Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SOUTH SHORE REHABILITATION
CHICAGO, IL · 248 certified beds · Last Life Safety survey July 26, 2024
CMS Certification Number 145977 · first certified November 1998
Ownership
Operated by EXTENDED CARE CLINICAL · For profit - Limited Liability company
- Ownership changed October 6, 2023 (change of ownership)from SYMPHONY SOUTH SHORE LLC
Position within IL
56 citations — more than 99% 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
The latest survey found 14 citations; the earlier surveys in the window averaged 21. 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 September 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
14 of the 56 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)
16 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 56 Life Safety citations above. The Physical Environment Index
- 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-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0924 Put firmly secured handrails on each side of hallways.
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 56 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 25, 2022 | 34 |
| June 14, 2023 | 8 |
| July 26, 2024 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| 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 | 2024-07-26 |
| K-0351 | Install an approved automatic sprinkler system. | 3 | 2024-07-26 |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | 3 | 2024-07-26 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-07-26 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2023-06-14 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2023-06-14 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2024-07-26 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-07-26 |
What the citations cover
- Smoke Deficiencies 18
- Emergency Preparedness Deficiencies 14
- Gas, Vacuum, and Electrical Systems Deficiencies 11
- Miscellaneous Deficiencies 6
- Other 7
| Category | Citations |
|---|---|
| Smoke Deficiencies | 18 |
| Emergency Preparedness Deficiencies | 14 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 11 |
| Miscellaneous Deficiencies | 6 |
| Egress Deficiencies | 5 |
| Construction Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 26, 2024 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 16, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (August 13, 2024) |
| 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 13, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (August 13, 2024) |
June 14, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (August 3, 2023) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (August 3, 2023) |
| 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 3, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (August 3, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 3, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 3, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (August 3, 2023) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (August 3, 2023) |
May 25, 2022 — 34 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 20, 2022) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 20, 2022) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (June 20, 2022) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (June 20, 2022) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (June 20, 2022) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (June 20, 2022) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (June 20, 2022) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (June 20, 2022) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (June 20, 2022) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (June 20, 2022) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (June 20, 2022) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (June 20, 2022) |
| 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 (June 20, 2022) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (June 20, 2022) |
| 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 (June 20, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (August 24, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 20, 2022) |
| 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 (June 20, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (June 20, 2022) |
| K-0930 | Ensure proper storage of liquid oxygen. | Deficient, Provider has date of correction (June 20, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.