HospitalInspections.org

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to construct corridor walls and separate egress corridors from treatment areas in accordance with Life Safety Code Section 19.3.6. This deficient practice could affect all patients using the therapy room should smoke and heat spread into the room due to the absence of a smoke resistive separation.
This was evidenced by the following:

The east therapy room was not separated from the egress corridor, as required. The former sun room was now equipped for use as a patient therapy room with parallel bars, an exercise machine and stair steps. The Chief Compliance Officer acknowledged the absence of separation during a tour of the facility.

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. Exceptions to 19.3.6.1 allow some areas to be open to the egress corridor. Treatment rooms are not allowed to be open to the egress corridor.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain corridor doors in accordance with Life Safety Code Section 19.3.6.3. This deficient practice could affect all patients, staff and visitors within the west smoke compartment should the egress corridor become untenable, due to smoke and heat transfer, via the non-latching corridor doors separating rooms from the egress corridor. This was evidenced by the following:

A) Corridor doors were not equipped with positive latching hardware, as required. The main pantry corridor door was equipped with panic hardware that had a latch disabling device.

B) Corridor doors were not arranged to be closed with a push or a pull, as required. The main dining room corridor double doors were observed to be held open with door chocks.

C) Self-closing corridor doors were not equipped with door coordinators to insure complete closing and positive latching, as required. The main dining room double doors and the employee dining room double doors were not equipped with door coordinators. When tested, the doors would self-close but not positively latch due to the absence of coordination.
The Director of Facility Management acknowledged the door arrangements during a tour of the facility.

Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Latching devices must not require the use of keys or special tools. Section 19.3.6.3.3 permits hold-open devices that release when the door is pushed or pulled. The Life Safety Code Annex (explanatory material) explains that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to provide continuous smoke barrier walls with a 30 minute fire resistance rating in accordance with the Life Safety Code Section 19-3.7.3 and Section 8.3. This deficient practice could affect all 20 first floor patients should the smoke barrier wall fail to prevent the spread of fire between smoke compartments during a compartment evacuation. This was evidenced by the following:

Fire rated smoke barrier walls were not constructed with a minimum fire resistance rating of 30 minutes, as required. The ECU smoke barrier wall was deficient, as follows:
1. The corridor wall (separating the activity room) was not a minimum of 30 minute fire rated due to an unprotected steel beam forming the upper section of the wall. The top of the beam as sealed to the floor deck above with a non-fire rated mineral wool stuffing.

2. The activity room wall (separation to room 125) was not constructed with a minimum fire rating of 30 minutes. The top of the gypsum board wall assembly was sealed at the floor deck with drywall tape and joint compound.

The Director of Facility Management acknowledged the wall arrangements during a tour of the facility.

Life Safety Code Section 19.3.7.3 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 ? hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to enclose sprinkler protected hazardous areas in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect all patients within the first floor smoke compartment and staff within the basement smoke compartment, should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following:

A) Sprinkler protected hazardous areas were not constructed with smoke resistive partition walls, as required. The first floor soiled linen holding room was observed to have a 12 " x 24 " unprotected air transfer grille in the corridor wall, which voided the smoke resistive rating of the corridor wall.

B) Sprinkler protected hazardous areas were not equipped with self-closing doors, as required. Medical records storage room (B720) was separated from the corridor with a one-hour fire rated door that was not equipped with a self-closer.

The Director of Facility Management acknowledged the hazardous area enclosure deficiencies during a tour of the facility.

Life Safety Code Section 19.3.2.1: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to enclose sprinkler protected hazardous areas in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect all patients within the west smoke compartment, should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following:

A) Sprinkler protected hazardous areas were not maintained to be smoke resistive, as required. The main boiler room was observed to have three unsealed pipe penetrations through the corridor wall (above the corridor door). The ceiling area was observed to have 3 unsealed all-thread rod penetrations.

B) Sprinkler protected hazardous area doors were not arranged or maintained to be self-closing, as required.
1. The self-closing medical records door was observed to be chocked open which voids the required self-closing function.
2. The Activities Office/Storage room was observed to have two 1hour fire rated corridor doors that were not equipped with self-closing devices. The self-closing devices had been disabled.

The Director of Facility Management acknowledged the above hazardous area enclosure deficiencies during a tour of the facility.
Life Safety Code Section 19.3.2.1: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain egress stair enclosures in accordance with Life Safety Code Section 19.3.1.1. This deficient practice could affect all patients and staff should there be smoke and heat transfer into the stair enclosure that could prevent egress from the building. This was evidenced by the following:

Fire doors protecting egress stair enclosures were not maintained, as required. The south stair door, second floor, would not self-close and latch into the door frame.

The Director of Facility Management acknowledged the non-latching door during a tour of the facility.

The Life Safety Code Section 19.3.1.1 requires that any vertical opening between stories shall be enclosed with construction having a one-hour fire resistance rating in accordance with Section 8.2.5. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to install door latching devices in accordance with Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect staff or residents occupying the soiled linen room, room 805 or bath 809, by delaying the ability to egress through the door equipped with multiple latching devices. This was evidenced by the following:

Doors in the means of egress were not arranged with latching devices that were operable with one releasing operation, as required. The soiled linen room, room 805 and bath 809 were equipped with separate spring loaded deadbolt locks that required the occupant to perform simultaneous unlatching operations on both the deadbolt and door handle latching devices.

The Director of Facility Management acknowledged the door latching arrangement during a tour of the facility.

Life Safety Code Section 7.2.1.5.4: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Haxtun Family Medical Center (Aspen ID: A-3)
Based on observation and staff interview, it was determined that the facility failed to arrange doors in the means of egress in accordance with Life Safety Code Section 39.2 and Section 7-2. This deficient practice could affect all patients, staff and visitors within the facility, if code compliant exit doors and corridors are not provided for building egress. This was evidenced by the following:

Egress doors were not arranged to be operable with not more than one releasing operation, as required. The main entrance door was equipped with multiple locking devices.
The Director of Facility Management acknowledged the door locking arrangement during a tour of the clinic facility.

Life Safety Code Section 7.2.1.5.4: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Note: Chapter 39 allows the provisions of Section 7.2.1.5.1 Exception #2 to be applied to principal entrance/exit doors.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to arrange doors in the means of egress in accordance with Life Safety Code Section 19.2.1 and Section 7-2. This deficient practice could affect all patients, staff and visitors within the facility, if code compliant exit doors and corridors are not provided for building egress. This was evidenced by the following:

A) Power operated sliding doors within the means of egress were not arranged to be readily opened from the egress side, as required.
1. The main entrance-inner sliding door was equipped with a deadbolt style lock that voided the break-away feature of the door.
2. The emergency department outer sliding door was equipped with a deadbolt style lock that voided the break-away feature of the door.

B) Doors opening into egress corridors were not arranged to project 7 inches or less into the required width of the corridor when fully open, as required. The pantry corridor door projected more than 7 inches into the corridor, when fully opened. The door was restricted from opening fully by the self-closing device.

The Director of Facility Management acknowledged the door latching and opening arrangements during a tour of the facility.

Life Safety Code Section 7.2.1.5.4: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
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.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to maintain horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 19.2.2.5. This deficient practice could affect all patients, staff and visitors within the building, if code compliant horizontal exits are not provided for building egress. This was evidenced by the following:

A) Two-hour fire rated horizontal exit walls were not maintained, as follows:
1. Above the south cross-corridor doors: A cable penetration (next to the sprinkler pipe) had an unsealed ? inch gap.
2. Above the north cross-corridor doors and sidewall area:
a) 2 inch gap at the mineral wool protected structural steel penetration.
b) ? inch conduit was not anchored to the wall and was not fire-stopped.
c) unsealed conduit at the steel roof deck (sidewall area)

B) 90 minute fire rated horizontal exit doors were not maintained, as required.
1. One of two door leafs (south corridor doors) was difficult to open.
2. One of two door leafs (north corridor doors) would not close and latch.

The Director of Facility Management acknowledged the door operation and fire barrier penetrations during a tour of the facility.

Life Safety Code Section 8-2.3.2.4 requires, in part, that penetrations and miscellaneous openings in fire barrier walls be filled with a material capable of maintaining the fire resistance rating of the barrier. Section 8.2.3.2.4.2(2) requires that penetrating sleeves be solidly set in the smoke barrier wall. Section 8.2.3.2.1 requires that fire doors be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies, and that doors be installed in accordance with NFPA 80 Standard for Fire Doors and Fire Windows. Rated fire doors must positively latch into the door frame in accordance with NFPA 80.

ECU Building (Aspen ID: A-2)
Based on observation, record review 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 deficient practice could affect all 20 patients, staff and visitors in the building should the battery emergency lighting or emergency generator fail to operate as designed. This was evidenced by the following:

A) The generator/transfer switch areas were not provided with battery operated emergency lighting, as required.
NFPA Standard 110 Section 5-3.1 requires that EPS equipment locations be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

B) Battery powered emergency lighting units were not maintained, as required. Records on premises documented that 11 battery powered lighting units failed the 90 minute annual duration test in January 2013. Documentation of battery replacement for the failed units was not available.
Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment, states: "A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1? hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

C) The emergency generator was not equipped with a remote manual stop, outside of the generator enclosure, as required. The Director of Facility Management confirmed that a remote manual stop was not provided for the emergency generator.

NFPA 110 Section 3-5.5.6: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station, located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside of the building.

Original 1965 Building (Aspen ID: A-1)
Based on observation, record review 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 deficient practice could affect all 20 patients, staff and visitors in the building should the battery emergency lighting or emergency generator fail to operate as designed. This was evidenced by the following:

A) The generator/transfer switch areas were not provided with battery operated emergency lighting, as required.
NFPA Standard 110 Section 5-3.1 requires that EPS equipment locations be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

B) Battery powered emergency lighting units were not maintained, as required. Records on premises documented that 11 battery powered lighting units failed the 90 minute annual duration test in January 2013. Documentation of battery replacement for the failed units was not available.
Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment, states: "A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1? hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

C) The emergency generator was not equipped with a remote manual stop, outside of the generator enclosure, as required. The Director of Facility Management confirmed that a remote manual stop was not provided for the emergency generator.

NFPA 110 Section 3-5.5.6: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station, located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside of the building.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to control and extinguish a fire due to non-code compliant installation. This was evidenced by the following:

Standard pendant sprinkler heads were not installed at a distance of 7? feet or less from a wall, as required. The following hazardous areas were observed to have standard pendant sprinkler heads installed 8 ? ft. to 9 ft. from the wall:
1. Clean linen room.
2. Laundry room (2 heads)
3. Soiled linen room.
4. B725 south-records storage room.
5. B725 north-records storage room (heavy combustible fuel loading).

The Director of Facility Management acknowledged the sprinkler spacing during a tour of the basement hazardous areas.

NFPA 13, Installation of Sprinkler Systems, Section 5-6 allows a maximum distance between the sprinkler head and the wall (light hazard) to be 7? feet.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all 20 patients, staff and visitors should a fire occur in an area not protected by the automatic sprinkler system. This was evidenced by the following:

Automatic sprinkler protection was not provided in all building areas, as required. The 6 ft. x 8 ft. emergency department entrance foyer was not sprinkler protected. The original dry sidewall sprinkler head had been removed and capped due to the installation of power operated automatic sliding doors.
The Director of Facility Management confirmed that the area was not sprinkler protected.

NFPA 13, Installation of Sprinkler Systems, Section 1-6.1 states: A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

ECU Building (Aspen ID: A-2)
Based on observation, staff interview and record review, 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 deficient practice could affect all 20 patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidenced by the following:

A) The automatic sprinkler system waterflow alarm was not tested quarterly, as required. Records on premises did not document a waterflow alarm test in the first quarter of 2013.
NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

B) The sprinkler system tamper switches were not tested semi-annually as required. Records on premises documented the testing of sprinkler system valve tamper switches in September 2012.
NFPA 25 Section 9-3.4.3 requires that valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

C) Sprinkler system pressure gauges were not replaced or calibrated every 5 years, as required. The sprinkler pressure gauges, installed at the main system riser, were dated "1990". The gauges had hand written labels that stated " calibrated 09-14-06 " , however, there was no written gauge calibration report available to document the 2006 calibration.
NFPA 25 Section 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

D) Sprinkler system branch lines were not supported from the building structure by listed sprinkler hangers, as required. The basement electric room was observed to have a 4 ft. section of branch line supported by a suspended light fixture.

E) Sprinkler system spray patterns were not maintained free of obstructions to water spray distribution, as required.
F) The central storage room was equipped with two banks of moveable storage shelf units, each unit was 3 ft. deep and 27 ft. in length. The units were divided into 3 ft. wide compartments with the compartment dividers approximately 1 inch below the pendant sprinkler deflectors. Depending on the location of the moveable units, up to 6 pendant sprinklers could be partially or fully obstructed.

G) Records storage room B725 was observed to have a fixed metal shelf storage unit with the unit dividers approximately 3 inches below the ceiling. As arranged, a portion of the shelf storage and floor area were not protected by the automatic sprinkler pedant head.

The Director of Facility Management acknowledged the sprinkler obstructions during a tour of the basement hazardous areas.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 2-2.1.2 states "Unacceptable obstructions to spray patterns shall be corrected."

Original 1965 Building (Aspen ID: A-1)
Based on observation and record review, 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 deficient practice could affect all 20 patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidenced by the following:

A) The automatic sprinkler system waterflow alarm was not tested quarterly, as required. Records on premises did not document a waterflow alarm test in the first quarter of 2013.
NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

B) The sprinkler system tamper switches were not tested semi-annually as required. Records on premises documented the testing of sprinkler system valve tamper switches in September 2012.
NFPA 25 Section 9-3.4.3 requires that valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

C) Sprinkler system pressure gauges were not replaced or calibrated every 5 years, as required. The sprinkler pressure gauge (upper gauge), installed at the main system riser, was dated "2006". NFPA 25 Section 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

Haxtun Family Medical Center (Aspen ID: A-3)
Based on observation and staff interview during the survey, it was determined that the facility failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers. This deficient practice could affect all patients and staff should a portable fire extinguisher not be immediately available for use by any staff member. This was evidenced by the following:

Portable fire extinguishers, installed throughout the clinic, exceeded the maximum allowed installation height above the floor. Extinguishers throughout were observed to be installed with the top of the extinguisher greater than 5 feet above the floor.
The Director of Facility Management acknowledged the portable fire extinguisher installation height during a tour of the facility.

NFPA 10 Section 1-6.10 requires that fire extinguishers having a gross weight not exceeding 40 lb. be installed so that the top of the fire extinguisher is not more than 5 ft. above the floor. Fire extinguishers having a gross weight greater than 40 lb. (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3? ft. above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to install and maintain gas fueled heating equipment in accordance with National Fire Protection Association (NFPA) 54, National Fuel Gas Code. This deficient practice could affect all 20 patients, staff and visitors should the natural gas fueled heating equipment create a fire hazard due to non-compliant installation or maintenance. This was evidenced by the following:

Type 2 natural gas fired clothes dryer exhaust ductwork was not maintained free of screws, as required. Type 2 natural gas fired commercial clothes dryers (2 units) were observed to have sheet metal screws installed in the metal exhaust ductwork.
The Director of Facility Management acknowledged the screws during a tour of the basement hazardous areas.

NFPA 54 Section 6.4.4 requires that ducts for exhausting clothes dryers not be assembled with screws or other fastening means that extend into the duct.

Original 1965 Building (Aspen ID: A-1)
Based on staff interview and observation, it was determined that the facility failed to install and protect cooking equipment in accordance with National Fire Protection Association (NFPA) Standard 96. This deficient practice could affect all 20 patients, staff and visitors within the main dining room smoke compartment should a fire occur within the unprotected equipment. This was evidenced by the following:

Cooking operations that produced grease laden vapors were not performed below an exhaust hood that complies with NFPA 96, as required. During a tour of the main dining room, a popcorn maker was observed to be in the process of being cleaned after use. Facility staff reported that the popcorn maker was used weekly by a facility volunteer and that the machine used ? cup of cooking oil per batch. The popcorn maker was observed to have a UL listing label " UL 534L " . The machine was used within the main dining room and was not operated below a compliant exhaust hood protected with a compliant fixed fire extinguishing system, installed in accordance with NFPA 96.

NFPA 96 Section 1-3.1: Cooking equipment used in processes producing smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard, and all such equipment and performance shall be maintained per this standard during all periods of operation of the cooking equipment. Section 7-1.2: Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.

ECU Building (Aspen ID: A-2)
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to document that window curtains were flame resistant in accordance with the provisions of the Life Safety Code Section 10.3.1. This deficient practice could affect patients, staff and visitors in the west smoke compartment should the hanging materials ignite and contribute to rapid fire extension. This was evidenced by the following:

Hanging drapes and curtains were not documented to be flame resistant, as required. Drapes and curtains installed in the second floor conference room and first floor patient sleeping rooms were not documented to be flame resistant.

The facility Chief Compliance Officer could not locate records on premises that would correlate the supplier invoice description with the provided material testing documentation.

The Life Safety Code Section 19.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Original 1965 Building (Aspen ID: A-1)
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to document that window curtains were flame resistant in accordance with the provisions of the Life Safety Code Section 10.3.1. This deficient practice could affect patients, staff and visitors in the west smoke compartment should the hanging materials ignite and contribute to rapid fire extension. This was evidenced by the following:

A) Hanging drapes were not documented to be flame resistant, as required. Drapes and curtains installed in the medical records room and patient sleeping rooms were not documented to be flame resistant.

B) Hanging decorative quilts were not documented to be flame resistant, as required. The hanging quilts were observed in room 129 and in the corridor (near the television lounge area).

The facility Chief Compliance Officer could not locate records on premises that would correlate the supplier invoice description with the provided material testing documentation.

The Life Safety Code Section 19.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed store trash containers in accordance with Life Safety Code Section 19.7.5.5. This deficient practice could affect patients, staff and visitors in the east smoke compartment should the trash ignite and produce significant smoke and heat production due to the quantity of materials stored. This was evidenced by the following:

Trash containers with capacities greater than 32 gallons, were not stored in a room protected as a hazardous area, as required. A plastic trash receptacle, greater than 32 gallon capacity, was observed to be stored in the corridor outside of the central supply room. The container was used to collect paper records for future shredding.

The Director of Facility Management acknowledged the trash container during a tour of the facility.
Life Safety Code Section 19.7.5.5: Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons per sq. ft. A capacity of 32 gal shall not be exceeded within any 64 sq. ft. area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to construct corridor walls and separate egress corridors from treatment areas in accordance with Life Safety Code Section 19.3.6. This deficient practice could affect all patients using the therapy room should smoke and heat spread into the room due to the absence of a smoke resistive separation.
This was evidenced by the following:

The east therapy room was not separated from the egress corridor, as required. The former sun room was now equipped for use as a patient therapy room with parallel bars, an exercise machine and stair steps. The Chief Compliance Officer acknowledged the absence of separation during a tour of the facility.

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. Exceptions to 19.3.6.1 allow some areas to be open to the egress corridor. Treatment rooms are not allowed to be open to the egress corridor.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to install and maintain corridor doors in accordance with Life Safety Code Section 19.3.6.3. This deficient practice could affect all patients, staff and visitors within the west smoke compartment should the egress corridor become untenable, due to smoke and heat transfer, via the non-latching corridor doors separating rooms from the egress corridor. This was evidenced by the following:

A) Corridor doors were not equipped with positive latching hardware, as required. The main pantry corridor door was equipped with panic hardware that had a latch disabling device.

B) Corridor doors were not arranged to be closed with a push or a pull, as required. The main dining room corridor double doors were observed to be held open with door chocks.

C) Self-closing corridor doors were not equipped with door coordinators to insure complete closing and positive latching, as required. The main dining room double doors and the employee dining room double doors were not equipped with door coordinators. When tested, the doors would self-close but not positively latch due to the absence of coordination.
The Director of Facility Management acknowledged the door arrangements during a tour of the facility.

Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Latching devices must not require the use of keys or special tools. Section 19.3.6.3.3 permits hold-open devices that release when the door is pushed or pulled. The Life Safety Code Annex (explanatory material) explains that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to provide continuous smoke barrier walls with a 30 minute fire resistance rating in accordance with the Life Safety Code Section 19-3.7.3 and Section 8.3. This deficient practice could affect all 20 first floor patients should the smoke barrier wall fail to prevent the spread of fire between smoke compartments during a compartment evacuation. This was evidenced by the following:

Fire rated smoke barrier walls were not constructed with a minimum fire resistance rating of 30 minutes, as required. The ECU smoke barrier wall was deficient, as follows:
1. The corridor wall (separating the activity room) was not a minimum of 30 minute fire rated due to an unprotected steel beam forming the upper section of the wall. The top of the beam as sealed to the floor deck above with a non-fire rated mineral wool stuffing.

2. The activity room wall (separation to room 125) was not constructed with a minimum fire rating of 30 minutes. The top of the gypsum board wall assembly was sealed at the floor deck with drywall tape and joint compound.

The Director of Facility Management acknowledged the wall arrangements during a tour of the facility.

Life Safety Code Section 19.3.7.3 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 ? hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to enclose sprinkler protected hazardous areas in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect all patients within the first floor smoke compartment and staff within the basement smoke compartment, should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following:

A) Sprinkler protected hazardous areas were not constructed with smoke resistive partition walls, as required. The first floor soiled linen holding room was observed to have a 12 " x 24 " unprotected air transfer grille in the corridor wall, which voided the smoke resistive rating of the corridor wall.

B) Sprinkler protected hazardous areas were not equipped with self-closing doors, as required. Medical records storage room (B720) was separated from the corridor with a one-hour fire rated door that was not equipped with a self-closer.

The Director of Facility Management acknowledged the hazardous area enclosure deficiencies during a tour of the facility.

Life Safety Code Section 19.3.2.1: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed to enclose sprinkler protected hazardous areas in accordance with Life Safety Code Section 19.3.2.1. This deficient practice could affect all patients within the west smoke compartment, should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following:

A) Sprinkler protected hazardous areas were not maintained to be smoke resistive, as required. The main boiler room was observed to have three unsealed pipe penetrations through the corridor wall (above the corridor door). The ceiling area was observed to have 3 unsealed all-thread rod penetrations.

B) Sprinkler protected hazardous area doors were not arranged or maintained to be self-closing, as required.
1. The self-closing medical records door was observed to be chocked open which voids the required self-closing function.
2. The Activities Office/Storage room was observed to have two 1hour fire rated corridor doors that were not equipped with self-closing devices. The self-closing devices had been disabled.

The Director of Facility Management acknowledged the above hazardous area enclosure deficiencies during a tour of the facility.
Life Safety Code Section 19.3.2.1: Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview during the survey, it was determined that the facility failed to maintain egress stair enclosures in accordance with Life Safety Code Section 19.3.1.1. This deficient practice could affect all patients and staff should there be smoke and heat transfer into the stair enclosure that could prevent egress from the building. This was evidenced by the following:

Fire doors protecting egress stair enclosures were not maintained, as required. The south stair door, second floor, would not self-close and latch into the door frame.

The Director of Facility Management acknowledged the non-latching door during a tour of the facility.

The Life Safety Code Section 19.3.1.1 requires that any vertical opening between stories shall be enclosed with construction having a one-hour fire resistance rating in accordance with Section 8.2.5. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to install door latching devices in accordance with Life Safety Code Section 19.2 and Chapter 7. This deficient practice could affect staff or residents occupying the soiled linen room, room 805 or bath 809, by delaying the ability to egress through the door equipped with multiple latching devices. This was evidenced by the following:

Doors in the means of egress were not arranged with latching devices that were operable with one releasing operation, as required. The soiled linen room, room 805 and bath 809 were equipped with separate spring loaded deadbolt locks that required the occupant to perform simultaneous unlatching operations on both the deadbolt and door handle latching devices.

The Director of Facility Management acknowledged the door latching arrangement during a tour of the facility.

Life Safety Code Section 7.2.1.5.4: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Haxtun Family Medical Center (Aspen ID: A-3)
Based on observation and staff interview, it was determined that the facility failed to arrange doors in the means of egress in accordance with Life Safety Code Section 39.2 and Section 7-2. This deficient practice could affect all patients, staff and visitors within the facility, if code compliant exit doors and corridors are not provided for building egress. This was evidenced by the following:

Egress doors were not arranged to be operable with not more than one releasing operation, as required. The main entrance door was equipped with multiple locking devices.
The Director of Facility Management acknowledged the door locking arrangement during a tour of the clinic facility.

Life Safety Code Section 7.2.1.5.4: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
Note: Chapter 39 allows the provisions of Section 7.2.1.5.1 Exception #2 to be applied to principal entrance/exit doors.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to arrange doors in the means of egress in accordance with Life Safety Code Section 19.2.1 and Section 7-2. This deficient practice could affect all patients, staff and visitors within the facility, if code compliant exit doors and corridors are not provided for building egress. This was evidenced by the following:

A) Power operated sliding doors within the means of egress were not arranged to be readily opened from the egress side, as required.
1. The main entrance-inner sliding door was equipped with a deadbolt style lock that voided the break-away feature of the door.
2. The emergency department outer sliding door was equipped with a deadbolt style lock that voided the break-away feature of the door.

B) Doors opening into egress corridors were not arranged to project 7 inches or less into the required width of the corridor when fully open, as required. The pantry corridor door projected more than 7 inches into the corridor, when fully opened. The door was restricted from opening fully by the self-closing device.

The Director of Facility Management acknowledged the door latching and opening arrangements during a tour of the facility.

Life Safety Code Section 7.2.1.5.4: A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
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.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to maintain horizontal exits in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code Section 19.2.2.5. This deficient practice could affect all patients, staff and visitors within the building, if code compliant horizontal exits are not provided for building egress. This was evidenced by the following:

A) Two-hour fire rated horizontal exit walls were not maintained, as follows:
1. Above the south cross-corridor doors: A cable penetration (next to the sprinkler pipe) had an unsealed ? inch gap.
2. Above the north cross-corridor doors and sidewall area:
a) 2 inch gap at the mineral wool protected structural steel penetration.
b) ? inch conduit was not anchored to the wall and was not fire-stopped.
c) unsealed conduit at the steel roof deck (sidewall area)

B) 90 minute fire rated horizontal exit doors were not maintained, as required.
1. One of two door leafs (south corridor doors) was difficult to open.
2. One of two door leafs (north corridor doors) would not close and latch.

The Director of Facility Management acknowledged the door operation and fire barrier penetrations during a tour of the facility.

Life Safety Code Section 8-2.3.2.4 requires, in part, that penetrations and miscellaneous openings in fire barrier walls be filled with a material capable of maintaining the fire resistance rating of the barrier. Section 8.2.3.2.4.2(2) requires that penetrating sleeves be solidly set in the smoke barrier wall. Section 8.2.3.2.1 requires that fire doors be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies, and that doors be installed in accordance with NFPA 80 Standard for Fire Doors and Fire Windows. Rated fire doors must positively latch into the door frame in accordance with NFPA 80.

ECU Building (Aspen ID: A-2)
Based on observation, record review 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 deficient practice could affect all 20 patients, staff and visitors in the building should the battery emergency lighting or emergency generator fail to operate as designed. This was evidenced by the following:

A) The generator/transfer switch areas were not provided with battery operated emergency lighting, as required.
NFPA Standard 110 Section 5-3.1 requires that EPS equipment locations be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

B) Battery powered emergency lighting units were not maintained, as required. Records on premises documented that 11 battery powered lighting units failed the 90 minute annual duration test in January 2013. Documentation of battery replacement for the failed units was not available.
Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment, states: "A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1? hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

C) The emergency generator was not equipped with a remote manual stop, outside of the generator enclosure, as required. The Director of Facility Management confirmed that a remote manual stop was not provided for the emergency generator.

NFPA 110 Section 3-5.5.6: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station, located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside of the building.

Original 1965 Building (Aspen ID: A-1)
Based on observation, record review 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 deficient practice could affect all 20 patients, staff and visitors in the building should the battery emergency lighting or emergency generator fail to operate as designed. This was evidenced by the following:

A) The generator/transfer switch areas were not provided with battery operated emergency lighting, as required.
NFPA Standard 110 Section 5-3.1 requires that EPS equipment locations be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

B) Battery powered emergency lighting units were not maintained, as required. Records on premises documented that 11 battery powered lighting units failed the 90 minute annual duration test in January 2013. Documentation of battery replacement for the failed units was not available.
Life Safety Code Section 7.9.3, Periodic Testing of Emergency Lighting Equipment, states: "A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1? hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

C) The emergency generator was not equipped with a remote manual stop, outside of the generator enclosure, as required. The Director of Facility Management confirmed that a remote manual stop was not provided for the emergency generator.

NFPA 110 Section 3-5.5.6: All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station, located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside of the building.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all residents, staff and visitors should the automatic sprinkler system fail to control and extinguish a fire due to non-code compliant installation. This was evidenced by the following:

Standard pendant sprinkler heads were not installed at a distance of 7? feet or less from a wall, as required. The following hazardous areas were observed to have standard pendant sprinkler heads installed 8 ? ft. to 9 ft. from the wall:
1. Clean linen room.
2. Laundry room (2 heads)
3. Soiled linen room.
4. B725 south-records storage room.
5. B725 north-records storage room (heavy combustible fuel loading).

The Director of Facility Management acknowledged the sprinkler spacing during a tour of the basement hazardous areas.

NFPA 13, Installation of Sprinkler Systems, Section 5-6 allows a maximum distance between the sprinkler head and the wall (light hazard) to be 7? feet.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview, it was determined that the facility failed to install the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13. This deficient practice could affect all 20 patients, staff and visitors should a fire occur in an area not protected by the automatic sprinkler system. This was evidenced by the following:

Automatic sprinkler protection was not provided in all building areas, as required. The 6 ft. x 8 ft. emergency department entrance foyer was not sprinkler protected. The original dry sidewall sprinkler head had been removed and capped due to the installation of power operated automatic sliding doors.
The Director of Facility Management confirmed that the area was not sprinkler protected.

NFPA 13, Installation of Sprinkler Systems, Section 1-6.1 states: A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

ECU Building (Aspen ID: A-2)
Based on observation, staff interview and record review, 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 deficient practice could affect all 20 patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidenced by the following:

A) The automatic sprinkler system waterflow alarm was not tested quarterly, as required. Records on premises did not document a waterflow alarm test in the first quarter of 2013.
NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

B) The sprinkler system tamper switches were not tested semi-annually as required. Records on premises documented the testing of sprinkler system valve tamper switches in September 2012.
NFPA 25 Section 9-3.4.3 requires that valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

C) Sprinkler system pressure gauges were not replaced or calibrated every 5 years, as required. The sprinkler pressure gauges, installed at the main system riser, were dated "1990". The gauges had hand written labels that stated " calibrated 09-14-06 " , however, there was no written gauge calibration report available to document the 2006 calibration.
NFPA 25 Section 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

D) Sprinkler system branch lines were not supported from the building structure by listed sprinkler hangers, as required. The basement electric room was observed to have a 4 ft. section of branch line supported by a suspended light fixture.

E) Sprinkler system spray patterns were not maintained free of obstructions to water spray distribution, as required.
F) The central storage room was equipped with two banks of moveable storage shelf units, each unit was 3 ft. deep and 27 ft. in length. The units were divided into 3 ft. wide compartments with the compartment dividers approximately 1 inch below the pendant sprinkler deflectors. Depending on the location of the moveable units, up to 6 pendant sprinklers could be partially or fully obstructed.

G) Records storage room B725 was observed to have a fixed metal shelf storage unit with the unit dividers approximately 3 inches below the ceiling. As arranged, a portion of the shelf storage and floor area were not protected by the automatic sprinkler pedant head.

The Director of Facility Management acknowledged the sprinkler obstructions during a tour of the basement hazardous areas.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 2-2.1.2 states "Unacceptable obstructions to spray patterns shall be corrected."

Original 1965 Building (Aspen ID: A-1)
Based on observation and record review, 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 deficient practice could affect all 20 patients, staff and visitors should the automatic sprinkler system fail to operate in a timely and effective manner due to non-code compliant maintenance. This was evidenced by the following:

A) The automatic sprinkler system waterflow alarm was not tested quarterly, as required. Records on premises did not document a waterflow alarm test in the first quarter of 2013.
NFPA 25 Section 9-2.7 requires that waterflow alarms be tested quarterly in accordance with manufacturer's instructions.

B) The sprinkler system tamper switches were not tested semi-annually as required. Records on premises documented the testing of sprinkler system valve tamper switches in September 2012.
NFPA 25 Section 9-3.4.3 requires that valve supervisory switches be tested semi-annually in accordance with manufacturer's instructions.

C) Sprinkler system pressure gauges were not replaced or calibrated every 5 years, as required. The sprinkler pressure gauge (upper gauge), installed at the main system riser, was dated "2006". NFPA 25 Section 9-2.8.2: Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

Haxtun Family Medical Center (Aspen ID: A-3)
Based on observation and staff interview during the survey, it was determined that the facility failed to install portable fire extinguishers in accordance with NFPA 10 Standard for Portable Fire Extinguishers. This deficient practice could affect all patients and staff should a portable fire extinguisher not be immediately available for use by any staff member. This was evidenced by the following:

Portable fire extinguishers, installed throughout the clinic, exceeded the maximum allowed installation height above the floor. Extinguishers throughout were observed to be installed with the top of the extinguisher greater than 5 feet above the floor.
The Director of Facility Management acknowledged the portable fire extinguisher installation height during a tour of the facility.

NFPA 10 Section 1-6.10 requires that fire extinguishers having a gross weight not exceeding 40 lb. be installed so that the top of the fire extinguisher is not more than 5 ft. above the floor. Fire extinguishers having a gross weight greater than 40 lb. (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3? ft. above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

ECU Building (Aspen ID: A-2)
Based on observation and staff interview, it was determined that the facility failed to install and maintain gas fueled heating equipment in accordance with National Fire Protection Association (NFPA) 54, National Fuel Gas Code. This deficient practice could affect all 20 patients, staff and visitors should the natural gas fueled heating equipment create a fire hazard due to non-compliant installation or maintenance. This was evidenced by the following:

Type 2 natural gas fired clothes dryer exhaust ductwork was not maintained free of screws, as required. Type 2 natural gas fired commercial clothes dryers (2 units) were observed to have sheet metal screws installed in the metal exhaust ductwork.
The Director of Facility Management acknowledged the screws during a tour of the basement hazardous areas.

NFPA 54 Section 6.4.4 requires that ducts for exhausting clothes dryers not be assembled with screws or other fastening means that extend into the duct.

Original 1965 Building (Aspen ID: A-1)
Based on staff interview and observation, it was determined that the facility failed to install and protect cooking equipment in accordance with National Fire Protection Association (NFPA) Standard 96. This deficient practice could affect all 20 patients, staff and visitors within the main dining room smoke compartment should a fire occur within the unprotected equipment. This was evidenced by the following:

Cooking operations that produced grease laden vapors were not performed below an exhaust hood that complies with NFPA 96, as required. During a tour of the main dining room, a popcorn maker was observed to be in the process of being cleaned after use. Facility staff reported that the popcorn maker was used weekly by a facility volunteer and that the machine used ? cup of cooking oil per batch. The popcorn maker was observed to have a UL listing label " UL 534L " . The machine was used within the main dining room and was not operated below a compliant exhaust hood protected with a compliant fixed fire extinguishing system, installed in accordance with NFPA 96.

NFPA 96 Section 1-3.1: Cooking equipment used in processes producing smoke or grease-laden vapors shall be equipped with an exhaust system that complies with all the equipment and performance requirements of this standard, and all such equipment and performance shall be maintained per this standard during all periods of operation of the cooking equipment. Section 7-1.2: Cooking equipment that produces grease-laden vapors (such as, but not limited to, deep fat fryers, ranges, griddles, broilers, woks, tilting skillets, and braising pans) shall be protected by fire-extinguishing equipment.

ECU Building (Aspen ID: A-2)
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to document that window curtains were flame resistant in accordance with the provisions of the Life Safety Code Section 10.3.1. This deficient practice could affect patients, staff and visitors in the west smoke compartment should the hanging materials ignite and contribute to rapid fire extension. This was evidenced by the following:

Hanging drapes and curtains were not documented to be flame resistant, as required. Drapes and curtains installed in the second floor conference room and first floor patient sleeping rooms were not documented to be flame resistant.

The facility Chief Compliance Officer could not locate records on premises that would correlate the supplier invoice description with the provided material testing documentation.

The Life Safety Code Section 19.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Original 1965 Building (Aspen ID: A-1)
Based on observation, record review and staff interview during the survey, it was determined that the facility failed to document that window curtains were flame resistant in accordance with the provisions of the Life Safety Code Section 10.3.1. This deficient practice could affect patients, staff and visitors in the west smoke compartment should the hanging materials ignite and contribute to rapid fire extension. This was evidenced by the following:

A) Hanging drapes were not documented to be flame resistant, as required. Drapes and curtains installed in the medical records room and patient sleeping rooms were not documented to be flame resistant.

B) Hanging decorative quilts were not documented to be flame resistant, as required. The hanging quilts were observed in room 129 and in the corridor (near the television lounge area).

The facility Chief Compliance Officer could not locate records on premises that would correlate the supplier invoice description with the provided material testing documentation.

The Life Safety Code Section 19.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Original 1965 Building (Aspen ID: A-1)
Based on observation and staff interview during the survey, it was determined that the facility failed store trash containers in accordance with Life Safety Code Section 19.7.5.5. This deficient practice could affect patients, staff and visitors in the east smoke compartment should the trash ignite and produce significant smoke and heat production due to the quantity of materials stored. This was evidenced by the following:

Trash containers with capacities greater than 32 gallons, were not stored in a room protected as a hazardous area, as required. A plastic trash receptacle, greater than 32 gallon capacity, was observed to be stored in the corridor outside of the central supply room. The container was used to collect paper records for future shredding.

The Director of Facility Management acknowledged the trash container during a tour of the facility.
Life Safety Code Section 19.7.5.5: Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons per sq. ft. A capacity of 32 gal shall not be exceeded within any 64 sq. ft. area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.