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 10/05/2016
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)
K0000


This STANDARD is not met as evidenced by:
Requirements for Hospitals Section 42 CFR 482.41 (b) except as otherwise provided in the section, the facility must meet the applicable provisions of the 2000 Edition of the Life Safety Code, Existing Health Care of the National Fire Protection Association. The facility was a fully sprinklered, one-story building of Type II (111) construction built in 1960. The building was equipped with a supervised automatic wet sprinkler and dry sprinkler system with an addressable fire alarm system. The facility had a capacity of 18 certified Medicare and Medicaid beds with a census of 4.