| 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) |
| K0902 | Gas and Vacuum Piped Systems - Other CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Other List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 5 (NFPA 99) This STANDARD is not met as evidenced by: Based on observation and staff interview, the facility failed to maintain the vacuum pump room in accordance with the 2012 NFPA 99, Life Safety Code. The failure to maintain the vacuum pump room as required could result in injury or death in an emergency. The deficiency affected one (1) of one (1) vacuum pump enclosures in the facility. The findings were: Observation on 4/26/22 at 10:25 AM in the vacuum pump room revealed that the facility was storing dirty linen inside of the room. NFPA 99 requires medical-surgical vacuum sources to be in a dedicated mechanical equipment area 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 99, Section 5.1.3.7.1.1(1) . |