Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MARSHALL REHAB & NURSING
MARSHALL, IL · 75 certified beds · Last Life Safety survey April 12, 2024
CMS Certification Number 146046 · first certified June 2003
Ownership
Operated by STERN CONSULTANTS · For profit - Partnership
- Ownership changed August 1, 2019 (change of ownership)to MARSHALL REHABILITATION AND NURSING from BURNSIDES COMMUNITY HEALTH CENTER
Position within IL
15 citations — more than 50% 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 4 citations; the earlier surveys in the window averaged 5.5. 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 (March 2025 to May 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was April 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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2 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
2 of the 15 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)
4 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 15 Life Safety citations above. The Physical Environment Index
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 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 | 15 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 25, 2022 | 2 |
| June 2, 2023 | 9 |
| April 12, 2024 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-04-12 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2024-04-12 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2023-06-02 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-06-02 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 1 | 2023-06-02 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 1 | 2023-06-02 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2022-03-25 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-04-12 |
What the citations cover
- Smoke Deficiencies 8
- Emergency Preparedness Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Miscellaneous Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Emergency Preparedness Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Egress Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 12, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 7, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 7, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (May 7, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 23, 2024) |
June 2, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (August 11, 2023) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (August 11, 2023) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (August 7, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (August 7, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 22, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (August 11, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 18, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 9, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 7, 2023) |
March 25, 2022 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 30, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 21, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.