Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ST CLARA'S REHAB & SENIOR CARE
LINCOLN, IL · 99 certified beds · Last Life Safety survey February 5, 2025
CMS Certification Number 145720 · first certified April 1992
Ownership
Operated by HERITAGE OPERATIONS GROUP · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
21 citations — more than 66% 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 7 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 (January 2026 to March 2026), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was February 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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3 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
3 of the 21 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)
2 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 21 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 | 21 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 17, 2022 | 4 |
| May 3, 2024 | 10 |
| February 5, 2025 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 3 | 2025-02-05 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2025-02-05 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-02-05 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2024-05-03 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-02-05 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2022-11-17 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-05-03 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2025-02-05 |
What the citations cover
- Smoke Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 3
- Emergency Preparedness Deficiencies 3
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 5, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (February 14, 2025) |
| 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 (February 26, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 28, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 26, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (February 25, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (February 25, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 25, 2025) |
May 3, 2024 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (May 21, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 3, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (May 21, 2024) |
| 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 (May 22, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 18, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 29, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 21, 2024) |
| 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 (May 24, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 21, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (May 24, 2024) |
November 17, 2022 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (January 4, 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 (December 9, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 9, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 30, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.