| 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) |
| K0225 | Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This STANDARD is not met as evidenced by: 1. Based on observation and staff interview, the facility failed to maintain stairs in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain stairs as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of two (2) exits containing stairs from the facility. The findings were: Observation on 4/26/2022 at 8:54 AM at the side/employee entrance/exit revealed the concrete stair structure, had degraded over time leaving the tread on one stair with 7 1/2" of tread depth at the minimum measurement. Interview with the maintenance manager at the time of observation acknowledged that the depth of the stair tread was insufficient, 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: 19.2.2.3, 7.2.2, Table 7.2.2.2.1.1(b) 2. Based on observation and staff interview, the facility failed to maintain stair handrails in accordance with the 2012 NFPA 101, Life Safety Code. Failure to maintain stair handrails as required could delay egress resulting in injury or death during an emergency. The deficiency affected one (1) of two (2) exits containing stairs from the facility. The findings were: Observation on 4/26/2022 at 8:57 AM at the side/employee entrance/exit revealed that the stairway handrail was no longer attached to the ground, having rusted away. As an existing handrail, the handrail falls under the maintenance, inspection, and testing section of chapter 4, of the 2012 NFPA 101. Whereby any existing life safety feature shall be maintained. Interview with the maintenance manager at the time of observation acknowledged that the handrail was no longer attached to the ground, 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: 19.2.2.3, 7.2.2, 7.2.2.4.4.9, 4.6.12.1, 4.6.12.2, 4.6.12.3 . |