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 04/26/2022
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)
K0223 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:
1. Based on observation and staff interview, the facility failed to maintain doors with self-closing devices in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain doors with self-closing devices as required could result in injury or death during an emergency. The deficiency affected two (2) of numerous doors with self-closing devices. The findings were: Observation on 4/26/2022 at 8:29 AM at the west storage door revealed the self-closing door was held open with a heavy object. Further observation at the kitchen storage self-closing door found that its door handle wrapped around the rooms shelving holding the door ajar. Interview with kitchen staff found that the door is kept open as described during the day and is closed at night. Interview with the maintenance manager at the time of observation acknowledged the doors being held open, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.2.2.2.1, 7.2.1.8.1 2. Based on observation and staff interview, the facility failed to maintain doors with self-closing devices in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain doors with self-closing as required could result in injury or death during an emergency. The deficiency affected three (3) of numerous doors with self-closing devices. The findings were: Observation on 4/26/2021 at 9:35 AM at the electrical mechanical room door revealed the the self-closing door failed to operate as designed. When dropped tested with no initial motion the door failed to shut and latch. Additional observation at 9:46 AM found the self-closing door separating the former waiting area (now office) from the corridor, found that the door failed to shut and latch when drop tested with no initial motion. Additional observation at 10:33 AM found the self-closing door separating the ambulance garage from the rear corridor unable to latch, due to missing hardware on the door frame. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. REF: 2012 NFPA 101, Sections: 19.2.2.2.1, 7.2.1.8 .