Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ARCADIA CARE HAVANA
HAVANA, IL · 98 certified beds · Last Life Safety survey March 21, 2025
CMS Certification Number 145774 · first certified February 1994
Ownership
Operated by ARCADIA CARE · For profit - Limited Liability company
- New ownershipOwnership changed December 1, 2024 (change of ownership)from HAVANA HCO LLC
Position within IL
44 citations — more than 95% 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 13 citations; the earlier surveys in the window averaged 15.5. 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 (February 2026 to May 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was March 2025. 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
16 of the 44 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)
13 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 44 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-0880 Provide and implement an infection prevention and control program.
- 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-0908 Keep all essential equipment working 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 | 44 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 3, 2023 | 14 |
| June 7, 2024 | 17 |
| March 21, 2025 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | 3 | 2025-03-21 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-03-21 |
| K-0324 | Provide properly protected cooking facilities. | 3 | 2025-03-21 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2025-03-21 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-03-21 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 2 | 2024-06-07 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2025-03-21 |
| E-0037 | Establish staff and initial training requirements. | 2 | 2024-06-07 |
What the citations cover
- Smoke Deficiencies 16
- Emergency Preparedness Deficiencies 16
- Miscellaneous Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 16 |
| Emergency Preparedness Deficiencies | 16 |
| Miscellaneous Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Construction Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 21, 2025 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (March 21, 2025) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (March 21, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 2, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 15, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 21, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (March 28, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 25, 2025) |
June 7, 2024 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 12, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (July 12, 2024) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (July 12, 2024) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (July 12, 2024) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (July 12, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (July 12, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 12, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 12, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 12, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (July 12, 2024) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (July 12, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 12, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 30, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 12, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (July 12, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 12, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 12, 2024) |
May 3, 2023 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 5, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (June 5, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (June 5, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (June 5, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (June 5, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 5, 2023) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (June 5, 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. | Deficient, Provider has date of correction (June 5, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 5, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 5, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 5, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 5, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (June 5, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 5, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.