Grafton City Hospital, Inc.

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 43676 Based on observation and staff interview, it was determined the facility failed to maintain the soiled linen and rubbish chutes in accordance with NFPA (National Fire Protection Association) 82. Facility Census 9. Findings include: a) Observation on 10/01/24 at approximately 11:14 a.m., revealed the forth floor rubbish chute door would not latch properly when closed. b) Observation on 10/01/24 at approximately 11:14 a.m., revealed the first floor soiled linen chute door would not latch properly when closed. c) Interview with the Facilities Department Manager at the time of discovery verified these findings and also acknowledged by the Administrative team upon the exit conference on 10/01/24 at approximately 3:30 p.m. Based on observation and staff interview, it was determined the facility failed to provide doors protecting corridor openings that resisted the passage of smoke in accordance with NFPA (National Fire Protection Association) 101. Facility Census 9. Findings include: a) Observation on 09/30/24 at approximately 9:30 a.m., revealed holes in the Emergency Room trauma room corridor door around the door handle. b) Observation on 10/01/24 at approximately 1:02 p.m., revealed holes in the Human Resources Storage room door located in the basement. c) Observation on 10/01/24 at approximately 1:09 p.m., revealed the garbage room corridor door would not latch when closed. d) Interview with the Facilities Department Manager at the time of discovery verified these findings and also acknowledged by the Administrative team upon the exit conference on 10/01/24 at approximately 3:30 p.m. Based on observation and staff interview, the facility failed to ensure that smoke barriers were constructed and maintained to the appropriate fire resistance rating in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 9. Findings include: a) Observation on 10/01/24 at approximately 1:05 p.m., revealed a penetration in the firewall located in the basement near the garbage room door. b) Observation on 10/01/24 at approximately 1:11 p.m., revealed a penetration in the smoke wall in the materials management storage/breakroom c) Observation on 10/01/24 at approximately 1:16 p.m., revealed a penetration in the smoke wall in the material management storage room beside of the spare office. c) Interview with the Facilities Department Manager at the time of discovery verified these findings and also acknowledged by the Administrative team upon the exit conference on 10/01/24 at approximately 3:30 p.m.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 43676 Based on observation and staff interview, the facility failed to ensure that hazardous areas are protected and separated from other spaces in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all Patients, staff, and visitors in the areas referenced. Facility census 9. Findings include: a) An observation on 10/01/24 at approximately 1:09 p.m. revealed the Materials Management Storage/Breakroom was greater than 50 square feet and contained stored combustible materials did not have a door closure. b) An observation on 10/01/24 at approximately 1:17 p.m. revealed a Materials Management Storage room located beside of the spare office was greater than 50 square feet and contained stored combustible materials did not have a door closure. c) Interview with the Facilities Department Manager at the time of discovery verified these findings and also acknowledged by the Administrative team upon the exit conference on 10/01/24 at approximately 3:30 p.m. Based on document review and staff interview, the facility failed to ensure and maintain the fire alarm system in accordance with NFPA (National Fire Protection Association) 72. This deficient practice could affect all Patient’s, staff, and visitors in the areas referenced. Facility census 77. Findings include: a) During the facility life safety document review conducted on 09/30/24 between the hours of 8:30 a.m. and 3:00 p.m., revealed that the facility did not have any documentation of semi-annual smoke detector visual inspections. b) Interview with the Facilities Department Manager at the time of discovery verified this finding and was also acknowledged by the Administrative team upon the exit conference on 10/01/24 at approximately 3:30 p.m.”

“BUILDING SAFETY CFR(s): Except as otherwise provided in this section, the CAH must meet the applicable provisions and must proceed in accordance with the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6). (1) Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities Code do not apply to a CAH. (2) If application of the Health Care Facilities Code required under paragraph (e) of this section would result in unreasonable hardship for the CAH, CMS may waive specific provisions of the Health Care Facilities Code, but only if the waiver does not adversely affect the health and safety of patients. This Standard is not met as evidenced by: 43676 Based on observation and staff interview, the facility failed to properly store and conveniently located, to permit frequent cleaning of floors, walls, woodwork, windows, and screens, and to facilitate all necessary building and ground maintenance. Facility census 9. Findings include: a) Observation on 09/30/24 at approximately 9:06 a.m. revealed the third floor housekeeping closet unlocked. b) Observation on 09/30/24 at approximately 9:25 a.m. revealed the emergency room housekeeping closet unlocked. c) Interview with the Maintenance Director at the time of discovery verified the findings. The findings were also acknowledged by the upon the exit interview on 10/ /24 at”

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 32177 Based on observation, document review and staff interview it was determined the facility failed to maintain decontamination supplies in the Emergency Department (ED) for Chemical/Biological Disasters. This failure has the potential to cause harm to any Patient who presents to the hospitals ED. Findings Include: An observation of the Emergency Department (ED) on 09/30/24 at approximately 9:30 a.m. no decontamination equipment noted for chemical or biological disasters. Staff #1 and 2 stated in part, the last chemical disaster we had we called the fire department, and they came and decontaminated the patient. When asked where they store the shower and other emergency equipment for a chemical/Biohazards? They stated in part, I don’t think we have any. Staff #3 toured the ED in the presence of this surveyor and also noted there was no decontamination equipment in the ED. Staff #4 on 10/01/24 at approximately 11:50 a.m. came to the conference room and brought the policy for decontamination. They stated in part, I have taught the two [2] staff that were here yesterday that we do have decontamination equipment and that we keep it on the second floor. I have retaught the other staff. This surveyor explained the equipment must be readily available in the ED and they stated they were working to find a place to put shelving up. A review of the document titled “Decontamination Procedures” with a last revised date of 09/24, states in part, Grafton City Hospital aims to provide the best possible protection for employees, patients, and visitors from contamination by substances during patient decontamination and in the event of substance related disaster. This policy aims to outline the decontamination procedures that will be instituted whenever contamination is suspected from gases, particulate matter, dust, inhalation, radioactive Vapors, Chemicals, or Biohazard substances ...Direct the patient to the Decon area adjacent to the ED entrance.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 43676 Based on observation and staff interview, the facility failed to ensure that hazardous areas are protected and separated from other spaces in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all Patients, staff, and visitors in the areas referenced. Facility census 9. Findings include: a) An observation on 10/01/24 at approximately 1:09 p.m. revealed the Materials Management Storage/Breakroom was greater than 50 square feet and contained stored combustible materials did not have a door closure. b) An observation on 10/01/24 at approximately 1:17 p.m. revealed a Materials Management Storage room located beside of the spare office was greater than 50 square feet and contained stored combustible materials did not have a door closure. c) Interview with the Facilities Department Manager at the time of discovery verified these findings and also acknowledged by the Administrative team upon the exit conference on 10/01/24 at approximately 3:30 p.m.”

“Interior Wall and Ceiling Finish CFR(s): NFPA 101 Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________ This Standard is not met as evidenced by: 43676 Based on observation and staff interview, the facility failed to ensure that smoke barriers were constructed and maintained to the appropriate fire resistance rating in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all Patients, staff, and visitors in the areas referenced. Facility census 9. Findings include: a) Observation on 10/01/24 at approximately 1:05 p.m., revealed a penetration in the firewall located in the basement near the garbage room door. b) Observation on 10/01/24 at approximately 1:11 p.m., revealed a penetration in the smoke wall in the materials management storage/reakroom c) Observation on 10/01/24 at approximately 1:16 p.m., revealed a penetration in the smoke wall in the material management storage room beside of the spare office. c) Interview with the Facilities Department Manager at the time of discovery verified these findings and also acknowledged by the Administrative team upon the exit conference on 10/01/24 at approximately 3:30 p.m.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 43676 Based on document review and staff interview, the facility failed to ensure and maintain the fire alarm system in accordance with NFPA (National Fire Protection Association) 72. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 77. Findings include: a) During the facility life safety document review conducted on 09/30/24 between the hours of 8:30 a.m. and 3:00 p.m., revealed that the facility did not have any documentation of semi-annual smoke detector visual inspections. b) Interview with the Facilities Department Manager at the time of discovery verified this finding and was also acknowledged by the Administrative team upon the exit conference on 10/01/24 at approximately 3:30 p.m. .”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 43676 Based on observation and staff interview, it was determined the facility failed to provide doors protecting corridor openings that resisted the passage of smoke in accordance with NFPA (National Fire Protection Association) 101. Facility Census 9. Findings include: a) Observation on 09/30/24 at approximately 9:30 a.m., revealed holes in the Emergency Room trauma room corridor door around the door handle. b) Observation on 10/01/24 at approximately 1:02 p.m., revealed holes in the Human Resources Storage room door located in the basement. c) Observation on 10/01/24 at approximately 1:09 p.m., revealed the garbage room corridor door located in the basement would not latch when closed. d) Interview with the Facilities Department Manager at the time of discovery verified these findings and also acknowledged by the Administrative team upon the exit conference on 10/01/24 at approximately 3:30 p.m.”

“Rubbish Chutes, Incinerators, and Laundry Chu CFR(s): NFPA 101 Rubbish Chutes, Incinerators, and Laundry Chutes 2012 EXISTING (1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5. (2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7. (3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.) (4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use. 19.5.4, 9.5, 8.4, NFPA 82 This Standard is not met as evidenced by: 43676 Based on observation and staff interview, it was determined the facility failed to maintain the soiled linen and rubbish chutes in accordance with NFPA (National Fire Protection Association) 82. Facility Census 9. Findings include: a) Observation on 10/01/24 at approximately 11:14 a.m., revealed the forth floor rubbish chute door would not latch properly when closed. b) Observation on 10/01/24 at approximately 11:24 a.m., revealed the first floor soiled linen chute door would not latch properly when closed. c) Observation on 10/01/24 at approximately 11:29 a.m., revealed the basement soiled linen chute door would not latch when closed. d) Interview with the Facilities Department Manager at the time of discovery verified these findings and also acknowledged by the Administrative team upon the exit conference on 10/01/24 at approximately 3:30 p.m.”