OSF Saint Clare Medical Center

“The Life Safety Code portion of a Recertification Survey was conducted on March 10, 2025. The surveyor was accompanied during the document review and the survey walk-through by: The Facility Supervisor (FS) The Safety Officer (SO) The Facility consists of the following: The Main Hospital building is three-story with a basement plus penthouses and dates from 1968. Single-story (some with basements) additions were completed in 1976, 1985, 1995, 2002, and 2006. An adjacent four-story-plus-penthouse Medical Office Building (MOB) also exists which was constructed in 1978 and is separated by a 2-hour fire resistant separation. The Main Hospital was surveyed as a single building. The Main Hospital’s original building was observed to be cast-in-place concrete of Type I (332) construction type. The Hospital additions and the MOB were observed to be protected steel frame construction also indicated to be of Type I (332) construction type. The Main Hospital, the Medical Office Building and the 1960 buildings are not fully sprinkler protected. The facility was surveyed as an Existing Healthcare and Business occupancy under the 2012 Edition of NFPA 101 Life Safety Code including Chapter 19 and Chapter 39. 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 direct 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.”

“Doors with Self-Closing Devices CFR(s): NFPA 101 Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8 This Standard is not met as evidenced by: 20224 Based an observations, not all exit doors required to be self closing are installed or maintained to permit egress and provide protection of the exit enclosure. This deficiency could affect patients, staff and visitors if the exit access door did not provide the proper protection during a fire emergency. The finding is: On 03/10/25 at 10:10 am while accompanied by the FS it was determined that not all exit components are provided with elements that maintain the fire resistant rating of the enclosure. Exit stair door hardware components did not provide a self closing assembly. This does not comply with the requirements of 19.3.1. 19.3.6.3.11 Location obsetved: Exit door at the top of Stair #1 (used as an exit from the Penthouse).”

“Stairways and Smokeproof Enclosures CFR(s): NFPA 101 Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2 This Standard is not met as evidenced by: 20224 Based on observation, not all stairs or smokeproof enclosures are constructed and maintained as required including stair components within the stair enclosure. This deficient practice could affect patients, staff, and visitors in the building because their egress from the building could be impeded if the stairs and smokeproof enclosures are not properly constructed and maintained. The finding is: At 11:20 am while in the company of the FS it was observed that the exit stair #S2203 also known as stair #3 lacked guards to prevent a 4” sphere from passing through the guard rail (or 6” sphere at the riser/tread triangle) to comply with 19.2.2.3, 7.1.8, 7.2.2.4 and 7.2.2.4.5.3. The exit stair is considered a means of egress for Second through Ground levels.”

“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 Based on observation, battery powered emergency lighting system is not maintained in accordance with Code requirements. Failure to properly perform maintenance activities can result in failure of the lighting system affecting patients, staff, and visitors. Findings include: A. On 3/10/2025 at 9:50 a.m. while in the company of the FS. it was observed that a battery powered emergency luminaire was not operational. The units battery appeared to not be charged. There is a switch installed on the unit which was in the off position, this appeared to prohibit the proper functioning of the units battery which is not in compliance with NFPA 70, 2011, 700.20. Location observed: Fourth floor Mechanical room 4002 Based on observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the emergency lighting could fail to operate properly when needed if they are not properly installed. Findings include: B. On 3/10/25 at 11:15 a.m. while in the company of the F.S. it was observed that a battery powered emergency luminaire was supplied from a receptacle not determined to be on a lighting circuit to comply with NFPA 70 2011 700.12(F). Location observed: First floor corridor C1104, across from Operating Room 1105 C. On 3/10/25 at 11:30 a.m. while in the company of the F.S. it was observed that a battery powered emergency luminaire was supplied from a receptacle not determined to be on a lighting circuit to comply with NFPA 99 2012, 6.3.2.2.11.3. Location observed: Operating Room 1105”

“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 upon observation, exit signs are not provided to identify access to two remote exits from the building. Failure to provide exit signs to correctly identify exit access can prevent occupants from reaching a required exit if the primary exit is blocked by a fire/smoke condition. The finding is: On 03/10/25 at 10:35 am while accompanied by the FS it was observed that corridors lacked proper 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. Location observed: Second floor corridor (containing Wound Care Clinic) leading to Stair S3304.”

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box. This Standard is not met as evidenced by: 20224 Based on observation, not all vertical openings in the building are protected as required. This deficient practice could affect patients, staff, and visitors in the building because smoke and fire could pass between building stories if vertical openings are not protected. Findings include: On 03/10/25, while accompanied by the FS, observation determined that a water pipe had been installed through the 2 hour fire rated enclosure walls and into the exit stair enclosure, this pipe installation goes through the stair and does not serve the stair which does not comply with 7.1.3.2.1(10). . Locations observed: Lower Level Exit Stair #3 shared wall with Mechanical room”

“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 upon observation, hazardous areas are not separated from the remainder of the occupancy and the means of egress. Failure to properly separate storage of combustible material (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 to block exiting. The findings are: A. On 03/10/25 at 10:10 am while in the company of the FS it was observed that a door to storage room contains a closer with a hold open therefore the door is not self closing to comply with 19.3.2.1.3. Location observed : third floor room #342. B. On 03/10/25 at 10:50am while in the company of the FS it was observed that a door to a sprinklered soiled utility room lacks the requirements to maintain a smoke tight installation to comply with 19.3.2.1.2, 8.4 due to containing a 1 inch by 2 inch hole filled with wood putty of unknown materials. Location observed Second floor soiled utility room #2003 near Pharmacy. C. On 03/10/25 at 10:55am while in the company of the FS it was observed that the ceiling within a sprinklered soiled utility room lacks the requirements to maintain a smoke tight installation to comply with 19.3.2.1.2 due to unprotected conduit penetrations and holes within the ceiling tiles. Location observed Second floor soiled utility room #2003 near Pharmacy.”

“Anesthetizing Locations CFR(s): NFPA 101 Anesthetizing Locations Areas designated for administration of general anesthesia (i.e., inhalation anesthetics) are in accordance with 8.7 and NFPA 99. Zone valves are: located immediately outside each life-support, critical care and anesthetizing location of moderate sedation, deep sedation, or general anesthesia for medical gas or vacuum; readily accessible in an emergency; and arranged so shutting off any one anesthetizing location will not affect others. Area alarm panels are provided to monitor all medical gas, medical-surgical vacuum, and piped WAGD systems. Panels are at locations that provide for surveillance, indicate medical gas pressure decreases of 20 percent and vacuum decreases of 12 inch gauge HgV, and provide visual and audible indication. Alarm sensors are installed either on the source side of individual room zone valve box assemblies or on the patient/use side of each of the individual zone box valve assemblies. The EES critical branch supplies power for task illumination, fixed equipment, select receptacles, and select power circuits, and EES equipment system supplies power to ventilation system. Heating, cooling, and ventilation are in accordance with ASHRAE 170. Medical supply and equipment manufacturer’s instructions for use are considered before reducing humidity levels to those allowed by ASHRAE, per S&C 13-58. 19.3.2.3 (LSC) 5.1.4.8.7, 5.1.4.8.7.2, 5.1.9.3, 5.1.9.3.4, 6.4.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 20224 Based on observation, the facility failed to install and maintain its piped medical gas system as required. This deficient practice could affect patients, staff, and visitors in the building because the piped medical gas system could fail to operate when needed if not properly installed and maintained. The finding is: On 03/10/25while in the company of the FS it was observed that medical gas shut off valves for any critical care, life support and anesthetizing location also served other locations. This is not in accordance with NFPA 99-2012, 5.3.6.19.3 Locations observed: 1. At 11:46am third floor med/surg patient rooms medgas outlets and the medgas outlets in the Special Procedure rooms (which was a remodeled area not part of original building) share the same shutoff valves. 2. At 11:16am second floor med/surg patient rooms #201-#214 medgas outlets and the medgas outlets in the Intensive Care rooms #259, #267 and #268 share the same shutoff valves.”

“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 spaces open to exit access corridors are protected in accordance with Code requirements. Failure to provide protective features can compromise the use of corridors during a fire condition. Findings include: On 03/10/25 at 10:50 am while in the company of the FS areas open to the corridor were observed, that lacked smoke detection or continuous supervision to comply with 19.3.6.1. Through staff interview it was determined that the door to this room remains in the open position at all times. Location observed: ICU Waiting room”

“Gas and Vacuum Piped Systems - Information an CFR(s): NFPA 101 Gas and Vacuum Piped Systems - Information and Warning Signs Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (Table 5.1.11), and operating pressure if other than standard. Labels are at intervals not more than 20 feet, are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. 5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99) This Standard is not met as evidenced by: 20224 Based on observation, the facility failed to install and maintain its piped medical gas system as required. This deficient practice could affect patients, staff, and visitors in the building because the piped medical gas system could fail to operate when needed if not properly installed and maintained. The finding is: On 03/10/25 At 11:20am while in the company of the FS it was observed that medical gas outlets for vacuum are present within the ICU however gas zone valves serving these outlets could not be located. This is not in accordance with NFPA 99-2012, 5.1.4.8.4 Location observed Second floor”

“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 during survey walk through, egress from the working space around electrical equipment is not maintained in accordance with Code requirements. This deficiency could affect staff and visitors in the event of an electrical equipment failure. Findings include: A. On 3/10/25 at 1:00 p.m. while in the company of the FS. it was observed that doors intended for entrance to and egress from electric rooms G210A and G210B were not equipped with hardware that releases with simple pressure, therefore not in compliance with NFPA 70 2011, 110.26(C)(3). Based on direct observation during survey walk through, not all portions of the electrical system are constructed in accordance with Code requirements. This deficiency could affect patients and staff in the event of electrical equipment failure during a procedure. Findings include: B. On 3/10/25 at 11:45 a.m. while in the company of the F.S. it was observed that the isolated power systems serving rooms did not include a line isolation monitor visible within the room. This condition does not comply with NFPA 99 2012, 6.3.2.6.3.4. Example locations Operating rooms 1107 and 1109”

“Electrical Systems - Receptacles CFR(s): NFPA 101 Electrical Systems - Receptacles Power receptacles have at least one, separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug. In pediatric locations, receptacles in patient rooms, bathrooms, play rooms, and activity rooms, other than nurseries, are listed tamper-resistant or employ a listed cover. If used in patient care room, ground-fault circuit interrupters (GFCI) are listed. 6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99) This Standard is not met as evidenced by: 20224 Based on observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed. Findings include: A. On 03/10/2025 at 9:45 a.m. while in the company of the F.S. it was observed that receptacles installed in the fourth floor elevator machine room were not equipped with G.F.C.I. protection for personnel. This condition does not comply with NFPA 70, 2011, 620.55. B. On 3/10/2025 at 10:55 a.m. while in the company of the F.M. it was observed that receptacles located in the second floor Pharmacy room 2006 were labeled as being supplied from the equipment branch of the essential electrical system which does not comply with NFPA 99 2012, 6.4.2.2.5”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Receptacles Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking. 6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99) This Standard is not met as evidenced by: 20224 Based on observation, not all portions of the essential electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed. Findings include: A. On 03/10/25 while in the company of the FS the surveyor observed branch circuit panels installed not marked to identify the device or equipment where the power supply originates. The labeling convention could not be determined to identify and locate the panel and circuit from which the receptacle was fed. therefore this does not comply with NFPA 70 2011, 408.4(B) 517.30 (C). Example locations: 1. At 10:25 am Third floor Endo Procedure rooms, Recovery rooms 2. At 11:20 am Second floor ICU 3. At 11:36 am Second floor Surgery area B. On 3/10/25 at 9:42 while in the company of the F.S., inside the fourth floor elevator machine room it was observed that lighting for the elevator cars is not supplied by the Life Safety branch of the Essential Electrical System, therefore not in compliance with NFPA 99 2012, 6.4.2.2.3.”

“Electrical Equipment - Other CFR(s): NFPA 101 Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, 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 10 (NFPA 99) This Standard is not met as evidenced by: 20224 Based on observation, not all portions of the electrical system are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors in the building because the electrical systems could fail to operate properly when needed if they are not properly installed. Findings include: On 3/10/25 at 9:40 a.m. while in the company of the FS. it was observed that an externally operable disconnecting means for elevator car lighting has not been provided in the fourth floor elevator machine room, therefore not in compliance with NFPA 70 2011, 620.53.”

“DRUG AND BIOLOGICALS CFR(s): Drugs and biologicals commonly used in life-saving procedures, including analgesics, local anesthetics, antibiotics, anticonvulsants, antidotes and emetics, serums and toxoids, antiarrythmics, cardiac glycosides, antihypertensives, diuretics, and electrolytes and replacement solutions. This Standard is not met as evidenced by: 50645 Based on observation, and interview, it was determined that the Facility failed to ensure all patient care supplies was not discarded when they expired. Findings include: 1. A tour of the treatment and storage areas was completed on 2//24/25 between 1:00 PM and 4:00 PM. During the tour, the following supplies were found outdated and were available for patient use. a. Nine 22 Gauge x 3.50-inch Spinal Needles. The manufacturer’s expiration date was 10/2024. b. Two 1.5-liter Jevity Complete Balanced Nutrition with Fiber. The manufacturer’s expiration date was 12/2024. c. Twenty packets of Sterile Aquasonic ultrasound transmission gel 20 grams. The manufacturer’s expiration date was 11/2023. 2. On 2/24/25 at approximately 2:00 PM, an interview was conducted with the Quality and Safety Coordinator (E #2). E #2 verbally agreed the supplies were expired and the expired supplies were removed from the treatment area. 3. On 2/24/25 at approximately 3:00 PM an interview was conducted with the Chef manager (E #9). E #9 verbally agreed the supplies were expired and the expired supplies were removed from the kitchen/dietary area.”

“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: 49555 Based on observation, document review and interview, it was determined for 1 of 1 Radiology Temperature log, the Hospital failed to ensure that all mechanical, electrical, and patient-care equipment was maintained in safe operating condition. Findings include: 1. During an observational tour of the CAH on 2/24/25 at approximately 2:30 PM, the “Radiology Temperature Log” was observed to have checklists to monitor the temperature of the CT (Computed Tomography) Refrigerator Contrast, CT Refrigerator Water, and Blanket Warmer each day. The following checklists were not completed: a) For the month of December 2024, 20 days (12/11, 12/12, and 12/14-12/31/24) lacked documentation of the temperatures being checked. b) For the month of January 2025, 31 days (1/1-1/31/25) lacked documentation of the temperatures being checked. c) No log observed for the month of February 2025. 2. An interview was conducted during the observational tour with Radiology Manager (E #15) on 2/24/25 at approximately 2:45 PM. E #15 reviewed the Radiology Temperature Log and verbally agreed the daily checklist had not been completed and should have been. 3. An interview was conducted on 2/27/25 at approximately 10:15 AM with the Quality and Safety Coordinator (E #2). E #2 stated, “Although we do not have a policy regarding monitoring the temperatures of the blanket warmers and refrigerators, the logs should have been completed.””

“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 observation during the survey walk-through, staff interview, and document review during the Life Safety portion of a Critical Access Hospital Federal Recertification Survey conducted on March 10, 2025, the surveyor finds 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 on the CMS Form 2567, dated March 10, 2025.”

“RESTRAINT AND SECLUSION CFR(s): The CAH must provide patient- centered, trauma informed competency- based training and education of CAH personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the CAH, on the use of restraint and seclusion. This Standard is not met as evidenced by: 30383 Based on document review and interview, it was determined for 1 of 2 (E#13 Employee) Physician files reviewed, the hospital failed to ensure the Physician’s ordering non-violent and violent restraints had a working knowledge of the hospital’s policy. Findings include: 1. The policy titled “Restraint and Seclusion Management” was reviewed on 2/26/25. The policy noted “9. Training: a. Physicians... that order and or evaluate for restraints, have working knowledge about the hospital policy for restraint use. Training occurs during orientation and as deemed necessary...” 2. The Physician files were reviewed on 2/26/25 at approximately 10:30 AM. E#13 (Employee-Medical Doctor) file lacked documentation the Physician had working knowledge of the hospital’s restraint/seclusion policy and competence in ordering restraints: 3. During an interview on 2/26/25 at approximately 11:40 AM, the Director of Quality and Safety (E#14) verbally agreed that E#13 personnel file lacked any documentation of violent and/or non violent restraint training and competence.”

“RECORDS SYSTEM CFR(s): For each patient receiving health care services, the CAH maintains a record that includes, as applicable-- (i) Identification and social data, evidence of properly executed informed consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient; This Standard is not met as evidenced by: 30383 Based on document review and staff interview it was determined for 1 of 3 (Pt #8) medical records reviewed the Hospital failed to follow the policy for consent to treat and failed to ensure consent for treatment was signed by the legal representative for minor patients. This has the potential to affect all patients who receive care by the hospital. Findings include: 1. The policy titled “General Informed Consent to Treat- Minor (effective 5/13/23) was reviewed on 7/31/24. The policy noted “Policy: ...2. Written or verbal consent from parent/ guardian is necessary to provide to a minor if parent/ guardian is unable to accompany minor...” 2. The clinical record of Pt #8 was reviewed on 7/30/24. Pt#8 was admitted on 6/17/24 to the ED with chief complaint of Psychiatric Evaluation. The patient was a minor. The record lacked a written/ verbal consent to treat by parent./ guardian. 3. On 7/31/24 at 10:30 AM, an interview was conducted with E#2 (Quality Safety Regulatory Coordinator) verbally agreed the lack of the consent for treatment from the mother for the consent for treatment for the 6/17/24 admission.”