| 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) |
| K0025 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Smoke barriers are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems. 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure smoke barriers on 1 of 3 floors was smoke resistance. The findings were: Observation of the second floor smoke barrier wall near the information technology closet on 11/7/11 at 11:24 AM showed a 1/2 inch gap around an unsealed conduit penetration. At the time of observation the facility supervisor could not explain why the hole had not been noticed and repaired during the semi-annual inspections. |