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 09/29/2016
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)
C0225 MAINTENANCE
CFR(s): 485.623(b)(4)

[The CAH has housekeeping and preventive maintenance programs to ensure that- the premises are clean and orderly;


This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to ensure the floors in 3 of 5 patient areas (hallway, entrance, and patient room) were kept clean and/or safe from potential fall hazards. The findings were: Observation of the facility on 9/26/16 at 2:30 PM showed the facility main hallway and hospital entrance floor were carpeted. The following concerns were identified: a. The carpet in the hallway throughout the facility and the hospital entrance area showed multiple darkened and whitish stains. In addition, there were prominent wrinkles in the carpet in front of the nursing station that posed a potential trip hazard. b. Measurements of these areas on 9/28/16 at 10:30 AM showed the largest stain measured 54 inches in diameter. The 8 wrinkles in the carpet remained present, and the largest wrinkle measured 69 inches across. In addition, there were multiple blackened scuff marks over the entire floor in patient room #3. c. Interview with the maintenance assistant on 9/28/16 at 10:05 AM revealed the carpet in the hospital hallways and conference room was about 20 years old and had been attempted to be cleaned and was "way beyond it's useful life." d. Interview with the maintenance director on 9/28/16 at 1:05 PM confirmed the facility was unable to remove the carpet stains and wrinkles, and the carpet needed to be removed as the surface was not cleanable and the unsafe wrinkles could not be removed. He further stated one contractor had made an offer for removal of the carpet and replacement with a non-carpet cleanable floor. However, he confirmed the facility failed to have a plan with a timeframe to replace the uncleanable carpet.