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 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)
K0064 LIFE SAFETY CODE STANDARD
CFR(s): NFPA 101

Portable fire extinguishers are provided in all health care occupancies in accordance with 9.7.4.1. 19.3.5.6, NFPA 10


This STANDARD is not met as evidenced by:
Based upon observation and staff interview the facility failed to maintain 1 portable fire extinguisher in 1 of 6 smoke compartments as required. The findings were: Observation on 5/1/12 at 11:48 AM revealed an AC water mist type of fire extinguisher attached to the wall in the cardiac therapy room (old education section). The top of the fire extinguisher was approximately six feet from the floor exceeding the maximal 5 ft requirement for extinguishers weighing less than 40 pounds. The fire extinguisher weighed 21 lbs. Interview with maintenance staff at the time of the observation confirmed the above findings. Reference: NFPA 101, Life Safety Code, 2000 edition. Sections 19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10. NFPA 10, Standard for the Installation of Portable Fire Extinguishers, 1990 ed. 1-6.9. Extinguishers having a gross weight not exceeding 40 lb shall be installed so that the top of the extinguisher is not more than 5 ft above the floor. Extinguishers having a gross weight greater than 40 lb shall be installed so installed that the top of the extinguisher is not more than 3.5 ft above the floor. In no case shall the clearance between the bottom of the extinguisher and the floor be less than 4 in.