OSF Saint Katharine Medical Center

“PHYSICAL ENVIRONMENT CFR(s): 482.41 The hospital must be constructed, arranged, and maintained to ensure the safety of the patient, and to provide facilities for diagnosis and treatment and for special hospital services appropriate to the needs of the community. This Condition is not met as evidenced by: 20224 Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of a Recertification Survey conducted on July 21-22, 2026, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. See the Life Safety Code deficiencies identified with K-Tags.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36774 Based on document review and interview, for 1 of 3 patients’ (Pt. #33) clinical records reviewed regarding use of non-violent restraints, the hospital failed to ensure that a renewal order was obtained, as required by policy. Findings include: 1. On 7/23/2026, the clinical record for Pt. #33 was reviewed with E #24 (Professional Development Coordinator/Educator, Register Nurse/RN). On 7/5/2026, Pt. #33 was admitted to the hospital’s ICU (intensive care unit) due to metabolic encephalopathy (type of brain dysfunction). The clinical record indicated that from 7/5/2026 at 8:11 PM through 7/7/2026 at 10:00 AM, Pt. #33 was placed in non-violent restraints due to restlessness and pulling medical device. The clinical record lacked a renewal order for the continuation of non-violent restraints on 7/6/2026, from 8:00 PM through 7/7/2026. 2. On 7/23/2026, the hospital’s policy titled, “Restraint and Seclusion Management (4/2026)” was reviewed and indicated, “... Process: 1. Obtain... renewal orders for restraint... based on patient assessment and according to the following... Non-violent/Non-Self Destructive Behavior Restraint. Order Renewal Frequency Required - Once daily, every calendar day...” 3. On 7/23/2026 at approximately 10:30 AM, findings were discussed with E #24 (Professional Development Coordinator/Educator, RN). E #24 stated that a renewal order should have been obtained from the physician for the continuation of restraints used on Pt. #33. E #24 stated that the renewal order was missing.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 36774 Based on document review and interview, for 1 of 3 patients’ (Pt. #32) clinical records reviewed regarding use of violent restraints, the hospital failed to ensure that the face-to-face evaluation within 1 hour after initiation of violent restraints was documented, as required by policy. Findings include: 1. On 7/23/2026, the clinical record for Pt. #32 was reviewed with E #24 (Professional Development Coordinator/Educator, Registered Nurse/RN). On 7/16/2026, Pt. #32 was brought to the ED (emergency department) due to altered mental status and alcohol intoxication. The clinical record indicated that on 7/16/2026, Pt. #32 was placed in violent restraints from 2:40 AM through 12:20 PM due to violent behaviors. The clinical record lacked documentation that a face-to-face evaluation was conducted within one hour after initiation of violent restraints. 2. On 7/23/2026, the hospital’s policy titled, “Restraint and Seclusion Management” (4/2026) was reviewed and indicated, “... Face-to-face Assessment of Restraint for Violent and/or Self-Destructive Behavior and/or Seclusion: 1. When a restraint and/or seclusion is used for the management of Violent... Behavior, ensure the patient is seen face-to-face within one hour after the initiation of the intervention: a. By a physician, authorized advanced practice registered nurse, authorized physician assistant, or authorized supervisory registered nurse who has received additional training... d. The evaluation is documented...” 3. On 7/23/2026 at approximately 10:30 AM, findings were discussed with E #24 (Professional Development Coordinator/Educator, RN). E #24 stated that a physician should conduct a 1-hour face-to-face evaluation after initiation of violent restraints on Pt. #32. E #24 stated that there was no documentation regarding the evaluation within Pt. #32’s record.”

“LIFE SAFETY FROM FIRE CFR(s): 482.41(b)(1)(2)(3) (b) Standard: Life safety from fire. (1) Except as otherwise provided in this section— (i) The hospital 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.) Outpatient surgical departments must meet the provisions applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. (ii) Notwithstanding paragraph (b)(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. (2) In consideration of a recommendation by the State survey agency or Accrediting Organization or at the discretion of the Secretary, may waive, for periods deemed appropriate, specific provisions of the Life Safety Code, which would result in unreasonable hardship upon a hospital, but only if the waiver will not adversely affect the health and safety of the patients. (3) The provisions of the Life Safety Code do not apply in a State where CMS finds that a fire and safety code imposed by State law adequately protects patients in hospitals. This Standard is not met as evidenced by: 20224 Based on observation during the survey walk-through, staff interview, and document review during the Life Safety code portion of a Recertification Survey conducted on July 21-22, 2026, the surveyors find that the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code. See the Life Safety Code deficiencies identified with K-Tags.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 40079 A. Based on observation, document review, and interview, it was determined that for 3 of 4 (E #28/Circulating Nurse, E#29/Certified Scrub Technician, and E#30/Certified Registered Nurse Anesthetist) staff observed in the Operating Room (OR), the Hospital failed to ensure adherence to the required attire while in the OR, as required by policy. Findings include: 1. On 07/22/2026 between 10:35 AM to 11:15 AM, an observational tour of the OR suites was conducted accompanied by the Manager of OR/Surgical Services (E #27). During the tour of OR #1, a set up for a procedure was observed. Disinfection of OR #1 was complete with an open sterile field with surgical equipment. E #28, E #29, and E #30 were in the OR all wearing hair bonnets, however, there were 2-3 inches of hair exposed at the nape and sides of the face. Additionally E #29, was wearing a mask that was not tied properly to form an appropriate seal. 2. On 07/22/2026, the hospital’s policy titled, “Dress Code for Periprocedural Areas” (revised 02/03/2026) was reviewed and required, “2. Surgical attire is worn in the semi-restricted and restricted areas of the surgical/procedural environment ... Masks: ... c. The mask should completely cover the mouth, nose, and chin and fit snugly in a manner that prevents gaps at the sides of the mask. 3. Hats: a. Completely cover head and facial hair, including sideburns, necklines, and beards.” 3. The findings were discussed with the Manager of OR/Surgical Services (E #27) on 07/22/2026 at approximately 11:30 AM. E #27 stated that surgical attire is worn to reduce the risk of infections, all staff must have all hair covered, and masks should be tied appropriately to form a proper seal. B. Based on observation, document review, and interview, it was determined that for 2 of 3 (E #28 and #29) staff observed in the Operating Room (OR #1) during the disinfection of the OR, the hospital failed to ensure that staff followed the proper procedure for disinfection of the OR and failed to perform hand hygiene as required by policy. This has the potential for cause cross-contamination. Findings include: 1. During the tour of OR #1 from 10:35 AM to 11:00 AM, disinfection and set-up for a procedure was initiated and the following was observed: -At approximately 10:35 AM, E #28 was observed counting used surgical gauze from the previous procedure, with visible blood, and placing each gauze in the designated receptacle. E #28 removed their soiled gloves and discarded them, then donned a new set of gloves, without using the alcohol-based rub. E #28 then proceeded to open a cabinet drawer to retrieve clean bags for the trash bins. -At approximately 10:40 AM, E #28 was observed using disinfectant wipes to clean three mayo stands (small stainless-steel tray for surgical equipment), E #28 cleaned the top of the first 2 trays, then the bottom of the trays, then went to clean the top of the 3rd tray then the bottom. E #29 was also disinfecting the OR and was observed removing their soiled gloves and donning new gloves without performing hand hygiene in between disinfection tasks. E #28 and E #29 completed the disinfection of the OR, however, the overhead surgical lights were not cleaned. -At approximately 10:45 AM, E #28 dropped the strap for the OR table on the floor which was still being mopped by another staff (E #29). E #28 picked up the contaminated strap and placed it on top of the OR bed that had already been disinfected. 2. On 7/24/2026, the hospital provided a guideline that included the following, “Hand Hygiene is the most important and most basic component in the prevention and control of the transmission of infection. ... If hands are not visibly soiled ... health care team members should use an alcohol-based hand rub for routinely decontaminating hands in these situations: Before and after direct contact with a patient or the patient’s environment. Before putting on gloves. Immediately after removing gloves... References: 1. Association of Peri-Operative Registered Nurses (AORN 2026). 2. Centers for Disease Control (CDC updated 2019). “ 3. On 7/24/2026, the hospital provided guidelines that included the following, “The content in Clinical Skills is evidenced based and intended to be a guide to clinical practice ... Procedure OR (Operating Room) Care ... 6. Do damp dusting on all horizontal surfaces (e.g., furniture, surgical lights, equipment) ... Complete damp dusting before case carts, supplies, and equipment are brought into the OR. Damp dust from top to bottom using a clean, low linting cloth with a disinfectant ... Procedure or Care ... 3. Clean the OR or procedure room in an organized manner, moving in a clockwise or counterclockwise direction in conjunction with a clean-to-dirty and top-to-bottom method. References: 1. Association of Peri-Operative Registered Nurses (AORN 2026). 2. Centers for Disease Control (CDC updated 2019). “ 4. The above findings were discussed with the Manager of OR/Surgical Services (E #27) on 07/22/2026 at 11:32 AM. E #27 stated that staff are required to use alcohol based rub after removing soiled gloves and prior to moving to another task. E #27 stated that when completing disinfection of the OR’s equipment, it should be done from clean-to-dirty, or top-to-bottom. E #27 stated when any object falls on the floor, it should be disinfected before placing on a equipment that has been disinfected. C. Based on observation, document review, and interview, for 1 of 1 staff (E #30/CRNA/Certified Registered Nurse Anesthetist) observed, the hospital failed to ensure use of antiseptic technique when administering intravenous (IV) medications in the operating room (OR). Findings include: 1. On 07/22/2026, an observational tour of the operating room was conducted. At approximately 11:09 AM, in OR #1, E #30 was observed administering a total of three medications to the patient’s intravenous port. E #30 did not disinfect the IV port prior to administering the medications with an antiseptic wipe. 2. On 7/24/2026, the hospital provided a guideline and included, “The content in Clinical Skills is evidenced based and intended to be a guide to clinical practice ... Access ports, including needleless connectors, should be first disinfected before the administration of IV push medications. References: 1. AORN 2026. 2. CDC updated 2019. “ 3. The above findings were discussed with the Manager of OR/Surgical Services (E #27) on 07/22/2026 at 11:34 AM. E #27 stated that when administering any medication by IV, the port should be disinfected to reduce risk for infection. D. Based on observation, document review, and interview, the Hospital failed to ensure sterile instruments were safe for use and that supplies were checked for expiration date as required. This can potentially affect any patient presenting to the Obstetrics outpatient clinic requiring D&C (dilatation and curettage/procedure to obtain tissue from a female body part). Findings include: 1. On 07/23/2026 at approximately 11:00 AM, an observational tour of the Obstetrics Outpatient Clinic was conducted along with the Director of the Obstetrics Outpatient Clinic (E #31). In the supply room, D&C forceps (specialized surgical instruments used during D&C) in peel packs were stored inside plastic bins. There was a total of four peel packs found, one peel pack was ripped open exposing the sterilized forceps, three of the peel packs had brown spots of an unknown substance on the paper side of the package. There were two expired (06/02/2026) Cancer detection kits. 2. The hospital’s policy titled, “Reprocessing Surgical Instrumentation” (revised 11/20/25) was reviewed and required, “Peel packs: Pouches used for small, lightweight, low-profile items that provide effective sterilization, safe handling and storage of all items until the moment they are used ... Storage: 2. Outside of SPD (Sterilization Process Department) and procedural areas: a. Store in a manner to protect package integrity ... iv. Items are stored to prevent crushing ... puncturing of packaging.” 3. The hospital’s policy titled, “Hospital Outpatient Department Equipment and Medication Readiness Tracking” (revised 12/22/2025) was reviewed and required, “To ensure availability of medications, supplies, and properly functioning equipment. 1. The availability, functionality, and quality control monitoring of medications and equipment is assessed on an ongoing basis ... 1. Licensed personnel or licensed provider must assess all medications/vaccines, all other checks may be delegated to non-licensed personnel. 2. Check the following items if present ... e. Medical Supplies.” 4. The hospital’s “Job Description for Medical Office Assistant-Clinics” (undated) was reviewed and required, “Primary Job Responsibilities and Accountability: ... Prepares, cleans and maintains exam rooms and is responsible for monitoring and maintaining current supply inventory.” 5. The above findings were confirmed with E #31 during the observational tour. E #31 stated that the medical office assistant is assigned the task to check the supply room for any expired items or damaged equipment. E #31 stated that they are not sure why these expired supplies and damaged peel packs were not removed.”

“On July 21-22, 2026, the Life Safety Code portion of a Re-Certification Survey was conducted. The surveyor was accompanied during the survey walk-through by the following provider representatives: Facilities Director (FD) Facilities Electrician (FE) Environmental Health and Safety Officer (EHSO) The hospital was observed to consist of an original structure and several additions. All portions of the hospital were observed to be of Type II (222) construction and to be fully covered by an automatic sprinkler system. The facility was surveyed as an existing health care occupancy under the 2012 Edition of the NFPA 101 Life Safety Code, including Chapter 19. Also included in the survey was the following off-site facility; see the separate CMS Form 2567 for: Commerce Towers Unless otherwise noted, those code sections listed herein that do not include a reference to a specific NFPA code and year of issue (such as NFPA 70 2011) are taken from the 2012 Edition of the NFPA 101 Life Safety Code. Unless otherwise noted, all deficiencies cited herein were found through observation during the survey walk-through, staff interview, or document review. The requirements of 42 CFR Subpart 482.41 Physical Environment, are NOT MET as evidenced by the deficiencies cited under the following K-Tags.”

“Egress Doors CFR(s): NFPA 101 Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 This Standard is not met as evidenced by: 20224 Based on observation, means of egress doors are locked using methods that do not comply with the code. Failure to install locking devices for means of egress doors in full compliance with all requirements can result in building occupants not being able to reach an area of safety or an exit during a fire/smoke event. Findings include: On 07/21/2026 at 11:30 am while accompanied by FE, 2nd floor cross corridor door entering the OB contains a delayed egress lock. The delayed egress locking arrangment was observed to lack signage to comply with 7.2.1.6.1.1(4).”

“Illumination of Means of Egress CFR(s): NFPA 101 Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8 This Standard is not met as evidenced by: 20224 Based on random observation during the survey walk-through, not all exit locations are provided with illumination to comply with NFPA-101, Sections 19.2.8, 7.8 and 7.9. These deficiencies could affect all persons in the facility required to utilize the exit by preventing safe and unimpeded access to the public way. The finding is: On 07/21/2026 at 11:20 am accompanied by the FE two light switches within the exit enclosure provided a manual means to discontinue illumination within a means of egress which does not comply with 19.2.8, 19.2.9, 7.9.1.2, 7.9.1.3, 7.9.2.3. for lighting to be of instantaneous operation so as not to leave the exit path in darkness. Location observed 4th floor North Stair, light switch turned off the lights on the 4th and 5th floors.”

“Emergency Lighting CFR(s): NFPA 101 Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1 This Standard is not met as evidenced by: 20224 Emergency lighting to be located in critical care areas is not maintained. This deficient practice could affect patients, staff and visitors if emergency lighting system is not available when needed during loss of normal power. Finding includes: On 07/22/2026 at 11:58 am accompanied by the EHSO battery powered emergency lighting was not provided within a critical care patient area to comply with NFPA 99, 2012, 6.3.2.2.11 and NFPA 70 2011, 517.63. Location observed Endo Procedure room #1 #E152”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 20224 Based on observation, exit signs were not provided, were not fully visible, or incorrectly identified paths of egress. Failure to provide exit signs to identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition. Findings include: On 07/22/2026, while accompanied by the FE, corridors were observed to lack exit signs to clearly identify access to at least two remote means of egress from the building to comply with 19.2.4.3, 19.2.10 and 7.10. Locations observed: 1. At 9:10 am 1st floor non sleeping patient care suite SC 1-2 lack an exit sign leading to the corridor to comply with 19.2.5.7.3.2 (B). 2. At 9:20 am 1st floor east west corridor serving North Stair lacks signage at the west end to comply with 7.10.1.5. 3. At 9:22 am 1st floor corridor west end leading to South Stair lacks signage to comply with 7.10.1.5.”

“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: 20224 Based on observation during the survey walk-through, hazardous areas are not separated by a minimum fire resistance construction. Failure to separate hazardous areas (which represents a degree of hazard greater than that normal to the general occupancy due to quantity and density of materials) from required means of egress paths can compromise the safety of occupants if a fire were to originate at the stored material compromising the use of the adjacent means of egress for exiting. Finding includes: A. On 07/22/2026 at 9:40am while in the company of EHSO it was observed that combustibles are being stored in a location not qualifying as hazardous areas/room. Material included gurneys with matresses, wheelchairs with gas cylindars attached. The room is open to a small storage room containing shelves with plastics and boxed items. This condition does not comply with NFPA 101 19.3.2.1, 19..3.2.1.4, 19.3.2.1.5(7) and 8.7.1. Location observed, 1st floor Staff Lounge E137. B. On 07/22/2026 at 9:50am while in the company of the EHSO, a means of egress vestibule between suites was observed used as storage which does not comply with 19.3.2.1.2, 7.5.1.6 and 8.4 for doors . Location observed 1st floor vestibule serving as a designated egress between the Endoscopy suite and the Surgery suite. C. On 07/21/2026 at 11:48 am accompanied by the FE storage of combustibles were observed on the 5th floor landing of the East Stair.”

“Fire Alarm System - Initiation CFR(s): NFPA 101 Fire Alarm System - Initiation Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse’s stations or other continuously attended staff location, provided alarm boxes are visible, continuously accessible, and 200’ travel distance is not exceeded. 18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5 This Standard is not met as evidenced by: 20224 Not all portions of the building fire alarm system provide a means of activation within the path of egress to an exit. These deficiencies could affect all patients, staff, and visitors in the building because the lack of an activation device could delay them from being aware of fire conditions. Findings include: A. On 07/22/2026 at 10:50 am accompanied by the EHSO, Exit doors from building stories or fire compartments were observed that lack fire alarm pull manual stations and smoke detection within 5’-0” either side of the door as required by 19.3.4, 9.6.2. and NFPA 72 2010 17.14.6, 17.7.5.6.5.1. Locations observed include: 1. 1st floor South Stair (indicated on life safety floor plan horizontal exit) to Corridor #176. 2. 1st floor South Stair (indicated on life safety floor plan horizontal exit) from Waiting area to pair of cross corridor doors. B. On 07/21/2026 at 9:10 am accompanied by the EHSO, corridor adjacent to the North Stair contains a manual pull station located 18’ from the exit stair which does not comply with NFPA 72 2010, 17.14.6 C. On 07/21/2026 at 9:00 am accompanied by the EHSO, corridor from surgery leading to the South Stair 2-hour fire rated enclosure lacks a manual pull station located 5’’ from the entry door to the 2-hour fire rated enclosure ( exit passageway) which does not comply with NFPA 72 2010, 17.14.6”

“Fire Alarm - Control Functions CFR(s): NFPA 101 Fire Alarm - Control Functions The fire alarm automatically activates required control functions and is provided with an alternative power supply in accordance with NFPA 72. 18.3.4.4, 19.3.4.4, 9.6.1, 9.6.5, NFPA 72 This Standard is not met as evidenced by: 20224 Based on document review and staff interview, not all of the control functions of the fire alarm system are operating as required. This deficient practice could affect patients, staff, and visitors during a fire event. The finding is: A. On 07/22/2026, at 10:35 a.m. accompanied by the FE record document review concerning testing of the fire alarm system showed the elevators failed to recall to the alternate level during testing. This condition does not comply with 2010 edition of NFPA 72, Section 21.3.12.2 and 2008 edition, ASME 17.1, 2.27.3.2.4. Based on observation, not all fire alarm initiation devices are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building, the fire alarm could fail to activate under emergency conditions. The finding is: B. On 07/21/2026 at 1:42 pm while accompanied by the FE, observation determined that fire alarm initiating devices (smoke detectors) are lacking in areas which can delay activation of the fire alarm system and does not comply with NFPA 72 2010 17.7.4. Location observed: Surveyor informed that the 3rd floor waiting room 323 door to corridor remains open.”

“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: 20224 Based on document review and staff interview, not all portions of the fire alarm are operating as required. This deficient practice could affect patients, staff, and visitors in the building because they could be unaware of a fire condition if the fire alarm is not fully operational. Findings include: On 07/22/2026, at 10:45 a.m. accompanied by the FE Record document review concerning the testing and maintenance of the fire alarm system showed multiple fire alarm notification devices had failed annual testing with no indication of correction.”

“Sprinkler System - Installation CFR(s): NFPA 101 Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1) This Standard is not met as evidenced by: 20224 Based on observation the facility failed to maintain the enclosure for quick response of fire protection appliances. Failure to install and maintain this installation could result in delayed response and fire suppression. This deficient practice could affect patients, staff and visitors during a fire event. Findings include: On 07/21/2026 in the company of the FD side wall sprinkler heads were observed located on one side of the room. Ceiling mounted booms appear to interrupt the water discharge from reaching a hazard located on the oposite side of the room at the floor level, this does not appear to comply with. NFPA 13, 2010, 8.7.5.3.1. Locations observed 1. At 1:45 pm 1st floor OR #2 2. At 1:50 pm 1st floor Cystoscopy”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 20224 Based on document review not all components of the HVAC system are functioning as required. This deficient practice could affect patients, staff, and visitors during a fire event if the HVAC system contributes to the distribution of smoke through the building. Findings Include: On 07/22/2026, at 10:40 a.m. accompanied by the FE and FD record document review concerning testing of the fire alarm system revealed activation of a duct smoke detector for the North Annex A.H.U. failed to shut down the supply fan(s). This condition does not comply with 2012 Edition of NFPA 90A Chapter 6.4.3.1.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 20224 Based on document review, The facility failed to provide records of required procedures needed to follow during a fire emergency. Failure to maintain records may result in inadequate preparedness during an actual emergency, which may affect patients, staff and visitors. Findings include: A. On 07/22/2026 at 12:30 p.m., accompanied by the FD during document review, it was determined the facility failed to provide documentation demonstrating the facility conducts fire drills that indicate every area of the Facility is covered. The failure to conduct drills once per shift per quarter to cover all areas of the facility leaves personnel unfamiliar with the signals and required emergency actions under varied conditions to comply with 19.7.1.2 B. On 07/22/2026 at 12:37 p.m., accompanied by the FD during document review, it was determined the facility failed to provide documentation demonstrating while during fire drills the fire alarm signal was transmited in accordance with NFPA 101, 2012 Edition, Section 19.7.1.4.”

“Maintenance, Inspection & Testing - Doors CFR(s): 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: 20224 Based on observation and document review, fire and smoke doors are not maintained in accordance with Code requirements. Failure to conduct and document fire and smoke door inspection and maintenance can compromise the safety of any building occupants if the door assemblies are not maintained as intended to restrict the spread of fire & smoke during a fire emergency. Finding includes: On 07/22/2026 at 12:55 pm accompanied by the FD documentation review for the Annual Fire and Smoke Door Inspections was not complete to comply with Section 19.7.6, 8.3.3.1, 7.2.1.15, and 2010 Edition of NFPA 80, Section 5.2.4.1 and 5.2.4.2. 1. There is no indication on the inspection report that door assemblies are inspected from both sides to assess the overall condition (NFPA 80, 2010, 5.2.4.1.) 2. There is no indication on the inspection report that each door assembly contains door hardware components appropriate to the function of the door [NFPA 80, 2010, 5.2.4.2. (3), (4), (6), (7), (8), (9), (11)].”

“Electrical Systems - Other CFR(s): NFPA 101 Electrical Systems - Other List in the REMARKS section any NFPA 99 Chapter 6 Electrical 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 6 (NFPA 99) This Standard is not met as evidenced by: 20224 Based on observation and staff interview during the facility walk through, not all electrical equipment is installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building if the staff is unable to de-energize electrical equipment during an emergency or routine maintenance. Findings include: A. On 07/22/2026, at 10:15 a.m. while accompanied by the facility director FD staff interview determined the Cath Lab lacks a battery powered emergency luminaire as required by 2012 edition of NFPA 99, 6.3.2.2.11.1. B. On 07/21/2026 between 11:15 a.m. - 12:30 p.m. while accompanied by the facility electrician FE the surveyor observed electrical branch circuit panels and disconnecting means that were not identified to their clear, specific use as required by 2011 edition of NFPA 70 Articles 408.4 , and 110.22. Examples include: a. Elevator penthouse: branch circuit disconnecting means for elevator car lights. b. Fourth floor mechanical room across from directors office: variable frequency drives for air handling unit fans. c. Fourth floor mechanical space between rooms 420 and 424: Critical branch circuit panel lacks circuit directory.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3 This Standard is not met as evidenced by: 20224 Based on observation during the facility walk through, not all components of the essential electrical system are tested and maintained as required. This deficient practice could affect patients, staff, and visitors during an interruption of normal or emergency power. Findings include: On 07/21/2026 at 1:15: p.m. while in the company of the FE, observation determined the battery powered emergency light in the generator room was not functional. This is not in compliance with 2010 edition of NFPA 110 Chapter 7.3.1.”

“Gas Equipment - Cylinder and Container Storag CFR(s): NFPA 101 Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum “CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING.” Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99) This Standard is not met as evidenced by: 20224 Based on observation the facility failed to provide protected storage for medical gas cylinders. This deficient practice could result in the uncontrolled spread of fire which may affect patients, staff and visitors. The finding is: A. On 07/21/2026 at 11:24 am accompanied by FE it was observed that approximately 28 e size oxygen tanks were both attached to the back of wheelchairs, C.O.W.s and within racks. This condition does not comply with the proper method of restraint for oxygen cylinders per NFPA 99, 2012, 11.3.2.3, 11.3.2.6, 19.3.2.4 and 8.7.1. Location observed: Floor 3 North Room 329 B. On 07/21/2026 at 11:24 am accompanied by FE it was observed empty, partial and full cylinders are not stored in a separated manner within the same enclosure to comply with NFPA 99, 2012 11.6.5.2. There is no signage for cylinders which makes it clear which group is empty or full or partial since there is no separation. This condition does not comply with NFPA 99, 2012, 11.6.5.3 .”