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

LINCOLNWOOD PLACE

LINCOLNWOOD, IL · 40 certified beds · Last Life Safety survey December 13, 2024

CMS Certification Number 145786 · first certified April 1994

Ownership

Operated by SENIOR LIFESTYLE · For profit - Limited Liability company

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

41
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
9
Tags cited more than once
Across separate surveys
15
Inspection & testing records
Of the citations on file

Position within IL

41 citations — more than 94% 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 11 citations; the earlier surveys in the window averaged 15. 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 (November 2025 to January 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was December 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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Which alerts

4 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

16 of the 41 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)

4 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 41 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.

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 facility41IL median15National median11
Citations on file over three years, compared
MeasureCitations
This facility41
Median facility in IL15
Median facility nationally11

Survey history

Citations at each Life Safety survey
222022-1282023-11112024-12
Citations at each Life Safety survey
Survey dateCitations
December 9, 202222
November 9, 20238
December 13, 202411

Most-cited tags

Most-cited tags at this facility
K-03533K-03453E-00352E-00232E-00152E-00242K-03552E-00222
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0353Inspect, test, and maintain automatic sprinkler systems.32024-12-13
K-0345Have approved installation, maintenance and testing program for fire alarm systems.32024-12-13
E-0035Provide family notifications of emergency plan.22024-12-13
E-0023Establish policies and procedures for medical documentation.22024-12-13
E-0015Address subsistence needs for staff and patients.22024-12-13
E-0024Establish policies and procedures for volunteers.22024-12-13
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.22023-11-09
E-0022Establish policies and procedures for sheltering.22024-12-13

What the citations cover

Citations by CMS category
  • Emergency Preparedness Deficiencies 16
  • Smoke Deficiencies 12
  • Egress Deficiencies 5
  • Gas, Vacuum, and Electrical Systems Deficiencies 5
  • Other 3
Citations by CMS category
CategoryCitations
Emergency Preparedness Deficiencies16
Smoke Deficiencies12
Egress Deficiencies5
Gas, Vacuum, and Electrical Systems Deficiencies5
Miscellaneous Deficiencies2
Services Deficiencies1

Every citation on file

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

December 13, 2024 — 11 citations

Citations issued on December 13, 2024
TagWhat the surveyor checksStatus
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (February 1, 2025)
E-0022Establish policies and procedures for sheltering.Deficient, Provider has date of correction (February 1, 2025)
E-0023Establish policies and procedures for medical documentation.Deficient, Provider has date of correction (February 1, 2025)
E-0024Establish policies and procedures for volunteers.Deficient, Provider has date of correction (February 1, 2025)
E-0035Provide family notifications of emergency plan.Deficient, Provider has date of correction (February 1, 2025)
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Deficient, Provider has date of correction (February 1, 2025)
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 1, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (February 1, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (February 1, 2025)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (February 1, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (February 1, 2025)

November 9, 2023 — 8 citations

Citations issued on November 9, 2023
TagWhat the surveyor checksStatus
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (December 7, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (December 27, 2023)
K-0352Properly install and monitor supervisory attachments on automatic sprinkler systems.Deficient, Provider has date of correction (December 27, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (December 27, 2023)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (December 7, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (December 27, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (December 27, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 27, 2023)

December 9, 2022 — 22 citations

Citations issued on December 9, 2022
TagWhat the surveyor checksStatus
E-0007Address patient/client population and determine types of services needed.Deficient, Provider has date of correction (January 26, 2023)
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (January 26, 2023)
E-0018Establish procedures for tracking staff and patients during an emergency.Deficient, Provider has date of correction (January 26, 2023)
E-0022Establish policies and procedures for sheltering.Deficient, Provider has date of correction (January 26, 2023)
E-0023Establish policies and procedures for medical documentation.Deficient, Provider has date of correction (January 26, 2023)
E-0024Establish policies and procedures for volunteers.Deficient, Provider has date of correction (January 26, 2023)
E-0030List the names and contact information of those in the facility.Deficient, Provider has date of correction (January 26, 2023)
E-0031Provide emergency officials' contact information.Deficient, Provider has date of correction (January 26, 2023)
E-0032Provide primary/alternate means for communication.Deficient, Provider has date of correction (January 26, 2023)
E-0035Provide family notifications of emergency plan.Deficient, Provider has date of correction (January 26, 2023)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (February 3, 2023)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (January 1, 2023)
K-0271Have exits that are accessible at all times.Deficient, Provider has date of correction (January 1, 2023)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (January 1, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (March 3, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (February 10, 2023)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (January 13, 2023)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (January 26, 2023)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (January 11, 2023)
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 20, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (February 6, 2023)
K-0929Ensure precautions for handling oxygen cylinders and equipment are correctly followed.Deficient, Provider has date of correction (January 20, 2023)

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