Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
FAIR HAVENS SENIOR LIVING
DECATUR, IL · 154 certified beds · Last Life Safety survey August 15, 2024
CMS Certification Number 145422 · first certified July 1981
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
- Ownership changed October 1, 2019 (change of ownership)from HICKORY POINT CHRISTIAN VILLAGE, INC
Position within IL
18 citations — more than 58% 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 6. 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 September 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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Emergency preparedness
18 of the 18 citations on file are Emergency Preparedness E-tags — every citation here is about the program, not the building. 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)
19 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 18 Life Safety citations above. The Physical Environment Index
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 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.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 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.
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 | 18 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 1, 2022 | 6 |
| September 8, 2023 | 6 |
| August 15, 2024 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0036 | Establish emergency prep training and testing. | 3 | 2024-08-15 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 3 | 2024-08-15 |
| E-0037 | Establish staff and initial training requirements. | 3 | 2024-08-15 |
| E-0039 | Conduct testing and exercise requirements. | 3 | 2024-08-15 |
| E-0029 | Develop a communication plan. | 3 | 2024-08-15 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 3 | 2024-08-15 |
What the citations cover
- Emergency Preparedness Deficiencies 18
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 18 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 15, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (October 15, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (October 15, 2024) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (October 15, 2024) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (October 15, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (October 15, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 15, 2024) |
September 8, 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 (September 29, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (September 22, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (September 22, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (September 29, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 29, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 24, 2023) |
November 1, 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 (November 22, 2022) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (November 22, 2022) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (November 22, 2022) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (November 22, 2022) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (November 22, 2022) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (November 28, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.