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

EDEN VISTA PROSPECT HEIGHTS

PROSPECT HEIGHTS, IL · 30 certified beds · Last Life Safety survey August 9, 2024

CMS Certification Number 145852 · first certified October 1995

Ownership

Independently operated (no chain recorded by CMS) · For profit - Corporation

Ownership changed March 1, 2024 (change of ownership)from S-H OPCO PROSPECT HEIGHTS LLC

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

55 citations — more than 98% 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 7 citations; the earlier surveys in the window averaged 24. 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 September 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 11–13 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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7 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

18 of the 55 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 55 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.

Citations on file over three years, compared
Measure	Citations
This facility	55
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 19, 2022	26
May 18, 2023	22
August 9, 2024	7

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.	3	2024-08-09
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	3	2024-08-09
K-0712	Have simulated fire drills held at unexpected times.	3	2024-08-09
E-0041	Implement emergency and standby power systems.	2	2023-05-18
K-0293	Have properly located and lighted "Exit" signs.	2	2023-05-18
E-0015	Address subsistence needs for staff and patients.	2	2023-05-18
E-0037	Establish staff and initial training requirements.	2	2023-05-18
E-0039	Conduct testing and exercise requirements.	2	2023-05-18

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 18
Smoke Deficiencies 11
Miscellaneous Deficiencies 9
Gas, Vacuum, and Electrical Systems Deficiencies 9
Other 8

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	18
Smoke Deficiencies	11
Miscellaneous Deficiencies	9
Gas, Vacuum, and Electrical Systems Deficiencies	9
Egress Deficiencies	4
Construction Deficiencies	3
Services Deficiencies	1

Every citation on file

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

August 9, 2024 — 7 citations

Citations issued on August 9, 2024
Tag	What the surveyor checks	Status
K-0344	Have an alternate power supply for its alarm system.	Deficient, Provider has date of correction (August 21, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (August 21, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 21, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (August 21, 2024)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (August 21, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (August 21, 2024)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (August 21, 2024)

May 18, 2023 — 22 citations

Citations issued on May 18, 2023
Tag	What the surveyor checks	Status
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (June 5, 2023)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (June 15, 2023)
E-0020	Establish policies and procedures including evacuation.	Deficient, Provider has date of correction (June 15, 2023)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (June 15, 2023)
E-0025	Create arrangements with other facilities to receive patients.	Deficient, Provider has date of correction (June 15, 2023)
E-0031	Provide emergency officials' contact information.	Deficient, Provider has date of correction (June 15, 2023)
E-0032	Provide primary/alternate means for communication.	Deficient, Provider has date of correction (June 15, 2023)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (June 15, 2023)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (June 15, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (June 15, 2023)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (June 15, 2023)
K-0133	Install a two-hour-resistant firewall separation.	Deficient, Provider has date of correction (June 15, 2023)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (June 15, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (June 15, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Waiver has been granted (July 7, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (June 15, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (June 15, 2023)
K-0754	Provide properly sized and located linen or trash receptacles.	Deficient, Provider has date of correction (June 15, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (June 15, 2023)
K-0916	Have a battery powered remote alarm panel in a location accessible by operating personnel.	Waiver has been granted (September 25, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (June 15, 2023)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (June 15, 2023)

August 19, 2022 — 26 citations

Citations issued on August 19, 2022
Tag	What the surveyor checks	Status
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (October 6, 2022)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (October 6, 2022)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (October 6, 2022)
E-0029	Develop a communication plan.	Deficient, Provider has date of correction (October 6, 2022)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (October 6, 2022)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (October 6, 2022)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (October 6, 2022)
K-0133	Install a two-hour-resistant firewall separation.	Waiver has been granted (February 9, 2023)
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (October 6, 2022)
K-0223	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	Deficient, Provider has date of correction (October 6, 2022)
K-0225	Have stairways and smokeproof enclosures used as exits that meet safety requirements.	Deficient, Provider has date of correction (October 6, 2022)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (October 6, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 21, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 6, 2022)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (October 6, 2022)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (October 21, 2022)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (October 6, 2022)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (October 6, 2022)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (October 6, 2022)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (October 6, 2022)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (October 6, 2022)
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 (October 6, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 6, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (October 6, 2022)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (October 6, 2022)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (October 6, 2022)

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