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation during the survey, it was determined that the facility failed to protect vertical openings in accordance with Life Safety Code Section 19.3.1.1 and 8.2.5. This was evidenced by the following:
A) Vertical openings were not protected in accordance with Life Safety Code Section 8.2.5, as required. The ACP main entrance area was observed to have a 3 story vertical opening that was not one-hour rated.
1) The first floor area is not separated from the unprotected vertical opening.
2) The second floor area is not separated from the unprotected vertical opening.
3) The third floor is separated from the unprotected vertical opening by a glass wall with no apparent fire rating.

B) Two hour rated vertical opening enclosures were not maintained, as required.
1. Stair #2, 5th floor was observed to have unsealed pipe penetrations through the wall.
2. Stair #2, 3rd floor was observed to have approximately 8 feet of missing fire stop between the 2 hour wall and the floor deck.

Life Safety Code Section 19.3.1.1 requires that any vertical opening between stories shall be enclosed in accordance with Section 8.2.5 with construction having a one-hour fire resistance rating. Section 8-2.3.2.4.2 requires, in part, that the space between cable or pipe penetrations and the fire barrier be filled with a material capable of maintaining the fire resistance rating of the barrier.

RMLEI-Rocky Mountain Lions Eye Institute-Aspen ID: Building A-4
Based on observation during the survey, it was determined that the facility failed to protect vertical openings in accordance with Life Safety Code Section 39.3.1.1 and 8.2.5. This was evidenced by the following:
Vertical openings were not protected in accordance with Life Safety Code Section 8.2.5, as required. The RMLEI main entrance area was observed to have a 3 story vertical opening that was not one-hour rated.
1) The first floor area is not separated from the unprotected vertical opening.
2) The second floor area is not separated from the unprotected vertical opening.
3) The third floor is separated from the unprotected vertical opening by a glass wall with no apparent fire rating.
Life Safety Code Section 39.3.1.1 requires that any vertical opening between stories shall be enclosed in accordance with Section 8.2.5 with construction having a one-hour fire resistance rating. Section 8-2.3.2.4.2 requires, in part, that the space between cable or pipe penetrations and the fire barrier be filled with a material capable of maintaining the fire resistance rating of the barrier.

This portion applies to Building AC, known as University Family Medicine - Boulder.

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

The building is served by two open stairways that extend from the ground floor to the second floor (three stories). These stairways are connected by open corridors on both the ground floor and the second floor, thus creating a three-story vertical opening affected in the entire facility. This vertical opening fails to meet any of the conditions set forth in NFPA 101 (2000), section 8.2.5, Vertical Openings.

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

This portion applies to Building AD, known as Boulder Physical Therapy Clinic.

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

The building is served by two open stairways that extend from the ground floor to the second floor (three stories). These stairways are connected by open corridors on both the ground floor and the second floor, thus creating a three-story vertical opening affected in the entire facility. This vertical opening fails to meet any of the conditions set forth in NFPA 101 (2000), section 8.2.5, Vertical Openings.

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

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

The building has an open stairway and an open atrium that extend from the ground floor to the second floor (two stories). This stairway and open atrium creates a two-story vertical opening. This vertical opening does not appear to meet any of the conditions set forth in NFPA 101 (2000), section 8.2.5, Vertical Openings. Note: Patrons of the facility must enter the facility through this vertical opening and the vertical opening is not separated by fire-rated construction from the facility.

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

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the survey, it was determined that the facility failed to mark access to exits in areas where the way to reach the exit was not readily apparent to occupants. This was evidenced by the following:

A) The PACU suite did not have an exit sign installed near the nurse's station to direct occupants to the suite exit.

B) The outpatient radiology area exit path was marked by an exit sign that did not have the required directional indicator.

Life Safety Code Section 7.10.1.4 requires that access to exits be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, it was determined that the facility failed to maintain the fire resistance rating of smoke barrier walls in accordance with the Life Safety Code Section 18-3.7.3 and Section 8.3. This was evidenced by the following:

One hour rated smoke barrier walls were not maintained, as required. The second floor one hour rated wall (at Cardio Lab 3.2302) was observed to have a cable tray penetration without a complete fire stop system. An intumescent fire stop brick was observed to be missing.

Life Safety Code Section 18.3.7.3 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than 1 hour. Section 8-3.6.1 requires, in part, that the space between cable and pipe penetrations and the smoke barrier wall be filled with a material capable of maintaining the 1 hour fire resistance rating of the barrier.
The deficiency was reported to be corrected at the exit conference.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation, it was determined that the facility failed to maintain the fire resistance rating of smoke barrier walls in accordance with the Life Safety Code Section 19-3.7.3 and Section 8.3. This was evidenced by the following:

Smoke barrier wall (second floor corridor near laser room) was observed to have two unsealed pipe penetrations.
Life Safety Code Section 8-2.3.2.4.2 requires, in part, that the space between cable or pipe penetrations and the fire barrier be filled with a material capable of maintaining the fire resistance rating of the barrier.
The deficiency was reported to be corrected at the exit conference.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the course of the survey, it was determined that the facility failed to install smoke barrier doors in accordance with the Life Safety Code Section 18.3.7.8. This was evidenced by the following:

One set of smoke barrier cross-corridor doors (10th floor) were not equipped with rabbets, bevels or astragals on the meeting edges of the doors, as required.
Life Safety Code Section 18.3.7.8 requires that the meeting edges on smoke barrier doors be equipped with rabbets, bevels or astragals.
The deficiency was reported to be corrected at the exit conference.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation during the course of the survey, it was determined that the facility failed to install smoke barrier doors in accordance with the Life Safety Code Section 19.3.7.6 and Section 8.3.4.
This was evidenced by the following:
Second floor smoke barrier doors were observed to have a gap between the door leafs that exceeded 1/8 inch.
Life Safety Code Section 8.3.4 requires that doors in smoke barriers close the opening leaving only the minimum clearance necessary for proper operation.
The deficiency was reported to be corrected at the exit conference.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the survey, it was determined that the facility failed to enclose hazardous areas in accordance with the Life Safety Code Section 18.3.2.1 and Section 8.4. This was evidenced by the following:

Storage rooms, greater than 100 square feet in area, were not provided with 45 minute (minimum) rated doors, as required. Pharmacy storage room 1C0501 was equipped with a 20 minute rated door.
The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 18.3.2.1 and Section 8.4. Section 8.4.1.3 requires that doors in fire rated barriers have a minimum ? hour fire resistance rating and that the doors be self-closing or automatic closing.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the survey, it was determined that the facility failed to maintain hazardous area enclosures in accordance with the Life Safety Code Section 18.3.2.1 and Section 8.4. This was evidenced by the following:

Hazardous area enclosure doors were not self-closing and positively latching, as required. The O/R area equipment storage room door (outside OR 3 and OR 4), would not positively latch into the door frame.
The Life Safety Code requires that hazardous areas be separated from other spaces in accordance with Section 18.3.2.1 and Section 8.4. Section 8.4.1.3 requires that doors in fire rated barriers have a minimum ? hour fire resistance rating and that the doors be self-closing or automatic closing. Rated fire doors must positively latch into the door frame in accordance with NFPA 80.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on record review during the survey, it was determined that the facility failed to conduct laboratory fire drills in accordance with NFPA 99, Health Care Facilities. This was evidenced by the following:

Laboratory fire drills were not conducted quarterly, as required. Records documented two fire drills during the prior 12 month period. Drills were conducted on September 28, 2012 and October 12, 2012.
NFPA 99 Section 10-2.1.4.3 requires that fire drills in laboratories be conducted quarterly.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:
A) Corridor doors were not installed in accordance with Section 7.2.1.4.4, as required. Doors opening into the corridor exceeded the allowed maximum of 7 inches from the wall when in the fully opened position. The following doors were observed to project 12 inches to 14 inches into the corridor clearwidth when in the fully open position:
1) electric room #1127
2) electric room #2127
3) janitor closet #2125
Life Safety Code Section 7.2.1.4.4: During its swing, any door in a means of egress shall leave not less than one-half of the required width of an aisle, corridor, passageway, or landing unobstructed and shall not project more than 7 inches into the required width of an aisle, corridor, passageway, or landing, when fully open.

B) Discharge from exits was not arranged in accordance with Life Safety Code Section 7.7.2, as required. Greater than 50% of the required number of exits and greater than 50% of the required egress capacity (exits from floors 5 through 12) discharged through areas on the level of exit discharge. Stair #1 and Stair #2 both discharged inside the building on the level of exit discharge. Neither stair discharge was arranged as an exit passageway in accordance with Life Safety Code Section 7.2.6.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 18.2.1 and Chapter 7. This was evidenced by the following:

A) Corridor doors were not arranged in accordance with Life Safety Code Section 7..1.4.4, as required. Doors opening into the corridor exceeded the allowed maximum of 7 inches from the wall, when in the full open position, in the following locations:
1) Room #B-2314 corridor door obstructed from fully opening, hits cross corridor door-approx
12 inch projection into the corridor
2) Room B-2305.19 electric room door, when fully open projects approximately 14 inches into
the corridor.

B) Penetrations in egress stair enclosures were not in accordance with Life Safety Code Section 7.1, as required. Egress stairs #3 and #4 were observed to have supply and return air duct penetrations throughout the stair enclosure. The duct penetrations were part of the HVAC system for normal heating and cooling of the egress stair enclosure and did not appear to be related to an independent stair pressurization system.
Life Safety Code Section 7.1.3.2.1 (e): Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.

This portion applies to Building AM, known as University Family Medicine - Park Meadows.

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

The northeast exit door, which serves an occupant load greater than 50 persons, was found to swing against the direction of egress travel.

The means of egress deficiency item was discussed during the survey and again during the exit conference.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, it was determined that the facility failed to arrange special door locking in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:
A) Egress doors equipped with delayed-egress locking devices were not programmed to start the irreversible unlocking sequence upon activation of an audible signal in the vicinity of the door, as required. The following doors were equipped with delayed-egress special locking that were programmed to sound a pre-alarm signal in the vicinity of the door:
1. Door 4.C134 (cross corridor door)
2. Door 4.B0704 (cross corridor door)
3. Door 4.C1302 (Stair 1)
4. Door 4.C0302 (Stair 2)
5. Stair 1 and stair 2 doors, 5th floor.
Upon sounding of the pre-alarm signal, the unlocking sequence did not start. Life Safety Code Section 7.2.1.6.1(c) requires, in part, that the initiation of the release process activate an audible signal in the vicinity of the door.
The pre-alarm signals were removed prior to the exit conference on February 4, 2013.

B) Doors equipped with delayed-egress special locking were not arranged in accordance with Life Safety Code Section 18.2.2.2.4, as required. 4th floor cross-corridor doors and stair exit doors were equipped with delayed egress special locking. The door arrangement resulted in more than one such devices located in an egress path.
Life Safety Code Section 18.2.2.2.4, Exception No. 2: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation, it was determined that the facility failed to arrange special door locking in accordance with Life Safety Code Section 18.2 and Chapter 7. This was evidenced by the following:
A) Egress doors equipped with delayed-egress locking devices were not programmed to sound an audible signal, in the vicinity of the door, at the start of the irreversible unlocking sequence, as required. The 4th floor NICU suite corridor door was equipped with delayed egress special locking. When tested during a tour of the facility, the locking device failed to sound an alarm at the start of the unlocking sequence.
Life Safety Code Section 7.2.1.6.1(c) requires, in part, that the initiation of the release process activate an audible signal in the vicinity of the door.

B) Doors equipped with delayed-egress special locking were not arranged in accordance with Life Safety Code Section 18.2.2.2.4, as required. The 4th floor NICU exit door and Stair #3door were equipped with delayed egress special locking. The door arrangement resulted in more than one such devices located in an egress path.
Life Safety Code Section 18.2.2.2.4, Exception No. 2: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
The stair 3 delayed egress hardware was disabled during the survey, and the alarm was restored on the NICU delayed egress hardware.

This portion applies to Building AC, known as University Family Medicine - Boulder.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AD, known as Boulder Physical Therapy Clinic.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AE, known as University Family Medicine - Westminster.

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

1) The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

2) The facility provides battery backed-up emergency lighting in all exam rooms; however, that the time of the survey, two (2) of these lights failed to operate when the button marked as "push to test" was depressed. Note: This item was corrected during the survey.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AF, known as University Physical Therapy at Stapleton.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AG, known as University Family Medicine - A.F. Williams.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AI, known as University of Colorado Hospital Imaging.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AJ, known as CU Sports Physical Therapy and Rehabilitation.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AK, known as CU Sports Medicine.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AL, known as Eye Center at Park Meadows.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AM, known as University Family Medicine - Park Meadows.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

This portion applies to Building AN, known as ToMo Therapy Cancer Treatment Center.

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

The facility failed to provide documentation at the time of the survey to reflect:
a. 30-second testing of the battery backed-up emergency lighting has taken place monthly, and
b. 90-minute testing of the battery backed-up emergency lighting has taken place yearly.

The emergency lighting deficiency items were discussed during the survey and again during the exit conference.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code Section 18.3.4.3. This was evidenced by the following:

Visual fire alarm system notification appliances were not installed inside critical care areas, as required. The following critical care areas were not provided with visual notification appliances:
1. 5th floor C Section room.
2. Labor and Delivery suite, 4th floor.
3. NICU O/R, 4th floor.

Life Safety Code Section 18.3.4.3.1: Occupant notification shall be accomplished automatically in accordance with Section 9.6.3. Exception: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code Section 19.3.4.3. This was evidenced by the following:

Visual fire alarm system notification appliances were not installed inside critical care areas, as required. Operating rooms (#1 through #8) were not provided with visual notification appliances.

Life Safety Code Section 19.3.4.3.1: Occupant notification shall be accomplished automatically in accordance with Section 9.6.3. Exception: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the survey, it was determined that the facility failed to install the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code Section 18.3.4.3. This was evidenced by the following:

Visual fire alarm system notification appliances were not installed inside critical care areas, as required. Windowless operating rooms (#1 through #16) were not provided with visual notification appliances.

Life Safety Code Section 18.3.4.3.1: Occupant notification shall be accomplished automatically in accordance with Section 9.6.3. Exception: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A) Fire pump supervisory signals were not tested quarterly, as required. The facility Electronic Systems Technician reported that fire pump loss of power supervision was tested annually during the pump flow test and any time a section of the system was drained and refilled. There was no documentation of this test situation. The facility Electronic Systems Technician was not aware of any testing of the pump power supply phase reversal supervision.
NFPA 72 Section 7-3.2 requires supervisory signal devices be tested quarterly. Section 7.5.2.2 requires, in part, that a permanent record of all inspections, testing and maintenance be maintained.

B) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

C) Fire alarm system secondary power supply sealed lead-acid batteries were not discharge tested annually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years. NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to an annual discharge test (30 minutes).

D) Fire alarm system sealed lead acid batteries were not replaced every four years, as required. The facility Electronic Systems Technician reported that all fire alarm system batteries were replaced every five years.
NFPA 72 Section 7.3.2 requires that sealed lead-acid type batteries be replaced every 4 years or when the recharged battery voltage or current falls below the manufacturer's recommendations.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A) Fire pump supervisory signals were not tested quarterly, as required. The facility Electronic Systems Technician reported that fire pump loss of power supervision was tested annually during the pump flow test and any time a section of the system was drained and refilled. There was no documentation of this test situation. The facility Electronic Systems Technician was not aware of any testing of the pump power supply phase reversal supervision.
NFPA 72 Section 7-3.2 requires supervisory signal devices be tested quarterly. Section 7.5.2.2 requires, in part, that a permanent record of all inspections, testing and maintenance be maintained.

B) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

C) Fire alarm system secondary power supply sealed lead-acid batteries were not discharge tested annually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years. NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to an annual discharge test (30 minutes).

D) Fire alarm system sealed lead acid batteries were not replaced every four years, as required. The facility Electronic Systems Technician reported that all fire alarm system batteries were replaced every five years.
NFPA 72 Section 7.3.2 requires that sealed lead-acid type batteries be replaced every 4 years or when the recharged battery voltage or current falls below the manufacturer's recommendations.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A) Fire pump supervisory signals were not tested quarterly, as required. The facility Electronic Systems Technician reported that fire pump loss of power supervision was tested annually during the pump flow test and any time a section of the system was drained and refilled. There was no documentation of this test situation. The facility Electronic Systems Technician was not aware of any testing of the pump power supply phase reversal supervision.
NFPA 72 Section 7-3.2 requires supervisory signal devices be tested quarterly. Section 7.5.2.2 requires, in part, that a permanent record of all inspections, testing and maintenance be maintained.

B) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

C) Fire alarm system secondary power supply sealed lead-acid batteries were not discharge tested annually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years. NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to an annual discharge test (30 minutes).

D) Fire alarm system sealed lead acid batteries were not replaced every four years, as required. The facility Electronic Systems Technician reported that all fire alarm system batteries were replaced every five years.
NFPA 72 Section 7.3.2 requires that sealed lead-acid type batteries be replaced every 4 years or when the recharged battery voltage or current falls below the manufacturer's recommendations.

E) First floor carbon dioxide room was observed to have a smoke detector detached from the junction box. The detector was supported only by the fire alarm system wiring.

RMLEI-Rocky Mountain Lions Eye Institute-Aspen ID: Building A-4:
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 101, Life Safety Code, and NFPA 72, National Fire Alarm Code. This was evidenced by the following:

A) Fire alarm system secondary power supply sealed lead-acid batteries were not load voltage tested semiannually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years.
NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to a load voltage test semiannually.

B) Fire alarm system secondary power supply sealed lead-acid batteries were not discharge tested annually, as required. The facility Electronic Systems Technician reported that there was no battery testing program in place, and all fire alarm system batteries were replaced every five years. NFPA 72, Section 7.3.2 subsection 6d requires that sealed lead-acid type fire alarm system batteries be subject to an annual discharge test (30 minutes).

C) Fire alarm system sealed lead acid batteries were not replaced every four years, as required. The facility Electronic Systems Technician reported that all fire alarm system batteries were replaced every five years.
NFPA 72 Section 7.3.2 requires that sealed lead-acid type batteries be replaced every 4 years or when the recharged battery voltage or current falls below the manufacturer's recommendations.

This portion applies to Building AE, known as University Family Medicine - Westminster.

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

During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

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

This portion applies to Building AF, known as University Physical Therapy at Stapleton.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AG, known as University Family Medicine - A.F. Williams.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AI, known as University of Colorado Hospital Imaging.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AJ, known as CU Sports Physical Therapy and Rehabilitation.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AK, known as CU Sports Medicine.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AL, known as Eye Center at Park Meadows.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AM, known as University Family Medicine - Park Meadows.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

This portion applies to Building AN, known as ToMo Therapy Cancer Treatment Center.

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

1) During the review of the facility records with staff, documentation was not available to verify that the smoke detectors had been sensitivity tested every other year as required by NFPA-72 Chapter 7, Section 7-3, Paragraph 7-3.2.1.

2) At the time of the survey the facility was unable to provide documentation to reflect that the Fire Alarm System had been tested and inspected at east annually, as required by and performed in accordance with NFPA 72 (1999).

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

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with National Fire Protection Association (NFPA) Standard 13, for all portions of the facility. This was evidenced by the following:

A) Single interlock pre-action sprinkler systems were not installed with fire/smoke detection systems throughout the protected area, as required. The east pre-action sprinkler system protected numerous building areas including the AOP generator room, AIP generator room, generator air supply "breezeway", chiller/storage room and the entire covered loading dock area (including the oxygen cylinder storage vault). Fire/smoke detection systems were not installed in the chiller/storage room, the breezeway air supply area in front of the AOP generators, or throughout the loading dock area, including the oxygen cylinder storage vault. The facility Electronic Systems Technician acknowledged the absence of fire/smoke detection in these areas during a tour of the facility and confirmed the installation of detection devices in the other protected rooms. Pre-action sprinkler design plans specified a single-interlock style system. As arranged without detection systems, the chiller/storage room (approximately 30 ft. x 42 ft.), the 15 ft. x 30 ft. air supply area in front of the AOP generators and the entire loading dock area (approximately 4000 sq.ft.) are not sprinkler protected. The facility Manager of Support Services confirmed the single interlock design specified on the sprinkler plans.
NFPA 13 Section 4-3.2.1: Single Interlock System- A single interlock system admits water to sprinkler piping upon operation of detection devices.

B) Sprinkler protection was not provided below ductwork (greater than 4 ft. wide), as required.
The 3rd floor mechanical room had four areas with ductwork that was 8 ft. wide. Sprinkler protection was not provided below the ductwork.
NFPA 13 Section 5-5.5.3.1: Sprinklers shall be installed under fixed obstructions over 4 ft. wide such as ducts, decks, open grate flooring, cutting tables and overhead doors.

AOP-Anschutz Outpatient Pavilion & ACP- Anschutz Cancer Pavilion-Aspen ID: Building A-3
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to provide a complete coverage automatic fire sprinkler system, installed in accordance with National Fire Protection Association (NFPA) Standard 13, for all portions of the facility. This was evidenced by the following:

Single interlock pre-action sprinkler systems were not installed with fire/smoke detection systems throughout the protected area, as required. The east pre-action sprinkler system protected numerous building areas including the AOP generator room, AIP generator room, generator air supply "breezeway", chiller/storage room and the entire covered loading dock area (including the oxygen cylinder storage vault). Fire/smoke detection systems were not installed in the chiller/storage room, the breezeway air supply area in front of the AOP generators, or throughout the loading dock area, including the oxygen cylinder storage vault. The facility Electronic Systems Technician acknowledged the absence of fire/smoke detection in these areas during a tour of the facility and confirmed the installation of detection devices in the other protected rooms. Pre-action sprinkler design plans specified a single-interlock style system. As arranged without detection systems, the chiller/storage room (approximately 30 ft. x 42 ft.), the 15 ft. x 30 ft. air supply area in front of the AOP generators and the entire loading dock area (approximately 4000 sq.ft.) are not sprinkler protected.
The facility Manager of Support Services confirmed the single interlock design specified on the sprinkler plans.
NFPA 13 Section 4-3.2.1: Single Interlock System- A single interlock system admits water to sprinkler piping upon operation of detection devices.

This portion applies to Building AC, known as University Family Medicine - Boulder.

It was determined through observation during the survey, that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

The facility failed to extend the sprinkler protection to the following areas:
a. CNC desk area,
b. Biohazard closet, and
c. the acoustical room.

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

This portion applies to Building AD, known as Boulder Physical Therapy Clinic.

It was determined through observation during the survey, that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

There were two pendant sprinkler heads within approximately two-feet of one another in the core gym room. Note: In accordance with NFPA 13 (1999), 5-6.3.4, the heads shall be no less than six-feet apart.

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

It was determined through observation during the survey, that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

The fire sprinkler heads in X-ray room 113 were obstructed by the ceiling mounted X-ray equipment.

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

This portion applies to Building AK, known as CU Sports Medicine.

It was determined through observation during the survey, that the facility failed to install the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13. This was evidenced by:

Seven (7) of eight (8) standard pendant style sprinkler heads in the storage area shell space were installed incorrectly. These heads were installed in the cavity created for flush-mount sprinkler heads, resulting in the sprinkler head being located above the plane of the ceiling and lacking the required escutcheon.

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

K-61
AOP-Anschutz Outpatient Pavilion & ACP- Anschutz Cancer Pavilion-Aspen ID: Building A-3
Sprinkler system valve tamper supervisory equipment (ACP- Anschutz Cancer Pavilion) was not tested semi-annually, as required. Valve tamper testing was documented once in 2012 on August 31, 2012. There were no other documented tests during calendar year 2012.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on record review, observation and staff interview, it was determined that the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This was evidenced by the following:
A) Sprinkler system pressure reducing valves were not:
1. Inspected quarterly in accordance with NFPA 25 Section 9-5.2.1.
2. Tested every 5 years with a full flow in accordance with NFPA 25 Section 9-5.2.2.
Sprinkler system pressure reducing valves were installed on floors basement through 8th.

B) Sprinkler system water supply check valves were not internally inspected every 5 years, as required. Numerous check valves were installed in the fire pump room and dry-pipe system risers. The facility Electronic Systems Technician was not aware of any five year inspection records. NFPA 25 Section 9-4.2.1 requires that check valves be inspected internally every 5 years to verify that all components operate properly, move freely and are in good condition.

C) Dry-pipe sprinkler systems were not trip tested annually, as required. The building was equipped with four dry-pipe systems partially protecting mechanical areas and the ambulance canopy. The facility Electronic Systems Technician was not aware of any records documenting annual trip tests on the dry pipe systems.
NFPA 25 Section 9.4.4.2 requires that the dry pipe valve be trip tested annually during warm weather. Every three years and whenever the system is altered, the dry pipe valve must be trip tested with the control valve fully open and the quick-opening device, if provided, in service. During those years when full flow testing is not required, each dry pipe valve must be trip tested with the control valve partially open. During the annual trip test, the interior of the dry pipe valve shall be cleaned thoroughly and parts replaced or repaired as necessary. A tag or card showing the date on which the dry pipe valve was last tripped and showing the name of the person and organization conducting the test shall be attached to the valve. Separate records of initial air and water pressure, tripping air pressure, and dry pipe valve operating condition shall be maintained on the premises for comparison with previous test results. Records of tripping time also shall be maintained for full flow trip tests.

D) Sprinkler system piping was not maintained free of external loads, as required. Approximately 50 feet of 1 inch copper pipe was observed to be suspended from the pre-action system sprinkler piping in the "breezeway" air supply room. The facility Manager of Support Services acknowledged the suspended piping during a tour of the facility.
NFPA 25 Section 2-2.2: Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

E) Sprinkler system pressure gauges were not recalibrated or replaced every 5 years, as required. Gauges in the Stair #1 first floor foyer were greater than 5 years old. The facility Electronic Systems Technician reported that a gauge replacement program was in progress and awaiting an additional shipment of replacement gauges.

F) Sprinkler system control valves were not equipped with signage indicting the building and/or area served, as required. The pump room 6 inch control valves, installed at the backflow preventer, were not equipped with signs.
NFPA 25 Section 9-3.2: Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

G) Pre-action system sprinkler piping and valves were not protected from physical damage and were not maintained in operable condition, as required. The two drum-drip/drain valve assemblies (east and west side of loading dock area) were both observed to be damaged with piping support units broken. The one of two west drain valves was missing the operating wheel.
NFPA 25 Section 2-2.2: Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment.

H) A hydraulic sprinkler system design information placard was not installed on the ambulance canopy dry-pipe sprinkler riser, as required.
NFPA 13 Section 10-5 requires that the installing contractor identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. The sign shall include the following information:
(1) Location of the design area or areas
(2) Discharge densities over the design area or areas
(3) Required flow and residual pressure demand at the base of the riser
(4) Occupancy classification or commodity classification and maximum permitted storage height and configuration
(5) Hose stream demand included in addition to the sprinkler demand

I) dry-pipe sprinkler system low air supervisory alarms were not tested quarterly, as required. Facility records documented annual testing of the low air alarms.
NFPA 25 Section 9-4.4.2.6 requires that dry-pipe system low air pressure alarms be tested quarterly in accordance with manufacturer's instructions.

J) Sprinkler heads were not maintained free of paint overspray, as required. Room 524 (bathroom) was observed to have paint on the automatic sprinkler head.
(Corrected during the survey)

K) Sprinkler heads were observed to be loaded with foreign materials in the following rooms:
417, 609, 908-3, 910 and 929.
(Corrected during the survey)

AOP-Anschutz Outpatient Pavilion & ACP- Anschutz Cancer Pavilion-Aspen ID: Building A-3
Based on record review, observation and staff interview, it was determined that the facility failed to install and maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This was evidenced by the following:
A) Pre-action sprinkler system waterflow alarms were not tested quarterly, as required. Facility records documented pre-action waterflow alarm tests on 02-07-12 and 07-12-12. Facility records did not document a test of the ACP wet system waterflow alarm during the 4th quarter of 2012.
NFPA 25 Section 9-2.7 requires quarterly testing of all waterflow alarms.

B) Sprinkler system pressure reducing valves were not inspected quarterly in accordance with NFPA 25 Section 9-5.2.1.

C) Fire pump pressure relief valves were not documented to be inspected weekly in accordance with NFPA 25 Section 9-5.5.2

D) Sprinkler system pressure gauges were not recalibrated or replaced every 5 years, as required. Gauges in the AOP fire pump room were labeled "B89". Gauges at the ACP main sprinkler riser appeared to be dated 1998 and 1999.The facility Electronic Systems Technician reported that a gauge replacement program was in progress and awaiting an additional shipment of replacement gauges.

E) Sprinkler system water supply check valves were not internally inspected every 5 years, as required. Numerous check valves were installed in the fire pump room. The facility Electronic Systems Technician was not aware of any fire year inspection records. NFPA 25 Section 9-4.2.1 requires that check valves be inspected internally every 5 years to verify that all components operate properly, move freely and are in good condition.

F) The elevator shaft pre-action system was not equipped with a listed air maintenance device, as required. NFPA 13 Section 3-1.1: All materials and devices essential to successful system operation shall be listed.

G) Sprinkler system control valves did not indicate the system or portion of the system controlled by the valve, as required. Sprinkler system control valves provide with "Control Valve" signs, but the area served by the valve was not indicated.
NFPA 25 Section 9-3.2: Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

H) Pre-action sprinkler systems were not trip tested annually, as required. The building was equipped with two pre-action systems partially protecting the elevator shaft, generator rooms, generator air supply "breezeway", chiller room and the entire open loading dock area (approximately 4000 square feet).The facility Electronic Systems Technician was not aware of any records documenting annual trip tests on the pre-action systems.
NFPA 25 Section 9.4.3.2.2 requires that each deluge or preaction valve be trip tested annually at full flow in warm weather and in accordance with the manufacturer ' s instructions. Where testing deluge systems, care shall be taken to prevent water damage by verifying that there is adequate drainage. Protection shall be provided for any devices or equipment subject to damage by system discharge during tests.

I) Pre-action sprinkler system low air supervisory alarms were not tested quarterly, as required. Facility records documented annual testing.

J) A pressure gauge was not provided on the city side of the ACP sprinkler system backflow preventor, as required.

K) A standard pendant sprinkler head was missing the required escutcheon plate in the AOP kitchen walk in freezer.

CCW-Critical Care Wing-Aspen ID: Building A-2
A) Sprinkler system pressure reducing valves were not inspected quarterly in accordance with NFPA 25 Section 9-5.2.1.

B) Sprinkler system water supply check valves were not internally inspected every 5 years, as required. Numerous check valves were installed in the fire pump room and the dry pipe system riser. The facility Electronic Systems Technician was not aware of any five year inspection records. NFPA 25 Section 9-4.2.1 requires that check valves be inspected internally every 5 years to verify that all components operate properly, move freely and are in good condition.

C) Dry-pipe sprinkler systems were not trip tested annually, as required. The building was equipped with one dry-pipe system partially protecting the north open storage area (first floor) and a portion of the 2nd floor elevated walkway. The facility Electronic Systems Technician was not aware of any records documenting annual trip tests on the dry pipe systems. During the survey, the dry-pipe system was trip tested by the facility outside fire protection vendor on January 22, 2013.
NFPA 25 Section 9.4.4.2 requires that the dry pipe valve be trip tested annually during warm weather. Every three years and whenever the system is altered, the dry pipe valve must be trip tested with the control valve fully open and the quick-opening device, if provided, in service. During those years when full flow testing is not required, each dry pipe valve must be trip tested with the control valve partially open. During the annual trip test, the interior of the dry pipe valve shall be cleaned thoroughly and parts replaced or repaired as necessary. A tag or card showing the date on which the dry pipe valve was last tripped and showing the name of the person and organization conducting the test shall be attached to the valve. Separate records of initial air and water pressure, tripping air pressure, and dry pipe valve operating condition shall be maintained on the premises for comparison with previous test results. Records of tripping time also shall be maintained for full flow trip tests.

D) A hydraulic sprinkler system design information placard was not installed on the sprinkler riser, as required. The facility Fire Prevention Officer confirmed that the hydraulic design information was not posted in the sprinkler riser area during a tour of the facility.
NFPA 13 Section 10-5 requires that the installing contractor identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. The sign shall include the following information:
(1) Location of the design area or areas
(2) Discharge densities over the design area or areas
(3) Required flow and residual pressure demand at the base of the riser
(4) Occupancy classification or commodity classification and maximum permitted storage height and configuration
(5) Hose stream demand included in addition to the sprinkler demand

E) Sprinkler system pressure gauges were not recalibrated or replaced every 5 years, as required. Gauges installed at the dry-pipe sprinkler riser were dated 2005 and 2006. The facility Electronic Systems Technician reported that a gauge replacement program was in progress and awaiting an additional shipment of replacement gauges.

F) Room B-2314 was protected by one standard upright sprinkler head with a distance to the rear room wall of 14 ft. 7 inches which exceeds the allowed spacing.

G) Room B-2305.19 was protected by a standard pendant sprinkler head installed approximately 60 inches below the floor deck above. The installation exceeded the allowed maximum of 12 inches.

H) dry-pipe sprinkler system low air supervisory alarms were not tested quarterly, as required. Facility records documented annual testing of the low air alarms.
NFPA 25 Section 9-4.4.2.6 requires that dry-pipe system low air pressure alarms be tested quarterly in accordance with manufacturer's instructions.

I) Sprinkler heads were not maintained to be free of paint overspray, as required. One sprinkler head was observed to be painted at the entrance to the morgue.

RMLEI-Rocky Mountain Lions Eye Institute-Aspen ID: Building A-4:
Based on record review and staff interview, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 25. This was evidenced by the following:
A) Sprinkler system waterflow alarms were not tested quarterly, as required. Facility records did not document a test of the waterflow alarm during the 2nd and 4th quarters of 2012. NFPA 25 Section 9-2.7 requires quarterly testing of all waterflow alarms.

B) Sprinkler system water supply check valves were not internally inspected every 5 years, as required. The facility Electronic Systems Technician was not aware of any five year inspection records. NFPA 25 Section 9-4.2.1 requires that check valves be inspected internally every 5 years to verify that all components operate properly, move freely and are in good condition.

This portion applies to Building AC, known as University Family Medicine - Boulder.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) There were no less than five (5) of the required escutcheon plates missing in the north portion of the facility, which houses the audiology department.

2) At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25, and
b) an annual test of the backflow preventer serving the fire sprinkler system.

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

This portion applies to Building AD, known as Boulder Physical Therapy Clinic.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25, and
b) an annual test of the backflow preventer serving the fire sprinkler system.

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

This portion applies to Building AE, known as University Family Medicine - Westminster.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) The required escutcheon plate for the pendant style sprinkler head located in the breakroom closet was missing at the time of the survey.

2) At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first half of 2012, conducted in accordance with NFPA 25, and
b) an annual test of the backflow preventer serving the fire sprinkler system, and
c) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012, and
iii) third quarter 2012.

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

This portion applies to Building AF, known as University Physical Therapy at Stapleton.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) The required escutcheon plate for the pendant style sprinkler head located in the lobby over the front desk was missing at the time of the survey.

2) At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.

3) At the time of the survey, the facility failed to provide documentation that the pendant style sprinkler heads, designed for corrosive atmospheres, located in the room housing the therapy pool, had been replaced or tested in the past five years, as required by NFPA 25 (2002), section 5.3.1.1.2.

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

This portion applies to Building AG, known as University Family Medicine - A.F. Williams.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

1) The required escutcheon plate for the pendant style sprinkler head located in the east store room was missing at the time of the survey.

2) At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.

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

This portion applies to Building AI, known as University of Colorado Hospital Imaging.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.

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

This portion applies to Building AJ, known as CU Sports Physical Therapy and Rehabilitation.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.
e) Treatment room #4 was missing a required escutcheon for the pendant style sprinkler head located therein.

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

This portion applies to Building AK, known as CU Sports Medicine.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.
e) A ceiling tile was missing in the storage area shell space, creating a void in the required smooth, flat ceiling needed for the associated sprinkler heads to operate as intended.

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

This portion applies to Building AL, known as Eye Center at Park Meadows.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.
e) A ceiling tile was missing in the data room, creating a void in the required smooth, flat ceiling needed for the associated sprinkler heads to operate as intended.


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

This portion applies to Building AM, known as University Family Medicine - Park Meadows.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.
e) The ceiling in the electrical closet has unsealed penetrations, creating a void in the required smooth, flat ceiling needed for the associated sprinkler heads to operate as intended.

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

This portion applies to Building AN, known as ToMo Therapy Cancer Treatment Center.

It was determined through observation during the survey that the facility failed to inspect and maintain the Automatic Fire Sprinkler System in accordance with the Life Safety Code, NFPA 13, and NFPA 25. This was evidenced by:

At the time of the survey the facility failed to provide documentation to reflect that the following required inspections had taken place:
a) an annual fire sprinkler system inspection, conducted in accordance with NFPA 25,
b) a semi-annual fire sprinkler system inspection of the tamper switches serving the system for the first and second halves of 2012, conducted in accordance with NFPA 25,
c) an annual test of the backflow preventer serving the fire sprinkler system, and
d) quarterly inspection of the water flow switches serving the system for the following quarters:
i) first quarter 2012,
ii) second quarter 2012,
iii) third quarter 2012, and
iv) fourth quarter 2012.

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

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to insure that the automatic sprinkler system has an adequate and reliable water supply in accordance with NFPA 20, Standard for the Installation of Stationary Fire Pumps for Fire Protection Service (1999) and NFPA 25. This was evidenced by the following:

A) Fire pump weekly churn tests are not documented in accordance with NFPA 25 Section 5-3.2.4. The printed work order specifies recording suction and discharge pressures, pump starting pressure, and pump run time. The required recordings are not documented during the weekly tests.

B) Battery operated emergency lighting was not provided in the pump room, as required. The room was not equipped with fixed or portable battery operated lights.
NFPA 20 Section 2-7.4: Emergency lighting shall be provided by fixed or portable battery-operated lights, including flashlights. Emergency lights shall not be connected to an engine-starting battery.

C) The fire pump room enclosure was not a one-hour fire rated assembly, as required. The pump room north wall was not fire rated per the facility Life Safety Plan. The facility Electronic Systems Technician confirmed that the north wall was a partition wall with gypsum board on one side only. The fire rating of the east pump room wall, adjacent to the stair #1 void space, could not be determined during the survey.
NFPA 20 Section 2-7.1.1 requires that indoor fire pump units be separated from all other areas of the building by 2-hour fire-rated construction.
Exception No. 2: In buildings protected with an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, the separation requirement shall be reduced to 1-hour fire-rated construction.

D) Fire pump supervisory signals were not displayed at a location within the protected building that was constantly attended by qualified personnel or at an approved, remotely located receiving facility. The facility Electronic Systems Technician reported that the fire pump supervisory annunciator panel was located in the fire command center which was not constantly attended and the annunciator was not connected to the building fire alarm system.

E) Fire pump power supplies did not appear to be monitored to transmit an alarm when the controller was connected to the alternate power source, as required. This function did not appear to have an indicator lamp on the main annunciator in the fire command center.

NFPA 20 Section 7-4.7 Alarm and Signal Devices Remote from Controller.
Where the pump room is not constantly attended, audible or visible alarms powered by a source not exceeding 125 V shall be provided at a point of constant attendance. These alarms shall indicate the following.
(a) Pump or Motor Running. The alarm shall actuate whenever the controller has operated into a motor-running condition. This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(b) Loss of Phase. The loss of any phase at the line terminals of the motor contactor shall be monitored. All phases shall be monitored.
Exception: When power is supplied from multiple power sources, monitoring of each power source for phase loss shall be permitted at any point electrically upstream of the line terminals of the contactor provided all sources are monitored.
(c) Phase Reversal. (See 7-4.6.2.) This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(d) Controller Connected to Alternate Source. Where two sources of power are supplied to meet the requirements of 6-2.3, this alarm circuit shall indicate whenever the alternate source is the source supplying power to the controller. This alarm circuit shall be energized by a separate reliable, supervised power source, reduced to not more than 125 V.

AOP-Anschutz Outpatient Pavilion & ACP- Anschutz Cancer Pavilion-Aspen ID: Building A-3
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to insure that the automatic sprinkler system has an adequate and reliable water supply in accordance with NFPA 20, Standard for the Installation of Stationary Fire Pumps for Fire Protection Service (1999) and NFPA 25. This was evidenced by the following:

A) Fire pump weekly churn tests are not documented in accordance with NFPA 25 Section 5-3.2.4. The printed work order specifies recording suction and discharge pressures, pump starting pressure, and pump run time. The required recordings are not documented during the weekly tests.

B) Fire pump components were not maintained, as required. The 10-27-12 fire pump test report noted that the pump should have new packing installed and adjusted. During the survey, the packing was noted to be leaking water steadily. NFPA 25 Section 5-5.1: A preventive maintenance program shall be established on all components of the pump assembly in accordance with the manufacturer ' s recommendations. Records shall be maintained on all work performed on the pump, driver, controller, and auxiliary equipment. In the absence of manufacturer ' s recommendations for preventive maintenance, Table 5-5.1 provides alternative requirements.

C) The fire pump room enclosure was not maintained to be a one-hour fire rated assembly, as required. The gypsum board enclosure wall was observed to have an 8" x 12" cut out in the wall which voided the one hour rating. The cutout appeared to be from a recent DWV plumbing modification. NFPA 20 Section 2-7.1.1 requires that indoor fire pump units be separated from all other areas of the building by 2-hour fire-rated construction.
Exception No. 2: In buildings protected with an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, the separation requirement shall be reduced to 1-hour fire-rated construction.

D) Battery operated emergency lighting was not provided in the pump room, as required. The room was not equipped with fixed or portable battery operated lights.
NFPA 20 Section 2-7.4: Emergency lighting shall be provided by fixed or portable battery-operated lights, including flashlights. Emergency lights shall not be connected to an engine-starting battery.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to insure that the automatic sprinkler system has an adequate and reliable water supply in accordance with NFPA 20, Standard for the Installation of Stationary Fire Pumps for Fire Protection Service (1999) and NFPA 25. This was evidenced by the following:

A) Fire pump weekly churn tests are not documented in accordance with NFPA 25 Section 5-3.2.4. The printed work order specifies recording suction and discharge pressures, pump starting pressure, and pump run time. The required recordings were not documented during the weekly tests.

B) Battery operated emergency lighting was not provided in the pump room, as required. The room was not equipped with fixed or portable battery operated lights.
NFPA 20 Section 2-7.4: Emergency lighting shall be provided by fixed or portable battery-operated lights, including flashlights. Emergency lights shall not be connected to an engine-starting battery.

C) The fire pump room enclosure was not a one-hour fire rated assembly, as required. The pump room north wall was not fire rated per the facility Life Safety Plan. The facility Electronic Systems Technician confirmed that the north wall was a partition wall with gypsum board on one side only. The fire rating of the east pump room wall, adjacent to the stair #1 void space, could not be determined during the survey.
NFPA 20 Section 2-7.1.1 requires that indoor fire pump units be separated from all other areas of the building by 2-hour fire-rated construction.
Exception No. 2: In buildings protected with an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, the separation requirement shall be reduced to 1-hour fire-rated construction.

D) Fire pump supervisory signals were not displayed at a location within the protected building that was constantly attended by qualified personnel or at an approved, remotely located receiving facility. The facility Electronic Systems Technician reported that the fire pump supervisory annunciator panel was located in the fire command center which was not constantly attended and the annunciator was not connected to the building fire alarm system.

E) Fire pump power supplies did not appear to be monitored to transmit an alarm when the controller was connected to the alternate power source, as required. This function did not appear to have an indicator lamp on the main annunciator in the fire command center.

NFPA 20 Section 7-4.7 Alarm and Signal Devices Remote from Controller.
Where the pump room is not constantly attended, audible or visible alarms powered by a source not exceeding 125 V shall be provided at a point of constant attendance. These alarms shall indicate the following.
(a) Pump or Motor Running. The alarm shall actuate whenever the controller has operated into a motor-running condition. This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(b) Loss of Phase. The loss of any phase at the line terminals of the motor contactor shall be monitored. All phases shall be monitored.
Exception: When power is supplied from multiple power sources, monitoring of each power source for phase loss shall be permitted at any point electrically upstream of the line terminals of the contactor provided all sources are monitored.
(c) Phase Reversal. (See 7-4.6.2.) This alarm circuit shall be energized by a separate reliable supervised power source or from the pump motor power, reduced to not more than 125 V.
(d) Controller Connected to Alternate Source. Where two sources of power are supplied to meet the requirements of 6-2.3, this alarm circuit shall indicate whenever the alternate source is the source supplying power to the controller. This alarm circuit shall be energized by a separate reliable, supervised power source, reduced to not more than 125 V.

This portion applies to Building AK, known as CU Sports Medicine.

It was determined through observation during the survey that the facility failed to maintain the Fire Extinguishers in accordance with the Life Safety Code and NFPA 10. This was evidenced by:

The fire extinguishers were last annually inspected in February of 2011.

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

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation and staff interview, it was determined that the facility failed to maintain air plenum rooms in accordance with National Fire Protection Association (NFPA) Standard 90A. This was evidenced by the following:

Air handling system plenum/air mixing rooms were not maintained free of combustible storage, as required. Filter storage (cardboard boxes on wood pallets) was observed inside the 3rd floor and penthouse mechanical areas. The storage was inside rooms utilized as return/fresh air plenum rooms.
NFPA 90A Section 2-3.10.1: Plenums shall not be used for occupancy or storage.

The condition was reported to be corrected at the exit conference.

This portion applies to Building AF, known as University Physical Therapy at Stapleton.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AG, known as University Family Medicine - A.F. Williams.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AH, known as University Medicine - Internal Medicine and Specialty Care.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AI, known as University of colorado Hospital Imaging.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AJ, known as CU Sports Physical Therapy and Rehabilitation.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AK, known as CU Sports Medicine.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AL, known as Eye Center at Park Meadows.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AM, known as University Family Medicine - Park Meadows.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

This portion applies to Building AN, known as ToMo Therapy Cancer Treatment Center.

It was determined through observation and document review during the survey that the facility failed to maintain the heating, ventilating, and air conditioning in accordance with the Life Safety Code and the references cited therein. This was evidenced by:

At the time of the survey, the facility failed to provide documentation that each smoke and/or fire damper in place within the facility had been inspected and tested at least every four years, as required by NFPA 90A, 3-4.7. Note: CMS has increased this frequency for Hospital organizations to every six-years.

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

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation and staff interview, it was determined that the facility failed to prohibit the use of portable space heating devices in accordance with Life Safety Code Section 18.7.8. This was evidenced by the following:

A portable electric space heater was observed inside office 1066.1. The maximum heating element temperature could not be determined during the survey. Facility staff removed the employee provided heater during a tour of the facility.

Life Safety Code Section 19.7.8 (Portable Space-Heating Devices): Portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212?F (100?C).

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the course of the survey, it was determined that the facility failed to arrange chute service rooms in accordance with National Fire Protection Association (NFPA) Life Safety Code Section 18.5.4 and Section 9.5. This was evidenced by the following:

A) Rubbish and linen chute inlet opening doors were not arranged to open to a room that was designed and used exclusively for accessing the chute opening, as required. The West rubbish and linen chute service inlet doors (1st floor through 12th floor) opened to the elevator access lobby on each floor. The access lobby/chute service room was separated from the egress corridor, on the north and south side, by double door sets.
Life Safety Code Section 9.5.1: Rubbish chutes and laundry chutes shall be separately enclosed by walls or partitions in accordance with the provisions of Section 8.2. Inlet openings serving chutes shall be protected in accordance with Section 8.2. Doors of such chutes shall open only to a room that is designed and used exclusively for accessing the chute opening. The room shall be separated from other spaces in accordance with Section 8.4.

B) Laundry chute doors would not close and positively latch into the frame, as required.
1) 3rd floor east chute door.
2) 11th floor chute door near elevator #1.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10 and 7.3.2. This was evidenced by the following:

Designated egress corridors were not continuously maintained free of obstructions and impediments to full instant use, as required. Egress corridors were observed to be obstructed in the following locations:
A) The pharmacy egress corridor (1D0403) was obstructed by 3 patient care beds and associated equipment including ceiling mounted cubicle curtains, 3 ft. wide wheeled cloth privacy screens and open folding chairs.

B) The Emergency Department waiting room exit access (1.CO41) was obstructed by patient bed and computer cart.

C) The Emergency Department waiting room exit vestibule (1.048.50) was obstructed by storage that included a computer cart, isolation cart, IV stands, blood pressure monitor and a chair.

The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10 and 7.3.2. This was evidenced by the following:

Designated egress corridors were not continuously maintained free of obstructions and impediments to full instant use, as required. Egress corridors were observed to be obstructed in the following locations:

1. The Outpatient Pavilion Radiology egress corridor (1E0001 and 1G0001) was obstructed by 3 patient care beds and 4 beds in storage. The patient care and stored beds reduced the corridor clearwidth to approximately 4 ft.

2. The corridor (AOP-2nd floor O/R area) was obstructed by 12 large wheeled carts utilized during various surgical procedures.

The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the survey, it was determined that the facility failed to maintain egress corridors that were clear and unobstructed in accordance with Life Safety Code Section 7.1.10 and 7.3.2. This was evidenced by the following:

Designated egress corridors were not continuously maintained free of obstructions and impediments to full instant use, as required. Egress corridors were observed to be obstructed in the following locations:
A) An x-ray machine was stored in the corridor outside room 4.22231.

B) Surgery equipment carts, x-ray machines and patient beds were stored in corridor C2300a (outside of the operating rooms).

C) X-ray machine was stored in the corridor outside of the NICU suite.

D) Materials Management supplies were stored in the corridor outside of the CMB office.

The Life Safety Code Section 7.1.10.1 requires that the means of egress be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Section 7.1.10.2.1 requires that no furnishings, decorations, or other objects obstruct exits, access thereto, egress therefrom, or visibility thereof.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation during the survey, it was determined that the facility failed to protect medical gas administration and storage areas in accordance with Life Safety Code Section 18.3.2.4 and NFPA 99. This was evidence by the following:

Electric fixtures were not installed at least 5 ft. above the floor in medical gas storage areas, as required. Carbon dioxide room 2.035 had a light switch installed less than 5 ft. above the floor.
NFPA 99 Section 8-3.1.11.2 (f): Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11(d): Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. above the floor to avoid physical damage.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the survey, it was determined that the facility failed to protect medical gas administration and storage areas in accordance with Life Safety Code Section 18.3.2.4 and NFPA 99. This was evidence by the following:

A) Electric fixtures were not installed at least 5 ft. above the floor in medical gas storage areas, as required. Medical gas storage room 1.2324 had a light switch installed less than 5 ft. above the floor and a duplex receptacle approximately 18 inches above the floor.
NFPA 99 Section 8-3.1.11.2 (f): Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11(d): Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. above the floor to avoid physical damage.

B) Oxygen cylinders were not racked or chained, as required. Unsecured oxygen cylinders were observed in room 1.2327.1 and in the radiology area.
NFPA 99 Section 8-3.1.11.2 (Storage for nonflammable gases less than 3000 cubic feet) requires, in part, that cylinder protection from mechanical shock meet the requirements of Section 4-3.5.2.1(b) 13, and cylinder or container restraint meet the requirements of Section 4-3.5.2.1(b)27.
The cylinder support deficiencies were corrected during the survey.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation during the course of the survey, it was determined that the facility failed to install the piped medical gas system in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This was evidenced by the following:

Zone Valves were not installed with a wall and door intervening between the valve and the outlet(s), as required. The MRI patient holding area medical gas zone valve box was not separated from the outlets controlled by the valves. An unprotected door opening, full ceiling height with no lintel, and approximately 6 feet wide, was observed between the room and the zone valve box.

NFPA 99 Section 4-3.1.2.3(d) requires, in part, that station outlets not be supplied directly from a riser unless a manual shutoff valve (located in the same story) is installed between the riser and the outlet with a wall intervening between the valve and the outlet. This valve shall be readily operable from a standing position in the corridor on the same floor it serves.
The NFPA Health Care Facilities Handbook (1999) offers background information on the installation of the zone valve. The purpose of the "wall" between the valves and outlets is to allow someone to shut off the flow of gas to a fire scene without being directly exposed to the fire and any products of combustion. NFPA Technical Assistance offered an opinion (not a Formal Interpretation) that the wall should also include any door assemblies with the objective to provide some degree of protection to someone trying to close the valve if the fire is in the room with the outlet. Having an opening in the wall without a door negates that protection, therefore, a wall includes doors to protect the opening.

This portion applies to Building AB, known as University of Colorado Hospital Lone tree Health Center.

It was determined through observation during the survey that the facility failed to maintain the MedGas storage location in accordance with the Life Safety Code (2000) and NFPA 99 (1999), Healthcare Facilities. This was evidenced by:

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

The MedGas storage location deficiency items were discussed during the survey and again during the exit conference.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on staff interview during the course of the survey, it was determined that the facility failed to protect anesthetizing locations in accordance with National Fire Protection Association Standard 99, Health Care Facilities. This was evidenced by the following:
Operating room relative humidity levels were not maintained at a level of 35%, or greater, as required. Relative humidity levels in the operating rooms were reported to be automatically controlled to maintain relative humidity at 26%.
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.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 99-Health Care Facilities and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

A) Level 1 Emergency Power Supplies were not installed within a room having a minimum 2 hour fire rating, as required.
1) The main generator room was observed to have an unprotected pipe penetration through a two-hour rated wall. The original fire caulking had been dislodged.

2) The generator room communicated to the air supply "breezeway" room via a non-fire rated single door, and a sheet metal covered air intake opening for a future generator. The two existing generators did not have fire dampers on the air intakes from the "breezeway" air supply room. Note: the "breezeway" air supply room also communicated via unprotected openings with the high-voltage switch vault, the mechanical room (exhaust fan opening) and the AOP generator room via non-dampered air intake openings and sheet metal wall sections. The "breezeway" air supply room also communicated with the covered loading dock area via double doors that were not fire rated.
NFPA 99 Section 3-4.1.1.6 requires, in part, that energy converters be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or be located in an adequate enclosure outside of the building. NFPA 110 Section 5-2.1 requires, in part, that Level 1 installations be installed in a separate room and shall be separated by a minimum of 2 hour fire rated construction.

B) Generator rooms were not maintained free of storage, as required. The main generator room was being used for storage of electrical supplies on storage racks and empty plastic 5 gallon motor oil containers. The communicating "breezeway" air supply room was observed to have 13 empty plastic 55 gallon drums in storage and two plastic pallets with cardboard boxes stored in the room. The Facility Manager of Support Services acknowledged the storage during a tour of the facility.
NFPA 110, Section 5-11.1 requires that the room in which Emergency Power Supply (EPS) is located not be used for storage purposes.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

A) Level 1 Emergency Power Supplies were not installed within a room having a minimum 2 hour fire rating, as required.
The generator room communicated to the air supply "breezeway" room via a non-fire rated sheet metal wall section. The two existing generators did not have fire dampers on the air intakes from the "breezeway" air supply room. Note: the "breezeway" air supply room also communicated via unprotected openings with the high-voltage switch vault, the mechanical room exhaust fan and the AIP generator room via non-dampered air intake openings, sheet metal wall sections and door opening with a non-fire rated door. The "breezeway" air supply room also communicated with the covered loading dock area via double doors that were not fire rated.

B) Generator rooms were not maintained free of storage, as required. The communicating "breezeway" air supply room was observed to have 13 empty plastic 55 gallon drums in storage and two plastic pallets with cardboard boxes stored in the room.
The facility Manager of Support Services acknowledged the storage during a tour of the facility.
NFPA 99 Section 3-4.1.1.6 requires, in part, that energy converters be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or be located in an adequate enclosure outside of the building. NFPA 110 Section 5-2.1 requires, in part, that Level 1 installations be installed in a separate room and shall be separated by a minimum of 2 hour fire rated construction.
NFPA 110, Section 5-11.1 requires that the room in which Emergency Power Supply (EPS) is located not be used for storage purposes.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 99-Health Care Facilities and NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

A) Level 1 Emergency Power Supplies were not installed within a room having a minimum 2 hour fire rating, as required.
1) The main generator room was observed to have an unprotected duct penetration on the south side two-hour rated wall. The facility Master Electrician confirmed the absence of a fire damper in the duct penetration during a tour of the facility.

2) The main generator room was observed to have a one inch unsealed hole in the south 2 hour rated gypsum board wall. Gaps were also observed around emergency lighting unit junction boxes mounted in the gypsum board wall.

NFPA 99 Section 3-4.1.1.6 requires, in part, that energy converters be located in a separate service room dedicated to the generating equipment, separated from the remainder of the building by fire separations having a minimum 2-hour fire rating, or be located in an adequate enclosure outside of the building. NFPA 110 Section 5-2.1 requires, in part, that Level 1 installations be installed in a separate room and shall be separated by a minimum of 2 hour fire rated construction.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
A) Based on observation and record review during the survey, it was determined that the building standpipe system was not installed and maintained in accordance with NFPA 14-Standard for the Installation of Standpipe, Private Hydrant and Hose Systems, and NFPA 25. This was evidenced by the following:

a) Hose connection pressure reducing valves were not:
1. Inspected quarterly in accordance with NFPA 25 Section 9-5.2.1.
2. Tested annually with a partial flow in accordance with NFPA 25 Section 9-5.2.3.
3. Tested every 5 years with a full flow in accordance with NFPA 25 Section 9-5.2.2.

b) 2.5 inch hose connections were not provided, as required, in the following locations:
1. On each side of the wall adjacent to the exit openings of horizontal exits. Horizontal exits are provided on the upper patient floors.
2. In each exit passageway at the entrance from the building areas into the passageway. Currently, the east stair discharges into a non-compliant exit passageway (see K-38). A standpipe hose outlet will have to be provided if this exit passageway is modified to be compliant, or at the west stair discharge if the facility upgrades this discharge to an exit passageway.
NFPA 14 Section 5-3.2- Class I Systems.
Class I systems shall be provided with 2.5 inch hose connections in the following locations:
(a) At each intermediate landing between floor levels in every required exit stairway.
Exception: Hose connections shall be permitted to be located at the main floor landings in exit stairways where approved by the authority having jurisdiction.
(b) On each side of the wall adjacent to the exit openings of horizontal exits.
(c) In each exit passageway at the entrance from the building areas into the passageway.
(d) In covered mall buildings, at the entrance to each exit passageway or exit corridor, and at exterior public entrances to the mall.
(e) At the highest landing of stairways with stairway access to a roof, and on the roof where stairways do not access the roof. An additional 21/2-in. (63.5-mm) hose connection shall be provided at the hydraulically most remote riser to facilitate testing of the system.
(f) Where the most remote portion of a nonsprinklered floor or story is located in excess of 150 ft (45.7 m) of travel distance from a required exit containing or adjacent to a hose connection, or the most remote portion of a sprinklered floor or story is located in excess of 200 ft (61 m) of travel distance from a required exit containing or adjacent to a hose connection, additional hose connections shall be provided, in approved locations, where required by the local fire department or the authority having jurisdiction.

B) Based on record review during the survey, it was determined that suites of sleeping rooms were not arranged in accordance with Life Safety Code Section 18.2.5.6, as required. This was evidenced by the following:

Suites of sleeping rooms were not limited to 5000 square feet or less in area, as required.
a) The 2nd floor INCU suite was labeled on the facility life safety plan as a sleeping suite of rooms. The plan indicated the suite area as 5109 square feet which exceeds the maximum sleeping suite area.

b) The Emergency Department central core suite was designated on the facility life safety plan as a non-sleeping suite of rooms, 6289 square feet in size. The facility was utilizing rooms within the suite as inpatient sleeping rooms. The suite of sleeping rooms exceeds the allowed maximum of 5000 square feet.
Life Safety Code Section 18.2.5.6: Suites of sleeping rooms shall not exceed 5000 square feet.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3
Based on staff interview during the course of the survey, it was determined that the facility failed to install mechanical ventilation systems in anesthetizing locations in accordance with National Fire Protection Association Standard 99, Health Care Facilities, Section 5-4.1. This was evidenced by the following:
Anesthetizing locations (2nd floor O/Rs) were not arranged to automatically vent smoke and products of combustion in accordance with NFPA 99 Section 5-4.1.2. Facility staff reported that operating rooms did not have any type of automatic smoke venting system.
NFPA 99 Section 5-4.1.2: Supply and exhaust systems for windowless 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.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on record review and observation during the survey, it was determined that non-sleeping suites were not arranged in accordance with Life Safety Code Section 18.2.5.8, as required. This was evidenced by the following:

Suites with two intervening rooms in the path of egress, were not arranged such that travel distance within the suite to an exit access door was less than 50 feet, as required. The Electrophysiology suite had 2 intervening rooms in the path of travel to the suite exit access door. The travel distance within the suite, via the two intervening rooms, was 75 feet.

Life Safety Code Section 18.2.5.8: Suites of rooms, other than patient sleeping rooms, shall be permitted to have one intervening room if the travel distance within the suite to the exit access door does not exceed 100 feet and shall be permitted to have two intervening rooms where the travel distance within the suite to the exit access door does not exceed 50 feet.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

Weekly inspections of emergency generators were not documented, as required. The facility Master Electrician reported that the generators were inspected weekly, but documentation of inspections was not maintained.
NFPA 110 Section 6-4.1 requires Level 1 and Level 2 Emergency Power Supply Systems (EPSS) including all appurtenant components, be inspected weekly and exercised under load at least monthly. Section 6-3.4 requires, in part, that a written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.

AOP-Anschutz Outpatient Pavilion & ACP-Anschutz Cancer Pavilion-Aspen ID: Building A-3:
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

Weekly inspections of emergency generators were not documented, as required. The facility Master Electrician reported that the generators were inspected weekly, but documentation of inspections was not maintained.
NFPA 110 Section 6-4.1 requires Level 1 and Level 2 Emergency Power Supply Systems (EPSS) including all appurtenant components, be inspected weekly and exercised under load at least monthly. Section 6-3.4 requires, in part, that a written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on record review and staff interview during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems. This was evidenced by the following:

Weekly inspections of emergency generators were not documented, as required. The facility Master Electrician reported that the generators were inspected weekly, but documentation of inspections was not maintained.
NFPA 110 Section 6-4.1 requires Level 1 and Level 2 Emergency Power Supply Systems (EPSS) including all appurtenant components, be inspected weekly and exercised under load at least monthly. Section 6-3.4 requires, in part, that a written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on record review during the course of the survey, it was determined that the facility failed to install and maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This was evidenced by the following:

A review of panelboard branch circuit index cards noted the following deficiencies:

A) The Life Safety Branch of the essential electrical system was supplying branch circuits that were not considered essential to life safety nor specifically allowed on the Life Safety Branch in accordance with Section 3-4.2.2.2 (b).
1) Panelboard IP-L4LE circuit #14: 4th floor mag doors (magnetic door hold open devices)

2) Panelboard IP-L6LE circuit #39: 7th floor mag doors (magnetic door hold open devices)

3) Panelboard IP-L8LE: 8th and 9th floor mag doors (magnetic door hold open devices)

4) Panelboard LBLE circuit #2, #4 and #7: mag door holds

5) Panelboard LBLE circuit #9: 1st floor door security

6) Panelboard LBLE circuit #33: Triatek Panel (undetermined-possible room lighting)

7) Panelboard LBLE circuit #34: Basement security west

NFPA 99 Section 3-4.2.2.2 (b) Life Safety Branch: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as
specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

B) The Critical Branch of the essential electrical system was supplying branch circuits that were not related to patient care in accordance with Section 3-4.2.2.2 (c).

1) Panelboard IP-C1LE1-S2, circuit #61 was powering heat tape installed on the front canopy
downspouts.

2) Panelboard IP-C1LW-S1, circuit #35 was powering heat tape installed on the front canopy
downspouts.

3) Panelboard IP-C3L-S2, circuit #72 was powering heat tape.

4) Panelboard IP-C3L-S3, circuit #94 was powering the east dry-pipe sprinkler system air
compressor.

5) Panelboard IP-C3L-S3, circuit #96 was powering the west dry-pipe sprinkler system air
compressor.

6) Panelboard IP-C1LE, circuit #100 was powering the ambulance canopy dry sprinkler system riser room unit heater blower motor.

7) Panelboard IP-CBLE circuit #27: CM-2 (unidentified load)

8) Panelboard IP-CBLE circuit #2: DWP-3 (unidentified load)

9) Panelboard IP-CBLE circuit #33: EF-23 (motor size unknown), UH-0-4 (unidentified load)

10) Panelboard IP-CBLE circuit #18: EF-9 (motor size unknown)

11) Panelboard IP-CBLE circuit #20: RD-1 (unidentified load)

12) Panelboard IP-CBLE circuit #22: DWH-1/DWH-2 &CM-4 (unidentified load)

NFPA 99 Section 3-4.2.2.2 (c) Critical Branch.: The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on record review during the course of the survey, it was determined that the facility failed to install and maintain the Type I essential electrical system in accordance with NFPA 99-Health Care Facilities. This was evidenced by the following:

A review of panelboard branch circuit index cards noted the following deficiencies:

A) The Life Safety Branch of the essential electrical system was supplying branch circuits that were not considered essential to life safety nor specifically allowed on the Life Safety Branch in accordance with Section 3-4.2.2.2 (b).

1) Panelboard B-LBLSE circuit #17: LL mag door holds

2) Panelboard B-LBLSE circuit #29: LL Security Doors

3) Panelboard B-LBLSE circuit #31 and #33: LL Roll Up Door

4) Panelboard B-LBLSE circuit #10: 1st floor mag holds

5) Panelboard B-LBLSE circuit #18 and #20: first floor security doors

6) Panelboard B-LBLNW circuit #11 and #12: LL and first floor mag hold opens

7) Panelboard B-LBLNW circuit #18: Roll up door control module

8) Panelboard B-L2LNW circuits #3 and #10: 2nd and 3rd floor mag holds

9) Panelboard B-L2LNW circuits #29: second floor security doors

10) Panelboard B-L2LNW circuits #31, #33 and #37: various roll up doors

11) Panelboard B-L4LSW circuits #9: 4th floor security doors

12) Panelboard B-L4LSW circuits #11: 4th floor mag holds

NFPA 99 Section 3-4.2.2.2 (b) Life Safety Branch: The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as
specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

B) The Critical Branch of the essential electrical system was supplying branch circuits that were not related to patient care in accordance with Section 3-4.2.2.2 (c).
The following circuit breakers, as identified on the panelboard index card, were not related to patient care and/or exceeded the allowed motor size:

1) Panelboard CBLNW-S1 circuit #32: MRI #2 door compressor (1 ? horsepower motor)

2) Panelboard CBHNW circuit #32 and #33: MRI chiller pumps (1 horsepower each)


NFPA 99 Section 3-4.2.2.2 (c) Critical Branch.: The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
4. Additional specialized patient care task illumination and receptacles, where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7. * Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

AIP-Anschutz Inpatient Pavilion-Aspen ID: Building A-1
Based on observation it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association Standard 70, National Electric Code. This was evidenced by the following:

Flexible cords were being used as a substitute for permanent wiring in the following locations:
1. One extension cord in the Cytology office.
2. Multi-outlet power strips were linked together in office #1008.
NFPA 70, National Electric Code Section 400-8 requires, in part, that flexible cords and cables not be used a substitute for the fixed wiring of a structure, and that they not be attached to a building surface.
The extension cords and power strips were removed from use during a tour of the facility.

CCW-Critical Care Wing-Aspen ID: Building A-2
Based on observation it was determined that the facility failed to install electrical equipment in accordance with National Fire Protection Association Standard 70, National Electric Code. This was evidenced by the following:

Flexible cords were being used as a substitute for permanent wiring in the following locations:
1. One extension cord was plugged into a multi-outlet power strip in room 4.2219.
2. One extension cord was plugged into a multi-outlet power strip in room 4.2215.
3. One extension cord was plugged into a multi-outlet power strip in the Materials Management storage room.
4. Extension cords and a multi-outlet power strip plugged into a 3 way outlet extender.
NFPA 70, National Electric Code Section 400-8 requires, in part, that flexible cords and cables not be used a substitute for the fixed wiring of a structure, and that they not be attached to a building surface.
The extension cords and power strips were removed from use during a tour of the facility.

This portion applies to Building AC, known as University Family Medicine - Boulder.

It was determined through observation during the survey that the facility failed to utilize the building's electrical system in accordance with the Life Safety Code. This was evidenced by:

1) A flexible cord was routed through the ceiling in the IT Closet. Note: In accordance with 1999 NFPA 70 Article 400-8, flexible cords may not be routed through ceilings.

2) A surge protected power strip was plugged into a second surge protected power strip in exam room #5.

3) A surge protected power strip was plugged into a second surge protected power strip in the doctor's office across from the linen closet.

4) The facility was utilizing an extension cord in place of the permanent wiring of the building in the audiology consult office.

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

This portion applies to Building AG, known as University Family Medicine - A.F. Williams.

It was determined through observation during the survey that the facility failed to utilize the building's electrical system in accordance with the Life Safety Code. This was evidenced by:

1) A surge protected power strip was plugged into a second surge protected power strip in gold pod.

2) A surge protected power strip was plugged into a second surge protected power strip at the front desk.

Note: The above items were corrected during the survey.

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

This portion applies to Building AD, known as Boulder Physical Therapy Clinic.

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

At the time of the survey the facility failed to provide documentation reflecting that the elevator had been inspected annually, as required. Note: The elevator is utilized by the facility's patrons for access to the floor on which the facility is located.

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