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

Flanagan Rehabilitation and Health Care Center

FLANAGAN, IL · 43 certified beds · Last Life Safety survey May 8, 2024

CMS Certification Number 145842 · first certified August 1995

Ownership

Independently operated (no chain recorded by CMS) · For profit - Corporation

  • Ownership changed October 31, 2019 (change of ownership)to FLANAGAN REHABILITATION & HEALTH CARE from PETERSEN HEALTH NETWORK, LLC
19
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
6
Tags cited more than once
Across separate surveys
12
Inspection & testing records
Of the citations on file

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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 7. 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 (April 2025 to June 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was May 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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Which alerts

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

6 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)

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 19 Life Safety citations above. The Physical Environment Index

  • 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.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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.

This facility19IL median15National median11
Citations on file over three years, compared
MeasureCitations
This facility19
Median facility in IL15
Median facility nationally11

Survey history

Citations at each Life Safety survey
52022-0692023-0752024-05
Citations at each Life Safety survey
Survey dateCitations
June 9, 20225
July 19, 20239
May 8, 20245

Most-cited tags

Most-cited tags at this facility
K-09183K-07122K-03242E-00372K-03532K-03452E-00131K-09141
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.32024-05-08
K-0712Have simulated fire drills held at unexpected times.22024-05-08
K-0324Provide properly protected cooking facilities.22023-07-19
E-0037Establish staff and initial training requirements.22024-05-08
K-0353Inspect, test, and maintain automatic sprinkler systems.22024-05-08
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22024-05-08
E-0013Develop Emergency Preparedness policies and procedures.12023-07-19
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.12022-06-09

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 7
  • Emergency Preparedness Deficiencies 6
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Miscellaneous Deficiencies 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies7
Emergency Preparedness Deficiencies6
Gas, Vacuum, and Electrical Systems Deficiencies4
Miscellaneous Deficiencies2

Every citation on file

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

May 8, 2024 — 5 citations

Citations issued on May 8, 2024
TagWhat the surveyor checksStatus
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (May 30, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (May 15, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Waiver has been granted (August 14, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 30, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (May 28, 2024)

July 19, 2023 — 9 citations

Citations issued on July 19, 2023
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (August 12, 2023)
E-0013Develop Emergency Preparedness policies and procedures.Deficient, Provider has date of correction (August 12, 2023)
E-0029Develop a communication plan.Deficient, Provider has date of correction (August 12, 2023)
E-0036Establish emergency prep training and testing.Deficient, Provider has date of correction (August 12, 2023)
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (August 12, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (August 12, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Waiver has been granted (November 29, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (August 12, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (September 5, 2023)

June 9, 2022 — 5 citations

Citations issued on June 9, 2022
TagWhat the surveyor checksStatus
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (July 15, 2022)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (July 15, 2022)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (July 15, 2022)
K-0914Ensure 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 15, 2022)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (August 15, 2022)

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