Star Valley Medical Center

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 37603 Based on observation, log review, staff interview, and policy review, the facility failed to ensure emergency equipment was inspected, tested and maintained for 2 of 8 crash carts (nursery cart, medical/surgical cart). The findings were: 1. Observation on 9/23/25 at 9:25 AM showed the nursery crash cart failed to have a daily completed checklist. The document named “Nursery Log” dated September 2025 failed to show entries for the 8th, 9th, 10th, and the 16th. Interview at that time with the labor and delivery nurse manager revealed the log was to be filled out daily. She confirmed the log was missing dates of entry. 2. Observation on 9/23/25 at 9:40 AM showed the medical/surgical crash cart failed to have a monthly completed checklist. The document named “Floor Crash Cart Check List” failed to show any entry since 3/3/25. Further observation showed a Zoll Pedi-Padz (AED Electrode Pad Set) had expired 4/20/25. Interview at that time with the medical/surgical nurse manager revealed it was her expectation that the crash cart be checked every month. Further, she confirmed the pad set was expired. 3. Review of the policy “Equipment and Supplies” last revision 3/2025 failed to show the facility’s expectation for frequency of checking the crash carts.”

“A Life Safety Code survey was conducted by Healthcare Licensing and Surveys on 09/23/2025. Requirements for Critical Access Hospitals Section 42 CFR 485.623 (b), except as otherwise provided in this section, the facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code, Existing Business, of the National Fire Protection Association. The Medical Office Building was a fully sprinklered single story building of Type II (000) construction with plan approval in 1979 and 2004. The building was equipped with a supervised automatic wet sprinkler system, and an addressable fire alarm system. Based upon the findings of the survey team, it was determined that the facility was in compliance with all regulations surveyed.”

“A Life Safety Code survey was conducted by Healthcare Licensing and Surveys on 09/23/2025. Requirements for Critical Access Hospitals Section 42 CFR 485.623 (b), except as otherwise provided in this section, the facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code, New Healthcare, of the National Fire Protection Association. The facility was a fully sprinklered single story building with a basement mechanical room of Type II (000) construction with plan approval in 2023. The building was equipped with a supervised automatic wet sprinkler system and an addressable fire alarm system. Based on the survey, it was determined the facility was in compliance with 42 CFR 485.623 (b).”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 52855 Based on observation and staff interview, the facility failed to ensure door leaf encroachment in a means of egress was in accordance with the 2012 NFPA, Life Safety Code. Failure to ensure proper door leaf encroachment could obstruct the means of egress, leading to injury or death for patients, staff, and visitors using the affected exit access corridor. The deficiency affected one (1) of multiple corridor doors. The findings were: Observations on 09/23/25 at 10:40 AM revealed the storage room door in the OB exit access corridor projected more than 7” into the required width of the exit access corridor when fully open. Interview with the facility director at the time of the observation acknowledged the deficiency. Interview with the facility administrator and the facility director at the time of exit confirmed the deficiency. REF: 2012 NFPA 101, Sections 19.2.1, 7.2.1.4.3.1”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 52855 Based on observation and staff interview, the facility failed to ensure doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position unless held open by a release device in accordance with the 2012 NFPA 101, Life Safety Code. Failure to ensure self-closing doors close and latch could allow for the spread of smoke and fire leading to injury or death in the event of a fire. The deficiency affected two (2) of multiple doors. The deficiency affected all residents, staff, and visitors. The findings were: Observation on 09/23/2025 at 9:04 AM revealed the Emergency Department storage room ED123 was protected with a self-closing door due to the room being greater than 50 SF in size and the storage of flammable or combustible materials. Further observation revealed the self-closing door failed to close and latch, keeping the door in the closed position. Observation on 09/23/2025 at 9:09 AM revealed the Emergency Department soiled holding ED128 was protected with a self-closing door due to the room being greater than 50 SF in size and the storage of flammable or combustible materials. Further observation revealed the self-closing door failed to close and latch, keeping the door in the closed position. Interview with the facility director at the time of the observation acknowledged the deficiency. Interview with the facility administrator and the facility director at the time of exit confirmed the deficiency. REF: 2012 NFPA 101, Sections 19.3.2.1, 19.3.2.1.3, 8.7.1, 7.2.1.8”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 52855 Based on observation and staff interview, the facility failed to provide readily visible signs to mark exit access in all cases where the exit or way to reach the exit is not readily apparent to the occupants in accordance with section 7.10 of the 2012 NFPA 101, Life Safety Code. Failure to provide exit and directional signage in accordance with the 2012 NFPA 101 could impede egress leading to injury or death in the case of an emergency. The deficiency affected one (1) of multiple exit access corridors. The deficiency could affect all patients, staff, and visitors using the facility. The findings were: Observation on 09/23/2025 at 9:48 AM revealed the facility failed to provide readily visible exit signs to mark exit access at cross corridor doors between the Medical Surgical unit exit access corridor and the Admissions lobby, in accordance with section 7.10 of the 2012 NFPA 101, Life Safety Code. Observation on 09/23/2025 at 10:58 AM revealed the respirator storage room door was located or arranged so that it is likely to be mistaken for an exit. Further observations revealed the facility had provided signage for the door indicating the door was not an exit, however the signage was not in accordance with the 2012 NFPA 110 section 7.10.8.3.1. Interview with the facility director at the time of the observation acknowledged the deficiency. Interview with the facility administrator and the facility director at the time of exit confirmed the deficiency. REF: 2012 NFPA 101, Sections 19.2.10, 7.10, 7.10.8.3.1”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 52855 Based on observation and staff interview, the facility failed to maintain doors protecting corridors in accordance with 2012 NFPA 101, Life Safety Code. Failure to protect corridor openings could result in the obstruction of a corridor resulting in injury or death in the event of a fire. The deficiency affected one (1) of multiple corridor doors in the facility and could potentially affect all patients, staff and visitors in the area. The findings were: Observation on 09/23/2025 at 9:17 AM revealed the Trauma 2 door was a corridor door equipped with positive latching hardware. Further observations revealed the horizontal sliding door rebounded when closed, failing to keep the door in the closed position in accordance with the 2012 NFPA 101. Interview with the facility director at the time of the observation acknowledged the deficiency. Interview with the facility administrator and the facility director at the time of exit confirmed the deficiency. REF: 2012 NFPA 101, Section 19.3.6.3.5, 19.2.2.2.10.2 (5)”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 52855 Based on observation and staff interview, the facility failed to provide category 1 piped gas and vacuum systems with identification for shutoff valves in accordance with the 2012 NFPA 99, Healthcare Facilities Code. Failure to identify shutoff valves could lead to injury or death of patients utilizing the affected piped gases. The deficiency affected one (1) of multiple zone valve boxes. The deficiency could affect all patients utilizing rooms served by the zone valves. The findings were: Observations on 09/23/2025 at 10:10 AM revealed the zone valve box located in the OR exit access corridor serving endoscopy rooms 1 and 2 included shutoff valves without identification in accordance with the 2012 NFPA 99, Healthcare Facilities Code. Interview with the facility director at the time of the observation acknowledged the deficiency. Interview with the facility administrator and the facility director at the time of exit confirmed the deficiency. REF: 2012 NFPA 101, Section 19.3.2.4, NFPA 99, Sections 5.1, 5.1.11.2”