| 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) |
| K0027 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Door openings in smoke barriers have at least a 20-minute fire protection rating or are at least 1¾-inch thick solid bonded wood core. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Doors are self-closing or automatic closing in accordance with 19.2.2.2.6. Swinging doors are not required to swing with egress and positive latching is not required. 19.3.7.5, 19.3.7.6, 19.3.7.7 This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to ensure smoke barrier doors were smoke resistant on 1 of 3 floors. The findings were: Observation of the smoke barrier double doors near the stress lab on 11/4/11 at 10:06 AM showed there was a 1/4 inch gap between the meeting edges of the doors, more than the allowed 1/8th inch gap. At the time of observation the facility supervisor could not explain why the gap had not been noticed and repaired during the semi-annual inspections. Reference: NFPA 101, 2000 Edition; 3.3.20* Barrier, Smoke. A continuous membrane, or a membrane with discontinuities created by protected openings, where such membrane is designed and constructed to restrict the movement of smoke. |