Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ELEVATE CARE SOUTH HOLLAND
SOUTH HOLLAND, IL · 171 certified beds · Last Life Safety survey December 13, 2024
CMS Certification Number 145671 · first certified May 1990
Ownership
Operated by ELEVATE CARE · For profit - Individual
- Ownership changed February 1, 2023 (change of ownership)from VILLA AT SOUTH HOLLAND, LLC
Position within IL
32 citations — more than 85% 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
The latest survey found 4 citations; the earlier surveys in the window averaged 14. 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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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 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
6 of the 32 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)
11 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 32 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 | 32 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 28, 2022 | 9 |
| February 23, 2024 | 19 |
| December 13, 2024 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2024-12-13 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 3 | 2024-12-13 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-12-13 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2024-02-23 |
| K-0133 | Install a two-hour-resistant firewall separation. | 2 | 2024-12-13 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2024-02-23 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2024-02-23 |
| E-0025 | Create arrangements with other facilities to receive patients. | 1 | 2024-02-23 |
What the citations cover
- Smoke Deficiencies 15
- Emergency Preparedness Deficiencies 6
- Egress Deficiencies 4
- Construction Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 15 |
| Emergency Preparedness Deficiencies | 6 |
| Egress Deficiencies | 4 |
| Construction Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 13, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (January 20, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Fire Safety Evaluation Survey (March 25, 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 (January 20, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 20, 2025) |
February 23, 2024 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 14, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (March 14, 2024) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0161 | Use approved construction type or materials. | Fire Safety Evaluation Survey |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Fire Safety Evaluation Survey |
| 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 (March 14, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0754 | Provide properly sized and located linen or trash receptacles. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 14, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 14, 2024) |
October 28, 2022 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Fire Safety Evaluation Survey (February 3, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (December 3, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 3, 2022) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (December 3, 2022) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Fire Safety Evaluation Survey (February 3, 2023) |
| 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 (December 3, 2022) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 3, 2022) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Waiver has been granted (April 17, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 3, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.