Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530025 (X3) Date Survey Completed 11/07/2011
Name of Provider or Supplier Ivinson Memorial Hospital Street Address, City, State 255 N 30th, Laramie, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
K0012 LIFE SAFETY CODE STANDARD
CFR(s): NFPA 101

Building construction type and height meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1


This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to ensure room walls and ceilings were smoke resistant on 2 of 3 floors. The findings were: 1. Periodic observation on 11/3-7/11 showed the ceiling tiles had been removed from the communication/security room, second floor telecommunication room, radiology information technology (IT) room, MRI equipment room, and the third floor IT closet. The largest gap measured 24 inches by 24 inches. On 11/3/11 at 2:32 PM the facility supervisor could not explain why the missing ceiling tiles had not been noticed and replaced during the semi-annual inspections. 2. Periodic observation on 11/3-4/11 showed the wall was incomplete in the second floor electrical room, executone room, and the ambulance garage storeroom. The largest gap measured 4 feet by 6 feet. On 11/3/11 at 3:06 PM the facility supervisor reported he was unaware the walls were required to be smoke resistance for proper operation of the smoke detector in the area. Reference: NFPA 101, 2000 Edition; 19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.