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)
K0531 Elevators
CFR(s): NFPA 101

Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter's Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter's Service Requirements of ASME/ANSI A17.3. (Includes firefighter's service Phase I key recall and smoke detector automatic recall, firefighter's service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3


This STANDARD is not met as evidenced by:
Based on observation and staff interview, the facility failed to maintain elevators in accordance with the 2012 NFPA 101, Life Safety Code. The failure to maintain elevators as required could result in injury or death during an emergency. The deficiency affected one (1) of one (1) elevators. The findings were: Interview on 4/25/22 at 4:30 PM with the maintenance manager revealed that the monthly testing of the elevator fire fighter recall system had not been completed. Further interviews revealed the elevator does not move more than 25 ft, but is equipped with a fire fighter recall system. Interview with the maintenance manager at the time of observation acknowledged the deficiency, and indicated they were not aware of the requirement. Interview with the director of nursing at the time of exit acknowledged the deficiency. Ref: 2012 NFPA 101: Sections: 19.5.3, 9.4.6.2, 4.6.12.1, 4.6.12.4 .