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)
K0075 LIFE SAFETY CODE STANDARD
CFR(s): NFPA 101

Soiled linen or trash collection receptacles do not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space does not exceed .5 gal/sq ft (20.4 L/sq m). A capacity of 32 gal (121 L) is not exceeded within any 64 sq ft (5.9-sq m) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are located in a room protected as a hazardous area when not attended. 19.7.5.5


This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to ensure soiled linen receptacles were properly separated on 1 of 3 floors. The findings were: Observation of the radiology corridor on 11/4/11 at 11:02 AM showed a double soiled linen/trash cart was being stored in the alcove near room #2241. At the time of observation the facility supervisor was unaware soiled linen and trash receptacles were required to be separated by 64 square feet.