Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

BRIA OF RIVER OAKS

BURNHAM, IL · 309 certified beds · Last Life Safety survey July 13, 2024

CMS Certification Number 145735 · first certified October 1992

Ownership

Operated by BRIA HEALTH SERVICES · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within IL

80 citations — more than 100% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 26 citations; the earlier surveys in the window averaged 27. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (June 2025 to August 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was July 2024. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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7 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

24 of the 80 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

11 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 80 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

How that compares

Citations on file over three years

Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	80
Median facility in IL	15
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
August 5, 2022	38
August 3, 2023	16
July 13, 2024	26

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2024-07-13
K-0311	Have an enclosure around a vertical opening shaft.	3	2024-07-13
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	3	2024-07-13
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	3	2024-07-13
K-0920	Ensure proper usage of power strips and extension cords.	3	2024-07-13
K-0161	Use approved construction type or materials.	3	2024-07-13
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	3	2024-07-13
E-0007	Address patient/client population and determine types of services needed.	2	2024-07-13

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 24
Smoke Deficiencies 24
Gas, Vacuum, and Electrical Systems Deficiencies 9
Egress Deficiencies 9
Other 14

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	24
Smoke Deficiencies	24
Gas, Vacuum, and Electrical Systems Deficiencies	9
Egress Deficiencies	9
Miscellaneous Deficiencies	6
Construction Deficiencies	5
Services Deficiencies	3

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

July 13, 2024 — 26 citations

Citations issued on July 13, 2024
Tag	What the surveyor checks	Status
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (July 18, 2024)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (July 18, 2024)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (July 18, 2024)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (July 18, 2024)
K-0133	Install a two-hour-resistant firewall separation.	Deficient, Provider has date of correction (July 18, 2024)
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (July 18, 2024)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (July 18, 2024)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (July 18, 2024)
K-0225	Have stairways and smokeproof enclosures used as exits that meet safety requirements.	Deficient, Provider has date of correction (July 18, 2024)
K-0226	Have horizontal exits used in accordance with safety requirements.	Deficient, Provider has date of correction (July 18, 2024)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (July 18, 2024)
K-0311	Have an enclosure around a vertical opening shaft.	Fire Safety Evaluation Survey
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (July 18, 2024)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (August 1, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (August 1, 2024)
K-0351	Install an approved automatic sprinkler system.	Waiver has been granted (September 9, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (July 18, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (July 18, 2024)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (July 18, 2024)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (July 18, 2024)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (July 18, 2024)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (July 18, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Waiver has been granted (August 26, 2024)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (July 18, 2024)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (July 18, 2024)
K-0929	Ensure precautions for handling oxygen cylinders and equipment are correctly followed.	Deficient, Provider has date of correction (July 18, 2024)

August 3, 2023 — 16 citations

Citations issued on August 3, 2023
Tag	What the surveyor checks	Status
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (August 23, 2023)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (August 23, 2023)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (August 23, 2023)
K-0225	Have stairways and smokeproof enclosures used as exits that meet safety requirements.	Deficient, Provider has date of correction (August 23, 2023)
K-0311	Have an enclosure around a vertical opening shaft.	Fire Safety Evaluation Survey
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (August 23, 2023)
K-0346	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	Deficient, Provider has date of correction (August 23, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 29, 2023)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (August 23, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (August 23, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (August 23, 2023)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (August 23, 2023)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (August 23, 2023)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (August 23, 2023)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (August 23, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (August 23, 2023)

August 5, 2022 — 38 citations

Citations issued on August 5, 2022
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (September 5, 2022)
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (September 5, 2022)
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (September 5, 2022)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (September 5, 2022)
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (September 5, 2022)
E-0020	Establish policies and procedures including evacuation.	Deficient, Provider has date of correction (September 5, 2022)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (September 5, 2022)
E-0023	Establish policies and procedures for medical documentation.	Deficient, Provider has date of correction (September 5, 2022)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (September 5, 2022)
E-0025	Create arrangements with other facilities to receive patients.	Deficient, Provider has date of correction (September 5, 2022)
E-0029	Develop a communication plan.	Deficient, Provider has date of correction (September 5, 2022)
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (September 5, 2022)
E-0031	Provide emergency officials' contact information.	Deficient, Provider has date of correction (September 5, 2022)
E-0032	Provide primary/alternate means for communication.	Deficient, Provider has date of correction (September 5, 2022)
E-0033	Establish methods for sharing information.	Deficient, Provider has date of correction (September 5, 2022)
E-0034	Provide a means of sharing information on occupancy/needs.	Deficient, Provider has date of correction (September 5, 2022)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (September 5, 2022)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (September 5, 2022)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (September 5, 2022)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (September 5, 2022)
K-0133	Install a two-hour-resistant firewall separation.	Deficient, Provider has date of correction (September 5, 2022)
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (September 5, 2022)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (September 5, 2022)
K-0311	Have an enclosure around a vertical opening shaft.	Fire Safety Evaluation Survey
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (September 5, 2022)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (September 15, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (September 26, 2022)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (October 7, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 7, 2022)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (September 5, 2022)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (September 5, 2022)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (September 5, 2022)
K-0754	Provide properly sized and located linen or trash receptacles.	Deficient, Provider has date of correction (September 5, 2022)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (September 5, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (September 9, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (September 5, 2022)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (September 5, 2022)
K-0929	Ensure precautions for handling oxygen cylinders and equipment are correctly followed.	Deficient, Provider has date of correction (September 5, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.