Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
APERION CARE WESTCHESTER
WESTCHESTER, IL · 120 certified beds · Last Life Safety survey August 28, 2024
CMS Certification Number 145660 · first certified November 1989
Ownership
Operated by APERION CARE · For profit - Corporation
- Ownership changed April 1, 2021 (change of ownership)from SSC WESTCHESTER OPERATING COMPANY LLC
Position within IL
53 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
The latest survey found 14 citations; the earlier surveys in the window averaged 19.5. 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 (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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6 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
6 of the 53 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)
9 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 53 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-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 | 53 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 4, 2022 | 19 |
| June 15, 2023 | 20 |
| August 28, 2024 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 3 | 2024-08-28 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 3 | 2024-08-28 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2024-08-28 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-08-28 |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | 3 | 2024-08-28 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2024-08-28 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2024-08-28 |
| 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 | 2024-08-28 |
What the citations cover
- Smoke Deficiencies 28
- Gas, Vacuum, and Electrical Systems Deficiencies 9
- Emergency Preparedness Deficiencies 6
- Egress Deficiencies 6
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 28 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 9 |
| Emergency Preparedness Deficiencies | 6 |
| Egress Deficiencies | 6 |
| Miscellaneous Deficiencies | 3 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 28, 2024 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (September 18, 2024) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (September 18, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 18, 2024) |
| 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 (September 18, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (September 18, 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 18, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (December 11, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (September 18, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 18, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 18, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 18, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 18, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 18, 2024) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (September 18, 2024) |
June 15, 2023 — 20 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (July 20, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 20, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 20, 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. | Waiver has been granted (July 24, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 20, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 23, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (July 20, 2023) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Waiver has been granted (September 9, 2023) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 20, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (August 25, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 20, 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 (July 20, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 20, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 20, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (July 20, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 20, 2023) |
| K-0791 | Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Deficient, Provider has date of correction (July 20, 2023) |
| 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 20, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 20, 2023) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (July 20, 2023) |
August 4, 2022 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (September 2, 2022) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 2, 2022) |
| 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. | Waiver has been granted (September 19, 2022) |
| 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 2, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (October 6, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (September 2, 2022) |
| 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 (September 2, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 8, 2022) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (September 2, 2022) |
| K-0930 | Ensure proper storage of liquid oxygen. | Deficient, Provider has date of correction (September 2, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.