Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
FAIR OAKS HEALTH CARE CENTER
CRYSTAL LAKE, IL · 51 certified beds · Last Life Safety survey June 6, 2024
CMS Certification Number 145917 · first certified December 1996
Ownership
Operated by WISCONSIN ILLINOIS SENIOR HOUSING, INC. · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
31 citations — more than 84% 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 8 citations; the earlier surveys in the window averaged 11.5. 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 2025 to July 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was June 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
12 of the 31 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 31 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 | 31 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 8, 2022 | 8 |
| May 10, 2023 | 15 |
| June 6, 2024 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-06-06 |
| E-0015 | Address subsistence needs for staff and patients. | 2 | 2023-05-10 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 2 | 2023-05-10 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2023-05-10 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 2 | 2023-05-10 |
| K-0711 | Provide a written emergency evacuation plan. | 2 | 2024-06-06 |
| E-0023 | Establish policies and procedures for medical documentation. | 1 | 2023-05-10 |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | 1 | 2023-05-10 |
What the citations cover
- Emergency Preparedness Deficiencies 12
- Smoke Deficiencies 10
- Egress Deficiencies 3
- Miscellaneous Deficiencies 2
- Other 4
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 12 |
| Smoke Deficiencies | 10 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Construction Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 6, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (July 26, 2024) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (July 26, 2024) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (July 26, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (July 26, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 30, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 26, 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 (August 14, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 26, 2024) |
May 10, 2023 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (July 3, 2023) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (July 3, 2023) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (July 3, 2023) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (June 28, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 15, 2023) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (July 3, 2023) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (July 3, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 3, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 3, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 28, 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 3, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (July 3, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (July 3, 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 14, 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 (July 3, 2023) |
June 8, 2022 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (August 3, 2022) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (August 3, 2022) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (August 3, 2022) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 3, 2022) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (August 3, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 3, 2022) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (August 3, 2022) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (August 3, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.