| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 531310 | (X3) Date Survey Completed 05/03/2012 |
| Name of Provider or Supplier Powell Valley Hospital | Street Address, City, State 777 Avenue H, Powell, 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) |
| K0062 | LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5 This STANDARD is not met as evidenced by: Based on observation and staff interview the facility failed to ensure the fire suppression (sprinkler) system was properly maintained in 2 of 6 smoke compartments. The findings were: Observation on 5/1/12 at 2:48 PM revealed a gap greater than one-half inch existed between the sprinkler head escutcheons and the ceiling in the mail room, in the soiled utility room in the surgical suite and in the purchasing supply room in the basement. In addition, a storage shelf in the housekeeping storage room by the mens' locker room had supplies stored less than 8 inches from the sprinkler head. Interview with maintenance staff at the time of the observation confirmed the findings. Ref: 2000 NFPA 101 Section 19.3.5.1 (existing). Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. 9.7.5 All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested and maintained in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of the Water-Based Fire Protection systems, 1992 edition. |