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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.

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.

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

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.