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

ACCOLADE HEALTHCARE OF PONTIAC

PONTIAC, IL · 97 certified beds · Last Life Safety survey June 4, 2025

CMS Certification Number 146010 · first certified November 2001

Ownership

Operated by ACCOLADE HEALTHCARE · For profit - Corporation

  • Ownership changed August 2, 2017 (change of ownership)from PONTIAC HEALTHCARE AND REHAB LLC
24
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
7
Inspection & testing records
Of the citations on file

Position within IL

24 citations — more than 73% 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 3 citations; the earlier surveys in the window averaged 10.5. 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 July 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was June 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

2 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

3 of the 24 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)

5 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 24 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 facility24IL median15National median11
Citations on file over three years, compared
MeasureCitations
This facility24
Median facility in IL15
Median facility nationally11

Survey history

Citations at each Life Safety survey
52023-06162024-0832025-06
Citations at each Life Safety survey
Survey dateCitations
June 8, 20235
August 23, 202416
June 4, 20253

Most-cited tags

Most-cited tags at this facility
K-03213K-03532K-09202K-03452E-00372K-07111K-03411K-07121
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.32025-06-04
K-0353Inspect, test, and maintain automatic sprinkler systems.22024-08-23
K-0920Ensure proper usage of power strips and extension cords.22024-08-23
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22024-08-23
E-0037Establish staff and initial training requirements.22025-06-04
K-0711Provide a written emergency evacuation plan.12024-08-23
K-0341Install a fire alarm system that can be heard throughout the facility.12023-06-08
K-0712Have simulated fire drills held at unexpected times.12024-08-23

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 13
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Emergency Preparedness Deficiencies 3
  • Miscellaneous Deficiencies 3
  • Other 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies13
Gas, Vacuum, and Electrical Systems Deficiencies4
Emergency Preparedness Deficiencies3
Miscellaneous Deficiencies3
Egress Deficiencies1

Every citation on file

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

June 4, 2025 — 3 citations

Citations issued on June 4, 2025
TagWhat the surveyor checksStatus
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (July 19, 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 (July 18, 2025)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (July 18, 2025)

August 23, 2024 — 16 citations

Citations issued on August 23, 2024
TagWhat the surveyor checksStatus
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (September 13, 2024)
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (September 18, 2024)
K-0271Have exits that are accessible at all times.Deficient, Provider has date of correction (September 13, 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 (September 13, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (September 19, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (September 13, 2024)
K-0346Follow proper procedures when the fire alarm was out of service for more than 4 hours.Deficient, Provider has date of correction (September 13, 2024)
K-0351Install an approved automatic sprinkler system.Waiver has been granted (October 2, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (September 13, 2024)
K-0354Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.Deficient, Provider has date of correction (September 13, 2024)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (September 13, 2024)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (September 13, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (September 13, 2024)
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 (September 13, 2024)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (September 13, 2024)
K-0930Ensure proper storage of liquid oxygen.Deficient, Provider has date of correction (September 13, 2024)

June 8, 2023 — 5 citations

Citations issued on June 8, 2023
TagWhat the surveyor checksStatus
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 (June 21, 2023)
K-0341Install a fire alarm system that can be heard throughout the facility.Deficient, Provider has date of correction (June 21, 2023)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (June 21, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (June 21, 2023)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (June 21, 2023)

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