Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
FRANCISCAN VILLAGE
LEMONT, IL · 127 certified beds · Last Life Safety survey August 9, 2024
CMS Certification Number 146029 · first certified April 1991
Also on this campus
The same campus holds a state-licensed assisted living facilities, with their own state records on the Assisted Living Index: Assisted Living at Franciscan Village (11400 Theresa Drive) and Franciscan Village of Lemont (1260 Franciscan Dr). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Operated by FRANCISCAN COMMUNITIES · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
22 citations — more than 69% of the 664 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 7 citations; the earlier surveys on file averaged 7.5. 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 (July 2025 to October 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Facilities in IL are typically surveyed 11–14 months after the last one (median 13), measured over 739 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 about three years in Virginia. How the window is measured
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1 inspection-and-testing tag has 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 cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 22 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)
7 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 22 Life Safety citations above. The Physical Environment Index
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 | 22 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 9, 2022 | 9 |
| October 19, 2023 | 6 |
| August 9, 2024 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | 3 | 2024-08-09 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 2 | 2024-08-09 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2023-10-19 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 2 | 2023-10-19 |
| E-0022 | Establish policies and procedures for sheltering. | 1 | 2024-08-09 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2024-08-09 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2024-08-09 |
| 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. | 1 | 2023-10-19 |
What the citations cover
- Smoke Deficiencies 9
- Services Deficiencies 3
- Miscellaneous Deficiencies 3
- Emergency Preparedness Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Services Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 9, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (August 27, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Fire Safety Evaluation Survey (December 5, 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 30, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 29, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (September 20, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 28, 2024) |
October 19, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (November 4, 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 (November 3, 2023) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Fire Safety Evaluation Survey |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (November 3, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (January 19, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 3, 2023) |
September 9, 2022 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (October 13, 2022) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Fire Safety Evaluation Survey |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (October 13, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 13, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 13, 2022) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (October 13, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 13, 2022) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 13, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 13, 2022) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.