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

ALTA REHAB AT WAUCONDA

WAUCONDA, IL · 149 certified beds · Last Life Safety survey August 21, 2024

CMS Certification Number 145887 · first certified August 1996

Ownership

Operated by APERION CARE · For profit - Corporation

Ownership changed January 1, 2024 (change of ownership)from WAUCONDA HEALTHCARE & REHABILITATION CENTRE, 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

51 citations — more than 97% 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 9 citations; the earlier surveys in the window averaged 21. 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 October 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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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

12 of the 51 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 51 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	51
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
June 16, 2022	10
July 26, 2023	32
August 21, 2024	9

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-0920	Ensure proper usage of power strips and extension cords.	3	2024-08-21
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2023-07-26
K-0351	Install an approved automatic sprinkler system.	2	2024-08-21
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2023-07-26
E-0039	Conduct testing and exercise requirements.	2	2024-08-21
K-0293	Have properly located and lighted "Exit" signs.	2	2024-08-21
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	2	2023-07-26
K-0363	Install corridor and hallway doors that block smoke.	2	2024-08-21

What the citations cover

Citations by CMS category

Smoke Deficiencies 15
Emergency Preparedness Deficiencies 12
Gas, Vacuum, and Electrical Systems Deficiencies 8
Egress Deficiencies 8
Other 8

Citations by CMS category
Category	Citations
Smoke Deficiencies	15
Emergency Preparedness Deficiencies	12
Gas, Vacuum, and Electrical Systems Deficiencies	8
Egress Deficiencies	8
Miscellaneous Deficiencies	4
Construction Deficiencies	2
Services Deficiencies	2

Every citation on file

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

August 21, 2024 — 9 citations

Citations issued on August 21, 2024
Tag	What the surveyor checks	Status
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (October 9, 2024)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (September 9, 2024)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (September 9, 2024)
K-0311	Have an enclosure around a vertical opening shaft.	Deficient, Provider has date of correction (September 9, 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 (September 9, 2024)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (September 9, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (September 9, 2024)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (September 9, 2024)
K-0929	Ensure precautions for handling oxygen cylinders and equipment are correctly followed.	Deficient, Provider has date of correction (September 9, 2024)

July 26, 2023 — 32 citations

Citations issued on July 26, 2023
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (August 29, 2023)
E-0013	Develop Emergency Preparedness policies and procedures.	Deficient, Provider has date of correction (August 29, 2023)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (August 29, 2023)
E-0022	Establish policies and procedures for sheltering.	Deficient, Provider has date of correction (August 29, 2023)
E-0023	Establish policies and procedures for medical documentation.	Deficient, Provider has date of correction (August 29, 2023)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (August 29, 2023)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (August 29, 2023)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (August 30, 2023)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (August 30, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (August 31, 2023)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (August 30, 2023)
K-0133	Install a two-hour-resistant firewall separation.	Deficient, Provider has date of correction (August 24, 2023)
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (August 25, 2023)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (August 28, 2023)
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 (August 25, 2023)
K-0271	Have exits that are accessible at all times.	Deficient, Provider has date of correction (September 25, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (August 25, 2023)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (August 15, 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 (August 29, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (August 25, 2023)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (September 25, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (September 25, 2023)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (September 25, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 29, 2023)
K-0362	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	Deficient, Provider has date of correction (August 24, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (August 28, 2023)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (August 25, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (August 29, 2023)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (August 29, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (August 25, 2023)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (August 31, 2023)
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 23, 2023)

June 16, 2022 — 10 citations

Citations issued on June 16, 2022
Tag	What the surveyor checks	Status
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (July 22, 2022)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (August 20, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 25, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (July 14, 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 (July 1, 2022)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (July 18, 2022)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (July 21, 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 (July 22, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (July 8, 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 (July 22, 2022)

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