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 531311 (X3) Date Survey Completed 11/15/2011
Name of Provider or Supplier Crook County Hospital Street Address, City, State 713 Oak Street, Sundance, 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)
K0047 LIFE SAFETY CODE STANDARD
CFR(s): NFPA 101

Exit and directional signs are displayed in accordance with section 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1


This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to ensure 6 of 14 emergency exit lights were properly illuminated. The findings were: Observations on 11/15/11 between 11:45 AM and 2:48 PM revealed six emergency exit lights had one of two light bulbs burned out in the following locations: a. Over the door between the kitchen and the staff dining room. b. Over the door between the kitchen and the main hallway. c. Over the main entrance into the reception area. d. In the hallway by the administration office and cross corridor doors. e. Over the door between the emergency room hallway and the ambulance area. f. Over the door between the ambulance area and the ambulance garage. Interview with the maintenance manager at the time of the observations confirmed the bulbs were burned out. Reference: NFPA 101, Life Safety Code, 2000 edition. 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10. 7.10.5.1 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Setion 7.8. 7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less that 0.2 ft-candles.