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)
K0761 Maintenance, Inspection & Testing - Doors

Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80)


This STANDARD is not met as evidenced by:
1. Based on observation and staff interview, the facility failed to maintain fire-rated doors and frames in accordance with the 2012 NFPA 101, Life Safety Code, and 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. The failure to maintain fire-rated doors and frames as required could result in injury or death in an emergency. The deficiency affected one (1) of numerous fire-rated doors and frames throughout the facility. The findings were: Observation on 4/26/2022 at 8:29 AM of the west storage corridor door revealed a hole that penetrated through the rated storage 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: 19.7.6; 4.6.12, 7.2.1.15.2 2010 NFPA 80, Section 5.2.4.2(1) 2. Based on observation and staff interview, the facility failed to maintain fire-rated doors and frames in accordance with the 2012 NFPA 101, Life Safety Code, and the 2010 NFPA 80, Standard for Fire Doors and Other Opening Protectives. The failure to maintain fire-rated doors and frames as required could result in injury or death in an emergency. The deficiency affected one (1) of numerous fire-rated doors and frames throughout the facility. The findings were: Observation on 4/26/2022 at 9:20 AM at the central supply room door revealed that the UL listing frame tag had been painted over. . Interview with the maintenance manager at the time of observation acknowledged the missing tag, 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: 19.2.2.5, 7.2.4.3.1, 8.3.3.1, 8.3.3.2, 8.3.3.2.2 .