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

MOUNT STERLING HEALTH AND REHAB CENTER

MOUNT STERLING, IL · 80 certified beds · Last Life Safety survey February 28, 2024

CMS Certification Number 145820 · first certified January 1995

Ownership

Operated by SUMMIT HEALTHCARE CONSULTING · For profit - Limited Liability company

  • Ownership changed July 1, 2023 (change of ownership)from HERITAGE MANOR - MT. STERLING, LLC
13
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
7
Inspection & testing records
Of the citations on file

Position within IL

13 citations — more than 44% 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

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 4 citations; the earlier surveys in the window averaged 4.5. 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 (January 2025 to April 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was February 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

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

2 of the 13 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 13 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-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-0880 Provide and implement an infection prevention and control program.

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 facility13IL median15National median11
Citations on file over three years, compared
MeasureCitations
This facility13
Median facility in IL15
Median facility nationally11

Survey history

Citations at each Life Safety survey
22021-1072022-1242024-02
Citations at each Life Safety survey
Survey dateCitations
October 7, 20212
December 15, 20227
February 28, 20244

Most-cited tags

Most-cited tags at this facility
K-09182K-07122K-03532K-07611K-01331K-09141K-03411E-00391
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.22024-02-28
K-0712Have simulated fire drills held at unexpected times.22024-02-28
K-0353Inspect, test, and maintain automatic sprinkler systems.22024-02-28
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.12022-12-15
K-0133Install a two-hour-resistant firewall separation.12022-12-15
K-0914Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.12022-12-15
K-0341Install a fire alarm system that can be heard throughout the facility.12022-12-15
E-0039Conduct testing and exercise requirements.12022-12-15

What the citations cover

Citations by CMS category
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Smoke Deficiencies 3
  • Miscellaneous Deficiencies 3
  • Emergency Preparedness Deficiencies 2
  • Other 1
Citations by CMS category
CategoryCitations
Gas, Vacuum, and Electrical Systems Deficiencies4
Smoke Deficiencies3
Miscellaneous Deficiencies3
Emergency Preparedness Deficiencies2
Construction Deficiencies1

Every citation on file

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

February 28, 2024 — 4 citations

Citations issued on February 28, 2024
TagWhat the surveyor checksStatus
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (March 15, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (March 15, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (March 15, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (April 10, 2024)

December 15, 2022 — 7 citations

Citations issued on December 15, 2022
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (February 16, 2023)
K-0133Install a two-hour-resistant firewall separation.Deficient, Provider has date of correction (January 6, 2023)
K-0341Install a fire alarm system that can be heard throughout the facility.Deficient, Provider has date of correction (January 6, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (January 10, 2023)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (January 6, 2023)
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 (January 6, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (January 6, 2023)

October 7, 2021 — 2 citations

Citations issued on October 7, 2021
TagWhat the surveyor checksStatus
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (November 12, 2021)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (November 12, 2021)

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