Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
DECATUR REHAB & HEALTH CARE CT
DECATUR, IL · 58 certified beds · Last Life Safety survey September 25, 2024
CMS Certification Number 14E848 · first certified October 1987
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
19 citations — more than 61% 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 6 citations; the earlier surveys in the window averaged 4.3. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (August 2025 to November 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was September 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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Emergency preparedness
18 of the 19 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)
12 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 19 Life Safety citations above. The Physical Environment Index
- 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-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0880 Provide and implement an infection prevention and control program.
- F-0924 Put firmly secured handrails on each side of hallways.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 | 19 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 27, 2022 | 6 |
| August 22, 2023 | 6 |
| February 7, 2024 | 1 |
| September 25, 2024 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | 3 | 2024-09-25 |
| E-0029 | Develop a communication plan. | 3 | 2024-09-25 |
| E-0036 | Establish emergency prep training and testing. | 3 | 2024-09-25 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 3 | 2024-09-25 |
| E-0039 | Conduct testing and exercise requirements. | 3 | 2024-09-25 |
| E-0037 | Establish staff and initial training requirements. | 3 | 2024-09-25 |
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | 1 | 2024-02-07 |
What the citations cover
- Emergency Preparedness Deficiencies 18
- Construction Deficiencies 1
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 18 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 25, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has plan of correction (November 15, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has plan of correction (November 4, 2024) |
| E-0029 | Develop a communication plan. | Deficient, Provider has plan of correction (November 4, 2024) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has plan of correction (November 4, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has plan of correction (November 4, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has plan of correction (November 4, 2024) |
February 7, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Deficient, Provider has date of correction (February 16, 2024) |
August 22, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (August 31, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (August 31, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (August 31, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (August 31, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (August 31, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 26, 2023) |
July 27, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (September 1, 2022) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (September 1, 2022) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (September 1, 2022) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (September 1, 2022) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 1, 2022) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 1, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.