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

BEACON HILL

LOMBARD, IL · 45 certified beds · Last Life Safety survey July 3, 2025

CMS Certification Number 145522 · first certified June 1985

Ownership

Operated by LIFESPACE COMMUNITIES · Non profit - Corporation

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

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within IL

40 citations — more than 92% 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

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 13 citations; the earlier surveys in the window averaged 13.5. 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 (May 2026 to August 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was July 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

13 of the 40 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)

6 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 40 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.

Citations on file over three years, compared
Measure	Citations
This facility	40
Median facility in IL	15
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
August 10, 2023	10
June 12, 2024	17
July 3, 2025	13

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2025-07-03
K-0293	Have properly located and lighted "Exit" signs.	2	2025-07-03
K-0363	Install corridor and hallway doors that block smoke.	2	2025-07-03
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	2	2025-07-03
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2025-07-03
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2025-07-03
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2025-07-03
K-0133	Install a two-hour-resistant firewall separation.	2	2025-07-03

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 13
Smoke Deficiencies 12
Gas, Vacuum, and Electrical Systems Deficiencies 4
Miscellaneous Deficiencies 4
Other 7

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	13
Smoke Deficiencies	12
Gas, Vacuum, and Electrical Systems Deficiencies	4
Miscellaneous Deficiencies	4
Egress Deficiencies	4
Construction Deficiencies	2
Services Deficiencies	1

Every citation on file

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

July 3, 2025 — 13 citations

Citations issued on July 3, 2025
Tag	What the surveyor checks	Status
K-0133	Install a two-hour-resistant firewall separation.	Deficient, Provider has date of correction (August 1, 2025)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (August 1, 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 (August 1, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (August 1, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 1, 2025)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (August 1, 2025)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (July 16, 2025)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (August 1, 2025)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (July 16, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (August 1, 2025)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (August 1, 2025)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (August 1, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (August 1, 2025)

June 12, 2024 — 17 citations

Citations issued on June 12, 2024
Tag	What the surveyor checks	Status
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (July 4, 2024)
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (July 4, 2024)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (July 4, 2024)
E-0023	Establish policies and procedures for medical documentation.	Deficient, Provider has date of correction (July 4, 2024)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (July 4, 2024)
E-0025	Create arrangements with other facilities to receive patients.	Deficient, Provider has date of correction (July 4, 2024)
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (July 4, 2024)
K-0133	Install a two-hour-resistant firewall separation.	Deficient, Provider has date of correction (July 3, 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 (July 3, 2024)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (July 8, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Waiver has been granted (August 1, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (July 8, 2024)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (July 3, 2024)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (July 1, 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 (July 1, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (July 3, 2024)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (July 8, 2024)

August 10, 2023 — 10 citations

Citations issued on August 10, 2023
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (September 22, 2023)
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (September 22, 2023)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (September 21, 2023)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (September 22, 2023)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (September 22, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (September 22, 2023)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (September 1, 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 (September 1, 2023)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (September 1, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (September 1, 2023)

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