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388 US HIGHWAY 20 SOUTH

BASIN, WY 82410

Exit Signage

Tag No.: K0293

Based on observation and staff interview, the facility failed to properly mark the means of egress in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly mark the means of egress could result in injury or death in the event of an emergency. The deficiency affected two (2) of six (6) smoke compartments.

The findings were:

Observation on 03/17/2022 at 10:02 AM and at 10:17 AM revealed glass exterior doors that exit into a courtyard that requires entry back into the hospital. Observation of the exterior doors revealed that they are likely to be mistaken for an exit, but were not marked to indicated they were not an exit. Any door that is not an exit or way of exit access, but is arranged that it is likely to be mistaken for an exit, shall be identified by a sign that reads "NO EXIT".

Interview with the Director of Plant Operations at the time of the observation acknowledged the deficiency, and indicated they were unaware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.2.10.1, 7.10.8.3.1
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Cooking Facilities

Tag No.: K0324

Based on observation and staff interview, the facility failed to protect cooking facilities in accordance with the 2012 NFPA 101, Life Safety Code. Failure to protect cooking facilities could result in injury or death in the event of a fire. The deficiency affected one (1) of one (1) kitchen.

The findings were:

Observation on 03/17/2022 at 10:22 AM revealed a gas cook-top under a commercial hood located in the facility's kitchen. Observation of the cook-top revealed that no means was provided to ensure it is returned to the approved location after being moved. Cooking appliances requiring fire-extinguishing protection shall be provided with a means of returning to the approved location after being moved for cleaning or maintenance purposes.

Interview with the Director of Plant Operations at the time of the observation acknowledged the deficiency, and indicated they were unaware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.3.2.5.5, 9.2.3; 2011 NFPA 96 12.1.2.3
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Alcohol Based Hand Rub Dispenser (ABHR)

Tag No.: K0325

Based on observation and staff interview, the facility failed to store alcohol-based hand sanitizer (ABHS) in accordance with the 2012 NFPA 101, Life Safety Code. Failure to properly store ABHS could result in injury or death in the event of a fire. The deficiency affected one (1) of six (6) smoke compartments.

The findings were:

Observation on 03/17/2022 at 11:13 AM revealed an ABHS storage closet located in the old portion of the hospital. Observation of the storage closet revealed that it contain approximately 80 one gallon containers of ABHS with an ethanol percentage of 70%. It could not be established at the time of survey that the room was provided with 1-hour fire-rated construction. Storage of ABHS in quantities greater than 5 gallons in a single smoke compartment shall meet NFPA 30 requirements of no more than 10 gallons stored together at a time in a control area that is 1-hour fire resistant.

Interview with the Director of Plant Operations at the time of the observation acknowledged the deficiency, and indicated that they were unaware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 101 19.3.2.6(7); 2012 NFPA 30 9.6.1, 9.7.1
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Gas and Vacuum Piped Systems - Central Supply

Tag No.: K0906

Based on observation and staff interview, the facility failed to protect central supply systems in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly protect central supply systems could result in injury or death in the event of an emergency. The deficiency affected one (1) of one (1) medical vacuum pump rooms.

The findings were:

Observation on 03/17/2022 at 10:37 AM revealed that the dedicated interior mechanical equipment room containing the medical vacuum supply pump was being used to store a large amount of combustible materials, such as flooring tiles and cardboard boxes. Only gas cylinders, reusable shipping containers, and their accessories shall be stored in rooms containing central supply systems.

Interview with the Director of Plant Operations at the time of the observation acknowledged the deficiency, and indicated they were unaware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 99 5.1.3.2.3

Gas Equipment - Cylinder and Container Storag

Tag No.: K0923

Based on observation and staff interview, the facility failed to protect medical gas storage in accordance with the 2012 NFPA 99, Health Care Facilities Code. Failure to properly protect medical gas storage could result in injury or death in the event of a fire. The deficiency affected one (1) of two (2) medical gas storage rooms.

The findings were:

Observation on 03/17/2022 at 12:13 PM revealed that the exterior medical gas storage room, located in the old portion of the hospital, contained approximately 48 full E tanks (25 cu. ft.), 3 full H tanks (250 cu. ft.), and two 200 Liter liquid oxygen containers. The room was provided with no ventilation. Interior medical gas storage rooms containing greater than 3,000 cu. ft. of oxidizing gases shall be supplied with natural ventilation consisting of two nonclosable louvered openings, each with an aggregate free opening area of at least 24 sq. in./ 1000 cu. ft. of fluid being stored. One opening shall be located within 1 ft. of the floor and the other shall be located within 1 ft. of the ceiling.

Interview with the Director of Plant Operations at the time of the observation acknowledged the deficiency, and indicated that they were unaware of the requirement.

Interview with the CEO at the time of exit acknowledged the deficiency.

Ref: 2012 NFPA 99 11.3.1, 9.3.7.5, 9.3.7.5.2