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

ALIYA OF EVANSTON

EVANSTON, IL · 57 certified beds · Last Life Safety survey January 24, 2025

CMS Certification Number 146058 · first certified February 2004

Ownership

Operated by ALIYA HEALTHCARE · For profit - Limited Liability company

  • Ownership changed March 1, 2024 (change of ownership)from EVANSTON NURSING & REHAB CENTER, LLC
33
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
10
Tags cited more than once
Across separate surveys
16
Inspection & testing records
Of the citations on file

Position within IL

33 citations — more than 87% 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 10 citations; the earlier surveys in the window averaged 11.5. 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 January 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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Which alerts

6 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.

Physical environment (health survey)

3 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 33 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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.

This facility33IL median15National median11
Citations on file over three years, compared
MeasureCitations
This facility33
Median facility in IL15
Median facility nationally11

Survey history

Citations at each Life Safety survey
102022-11132024-02102025-01
Citations at each Life Safety survey
Survey dateCitations
November 23, 202210
February 16, 202413
January 24, 202510

Most-cited tags

Most-cited tags at this facility
K-07123K-02253K-03632K-03532K-05312K-03452K-03512K-03212
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0712Have simulated fire drills held at unexpected times.32025-01-24
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.32025-01-24
K-0363Install corridor and hallway doors that block smoke.22025-01-24
K-0353Inspect, test, and maintain automatic sprinkler systems.22025-01-24
K-0531Have elevators that firefighters can control in the event of a fire.22025-01-24
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22024-02-16
K-0351Install an approved automatic sprinkler system.22024-02-16
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.22024-02-16

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 15
  • Gas, Vacuum, and Electrical Systems Deficiencies 7
  • Egress Deficiencies 4
  • Miscellaneous Deficiencies 4
  • Other 3
Citations by CMS category
CategoryCitations
Smoke Deficiencies15
Gas, Vacuum, and Electrical Systems Deficiencies7
Egress Deficiencies4
Miscellaneous Deficiencies4
Services Deficiencies2
Construction Deficiencies1

Every citation on file

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

January 24, 2025 — 10 citations

Citations issued on January 24, 2025
TagWhat the surveyor checksStatus
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Fire Safety Evaluation Survey (March 18, 2025)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (January 27, 2025)
K-0346Follow proper procedures when the fire alarm was out of service for more than 4 hours.Deficient, Provider has date of correction (January 27, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (January 27, 2025)
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.Deficient, Provider has date of correction (January 27, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (January 27, 2025)
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has date of correction (January 27, 2025)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (January 27, 2025)
K-0914Ensure 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 (January 27, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (January 27, 2025)

February 16, 2024 — 13 citations

Citations issued on February 16, 2024
TagWhat the surveyor checksStatus
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (February 23, 2024)
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Fire Safety Evaluation Survey
K-0311Have an enclosure around a vertical opening shaft.Deficient, Provider has date of correction (February 23, 2024)
K-0321Ensure 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 23, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (February 23, 2024)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (February 23, 2024)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (February 23, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (February 23, 2024)
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has date of correction (February 23, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (February 23, 2024)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (February 23, 2024)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (February 23, 2024)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (March 11, 2024)

November 23, 2022 — 10 citations

Citations issued on November 23, 2022
TagWhat the surveyor checksStatus
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Fire Safety Evaluation Survey
K-0271Have exits that are accessible at all times.Deficient, Provider has date of correction (December 20, 2022)
K-0321Ensure 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 (December 20, 2022)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (December 20, 2022)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (December 20, 2022)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (February 8, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (December 20, 2022)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 28, 2022)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (December 20, 2022)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (December 20, 2022)

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