Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BRIA OF ELMWOOD PARK
ELMWOOD PARK, IL · 245 certified beds · Last Life Safety survey February 3, 2025
CMS Certification Number 145419 · first certified April 1982
Ownership
Operated by BRIA HEALTH SERVICES · For profit - Limited Liability company
- Ownership changed May 1, 2023 (change of ownership)to BRIA OF ELMWOOD PARK LP from GENERATIONS AT ELMWOOD PARK, INC
73
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
20
Tags cited more than once
Across separate surveys
17
Inspection & testing records
Of the citations on file
Position within IL
73 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 14 citations; the earlier surveys in the window averaged 29.5. 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 (December 2025 to March 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was February 2025. 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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5 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
32 of the 73 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)
13 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 73 Life Safety citations above. The Physical Environment Index
- 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-0908 Keep all essential equipment working safely.
- 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.
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 | 73 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 3, 2023 | 20 |
| March 14, 2024 | 39 |
| February 3, 2025 | 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 | 2025-02-03 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-02-03 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-02-03 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2025-02-03 |
| 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. | 3 | 2025-02-03 |
| E-0030 | List the names and contact information of those in the facility. | 3 | 2025-02-03 |
| E-0037 | Establish staff and initial training requirements. | 3 | 2025-02-03 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2025-02-03 |
What the citations cover
- Emergency Preparedness Deficiencies 32
- Smoke Deficiencies 21
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Egress Deficiencies 6
- Other 7
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 32 |
| Smoke Deficiencies | 21 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Egress Deficiencies | 6 |
| Miscellaneous Deficiencies | 4 |
| Services Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 3, 2025 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (February 10, 2025) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (February 10, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (February 10, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (February 10, 2025) |
| 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 (February 10, 2025) |
| 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 (February 10, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 10, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (March 17, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (February 10, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (February 10, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (February 10, 2025) |
| K-0915 | Have proper power supply for life support equipment. | Waiver has been granted (April 10, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 10, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 10, 2025) |
March 14, 2024 — 39 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 14, 2024) |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 14, 2024) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (March 14, 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 (March 14, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (March 14, 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 (March 14, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0915 | Have proper power supply for life support equipment. | Waiver has been granted (June 17, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 14, 2024) |
February 3, 2023 — 20 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 17, 2023) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (February 17, 2023) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (February 17, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (February 17, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (February 17, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 8, 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 (February 16, 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 (February 16, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 16, 2023) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (February 8, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 26, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 26, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 26, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (February 8, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (February 8, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (February 11, 2023) |
| K-0754 | Provide properly sized and located linen or trash receptacles. | Deficient, Provider has date of correction (February 8, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (February 27, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 23, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.