OSF Saint Luke Medical Center

“COMPLIANCE STATE AND LOCAL LAWS AND REGS CFR(s): All patient care services are furnished in accordance with applicable State and local laws and regulations. This Standard is not met as evidenced by: 45565 A. Based on record review and staff interview, the facility failed to report allegations of abuse to the Department within 24 hours after obtaining a report of alleged abuse. Findings include: 1. The incident and adverse event log was reviewed on 5/6/2026 at approximately 9:00 AM. An entry on 4/28/2026 at 2:00 PM, with Pt #11’s name and medical record number was observed and stated, “Security Guard very rude to pt which was a 5-year-old child. Pt attempted to bite him and guard said, “I bipped him in the head twice. I lost my patience.” He said, “child is out of control I should not have to sit here and deal with him, this is not (expletive) my job. I’m losing my patience.” 2. A follow-up entry to the log by the Emergency Department Manager (E #11) dated 4/28/2026 at 2:58 PM stated, “Referred to Security Manager.” Another follow-up entry to the log by the Security Manager (E #12) dated 5/4/2026 at 11:59 AM stated, “I spoke with (E #13) regarding the MIDAS report that was submitted...” 3. The Policy titled “Allegations of Abuse or Neglect While Patients are Receiving Care: Illinois” (Effective 5/22/2025) states, “...POLICY ...9. Upon a designated Facility administrator receiving a report from any Facility administrator, agent, Mission Partner or medical staff member of the Facility stating their reasonable belief that any patient with whom such individual has had direct contact has been subjected to abuse in the Facility: a. Event is reported to Illinois Department of Public Health (IDPH) within 24 hours after the designated Facility administrator receives such report ...” 4. During an interview with the Quality and Safety Manager (E #7) on 5/6/2026 at approximately 1:35 PM, E #7 noted the allegation was not reported to IDPH within 24 hours stating, “We did not have enough information yet.” B. Based on record review and staff interview, the facility failed to ensure the alleged victim’s safety by removing suspected violators from further patient contact during the hospital’s internal review. Findings include: 1. The incident and adverse event log was reviewed on 5/6/2026 at approximately 9:00 AM. An entry on 4/28/2026 at 2:00 PM, with Pt #11’s name and medical record number was observed and stated, “Security Guard very rude to pt which was a 5-year-old child. Pt attempted to bite him and guard said, “I bipped him in the head twice. I lost my patience.” He said, “child is out of control I should not have to sit here and deal with him, this is not (expletive) my job. I’m losing my patience.” 2. A follow-up entry to the log by the Security Manager (E #12) dated 5/4/2026 at 11:59 AM stated, “I spoke with (E #13) regarding the MIDAS report that was submitted. The report states that the patient attempted to bite him and that the guard ‘bipped him in the head twice.’ (E #13) confirmed that the patient did, in fact, bite him. He stated he used his free hand to tap the patient on the head in order to prevent being bitten again and to redirect the patient’s head away from him. 3. The Policy titled “Allegations of Abuse or Neglect While Patients are Receiving Care: Illinois” (Effective 5/22/2025) states, “ ...PROCESS: 1. Mission Partners who witness or have knowledge of suspected or alleged patient abuse or neglect ensure the immediate care and protection of alleged victim. a. Removed alleged abuser from patient contact or contact a supervisor or security staff member to do the same. 4. During an interview with the Quality and Safety Manager (E #7) on 5/6/2026 at approximately 1:35 PM, E #7 stated “Not to my knowledge” when asked if the alleged abuser had been removed from patient contact after the allegation and while the investigation was being conducted.”

“PRIVACY AND SAFETY CFR(s): The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 45565 Cowan, Kristen Based on observation, document review, and interview, it was determined that for 1 of 11 patients (Pt # 11) reviewed, the Facility failed to remove an employee from service following a report of alleged abuse of the patient, and failed to notify the State Survey Agency of the alleged abuse within 24 hours, in accordance with State law through established procedures Findings include: 1. The incident and adverse event log was reviewed on 5/6/2026 at approximately 9:00 AM. An entry on 4/28/2026 at 2:00 PM, with Pt #11’s name and medical record number, stated, “Security Guard very rude to pt which was a 5-year-old child. Pt attempted to bite him and guard said, “I bipped him in the head twice. I lost my patience.” He said, “child is out of control I should not have to sit here and deal with him, this is not (expletive) my job. I’m losing my patience.” A follow-up entry to the log by the Emergency Department Manager (E #11) dated 4/28/2026 at 2:58 PM stated, “Referred to Security Manager.” A follow-up entry to the log by the Security Manager (E #12) dated 5/4/2026 at 11:59 AM stated, “I spoke with (E #13) regarding the MIDAS report that was submitted. The report states that the patient attempted to bite him and that the guard ‘bipped him in the head twice.’ (E #13) confirmed that the patient did, in fact, bite him. He stated he used his free hand to tap the patient on the head in order to prevent being bitten again and to redirect the patient’s head away from him. (E #13) emphasized that his actions were solely for defensive purposes and not intended to punish or cause harm to the patient. I also spoke with (E #11) regarding the incident. (E #11) stated that he was not present in the room at the time of the alleged event. However, he did report he observed (E #13) interacting with the patient earlier and described his actions as appropriate and helpful. Additionally, I interviewed (E #15), who was present in the Emergency Department along with (E #5) at the time of the incident. (E #15) stated that neither she nor (E #5) witnessed (E #13) strike the patient. She also reported that (E #13) did not use any inappropriate language or appear upset during the interaction. (E #15) noted that she and (E #5) were standing at the ED nurses’ station and were not directly involved in the patient’s care.” 2. The Policy titled “Allegations of Abuse or Neglect While Patients are Receiving Care: Illinois” (Effective 5/22/2025) states, “ ...PROCESS: 1. Mission Partners who witness or have knowledge of suspected or alleged patient abuse or neglect ensure the immediate care and protection of alleged victim. a. Removed alleged abuser from patient contact or contact a supervisor or security staff member to do the same. ...POLICY ...9. Upon a designated Facility administrator receiving a report from any Facility administrator, agent, Mission Partner or medical staff member of the Facility stating their reasonable belief that any patient with whom such individual has had direct contact has been subjected to abuse in the Facility: a. Event is reported to Illinois Department of Public Health (IDPH) within 24 hours after the designated Facility administrator receives such report ...” 3. During an interview with the Quality and Safety Manager (E #7) on 5/6/2026 at approximately 1:35 PM, E #7 stated “Not to my knowledge” when asked if the alleged abuser had been removed from patient contact after the allegation and while the investigation was being conducted. E #7 further noted the allegation was not reported to IDPH within 24 hours stating, “We did not have enough information yet.””

“PHYSICAL PLANT AND ENVIRONMENT CFR(s): §485.623 Condition of Participation: Physical Plant and Environment This Condition is not met as evidenced by: 20224 Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on February 27, 2026 the surveyors find the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code therefore the requirements of 42 CFR Subpart 485.625, Physical Plant and Environment are NOT MET. See the life safety code deficiencies on the associated K-tags”

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 53146 Based on observation, document review, and interview, it was determined that the Facility failed to ensure that all expired patient care supplies were discarded and not available for patient use. Findings include: 1. A tour of the Medical/Surgical/ICU (Intensive Care Unit) areas was completed on 2/18/2026 at approximately 10:45 am with Quality and Safety (E #2), Charge Nurse (E #7), and Manager of Inpatient Care (E #8). During the tour, the following outdated dietary supplies were found and were available for patient use. a. Two bags of condiments that included: butter, coffee creamer, jelly, mayonnaise, ketchup, salad dressing, and one shelf of prune juice. Products had been removed from their original packaging, and no discernible expiration dates were noted. 2. On 2/18/2026 at approximately 11:30 am, an interview was conducted with the Charge Nurse (E #7) and the Manager of Inpatient Care (E #8). Both verbally agreed that the supplies had expired. 3. On 2/192025 at approximately 10:19 am, the policy “Floor Stock Distribution” (approved 10/27/2025) was reviewed. The policy states, “ ...4. (b.) Discarding expired and unlabeled products, including non-patient food items.””

“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: 20224 Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on February 27, 2026 the surveyors find the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code. See the life safety code deficiencies on the associated K-tags.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 52206 Based on observation, document review, and staff interview, the Hospital failed to ensure that leak-proof, hard-sided containers marked with a bio-hazard sticker were not available for the Med/Surg and ICU areas to use for dirty instrument transportation from the point of use to the decontamination area or for transportation to the sterilizing area. Findings include: 1. During the Medical/Surgical (Med/Surg) and Intensive Care (ICU) unit tour with the Quality and Safety Manager (E #2), and the Medical Charge Nurse (E #7) on 2/18/26 at approximately 10:45 am, the process and steps for pre-cleaning and transporting dirty instruments from point of use to sterilization were reviewed and verbally described by E #7. At the time of the review, E #7 noted that the leak-proof, hard-sided containers marked with a bio-hazard sticker were not available for use on the unit, but should have been in the storage cabinet with the pre-cleanse spray. 2. Review of the Hospital’s Elsevier Guidelines for proper handling and preparation for transportation of instruments after use to the decontamination/sterile processing department states, “Handling of Instruments at Point of Use ...Bedside ...Prior to the procedure, Mission Partner obtains a clean container and biohazard sticker used for transportation and brings it to the patient’s bedside. Once the instruments have been used:...Place instruments in the transport container with working ends facing same direction ...Secure lid onto transport container ...Adhere biohazard sticker on top of container lid.” The Elsevier Guidelines state, “Transportation to Decontamination Area ...Transport soiled instruments to the decontamination area in a closed container ....Ensure the container or cart is leak proof, puncture resistant, large enough to contain all contents, and labeled indicating biohazard ...Label container with a biohazard label or use a red container.” 3. In an interview with the Med/Surg and ICU Inpatient Services Manager (E #8) on 2/18/26 at approximately 11:20 am, E # 8 verbally confirmed that the leak-proof, hard-sided containers marked with a bio-hazard sticker should have been in the cabinet with the pre-cleaning spray.”

“On February 27, 2026, the Life Safety Code portion of a ReCertification survey was conducted. The surveyors were accompanied during the survey walk-through by the following provider representative: Manager Facilities Operation (MFO) The building, constructed in 2008, was observed to consist of two stories plus a mechanical penthouse. The building is construction type II (222) and fully sprinkler protected. The facility was surveyed as an existing health care occupancy under the 2012 Edition of the NFPA 101 Life Safety Code, chapter 19. 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 485.623 Physical Plant and Environment are NOT MET as evidenced by the deficiencies cited under the following K-Tags.”

“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, not all exit signs are installed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because their egress under emergency conditions could be impeded if exit signs are not properly installed and maintained. Finding includes: On 02/27/2026, at 10:30am while accompanied by the MFO, observation determined that the egress path on the second floor at the north end of the north-south corridor within the med/surg floor is not identified by an exit sign to comply with 19.2.4.3, 19.2.10,7.5.1.1.2 and 7.10.2.1.”

“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, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass from the hazardous areas to the means of egress corridor if not protected as required. The Finding is: On 02/27/2026 at 1:46pm, while accompanied by the MFO, observation determined that a vision panel in the fire rated wall of the Clean Linen Storage Room is indicated to be tempered glass which does not appear to comply with Table 8.3.4.2 for a minimum fire rating of 45 minutes.”

“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 observation, not all fire alarm control functions are installed or operate as required. This deficient practice could affect patients, staff, and visitors in the building because the fire alarm system could fail to operate if its controls are not installed and do not function as required. Findings include: A. On 02/27/2026 at 10:42am, while accompanied by the MFO, observation determined that the location of a fire alarm NAC circuit is located on the critical branch panel in the second floor eletrical room # 2101. This condition does not comply with comply with NFPA 99 2012 edition 6.4.2.2.3.2.(7) and NFPA 72 2010 10.5.5.1. B. On 02/27/2026 at 11:02am, while accompanied by the MFO, observation determined that the location of a fire alarm circuit located on the life safety electrical panel located on the first floor in the electrical room containing the ATS and adjacent to the loading dock NAC has a circuit that does not comply with NFPA 72 2010 10.5.5.2.4 for a means of locking.”

“Corridors - Areas Open to Corridor CFR(s): NFPA 101 Corridors - Areas Open to Corridor Spaces (other than patient sleeping rooms, treatment rooms and hazardous areas), waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are in accordance with the criteria under 18.3.6.1 and 19.3.6.1. 18.3.6.1, 19.3.6.1 This Standard is not met as evidenced by: 20224 Based on observation, not all use areas are separated from exit access corridors as required. These deficiencies could affect patients, staff, or visitors in the building because smoke or fire could pass from the use areas into the remainder of the building during a fire/smoke event. The finding is: On 02/27/2026 at 2:10pm while accompanied by the MFO, on the first floor, observation determined that the Cafe area containg multiple seating arrangements is open to the exit corridor and does not comply with Section 19.3.6.1 (1) (c).”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 20224 Based on observation, not all smoke barriers are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors on the floor because smoke could pass between adjacent spaces if the smoke barriers are not properly constructed. the Finding is: On 02/27/2026 at 11:15am while accompanied by the MFO, observation determined that suspended ceiling tiles are installed which do not form a continuous membrane and allows for the passage of smoke which does not comply with 8.4.2 2) a) and 8.5.6.2. location observed Second floor Telecom room #2154.”

“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 and staff interview, the facility failed to document / conduct fire drills as required. This deficient practice could affect patients, staff and visitors if the staff failed to respond promptly during an emergency due to a lack of properly conducted fire drills. The Finding is: On 02/27/2026 at 1:50 pm while accompanied by th OFM during document review fire drill documentation for the past 12 months indicated that drills are not conducted under varying conditions to comply with 19.7.1.6. The document review indicated all drills are conducted the last week of the month.”

“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. The findings are: A. On 02/27/2026 at 1:25pm while in the company of the OFM, it was observed that the documentation for Annual Fire and Smoke Door Inspections lacked indication of the type of door hardware associated with each specific door to comply with 2010 Edition of NFPA 80, Section 5.2.4.2, 5.2.9 B. On 02/27/2026 at 1:30pm while in the company of the OFM, it was observed that the documentation for Annual Fire and Smoke Door Inspections indicated that the check off list for each door contained a catagory for fusable links which was marked as ok for every door including door that did not hav fusable links which does not comply with 2010 Edition of NFPA 80, Section 5.2.4.2., 5.2.9 as not performed per code requirements.”