Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evercare Of Jerseyville during CMS and state inspections, most recent first.
Failure to Screen Resident Criminal History Led to Resident-to-Resident Sexual Abuse A resident with a documented criminal history was admitted without proper screening, reporting, or risk assessment, and later exposed himself and grabbed another resident’s breast. The victim was severely cognitively impaired and dependent on staff, while the other resident was cognitively intact and had multiple criminal convictions, but the facility did not notify the ISP Identified Offender Program or document a risk level in the care plan.
A resident with dementia, stroke-related left-sided weakness, limited mobility, and incontinence was left with her call light out of reach while seated in her wheelchair after being moved to her room. She stated she had wet herself, could not reach the call light, and sat wet for hours, reporting anger, embarrassment, feeling like a burden, and depression. Staff and the physician stated she could use the call light when it was within reach.
A facility failed to protect a severely cognitively impaired resident from sexual abuse by another resident with a criminal felony background. Staff witnessed the resident expose himself and grab the other resident’s breast, but the incident was later deemed unsubstantiated despite CNA witness statements. The aggressor’s care plan noted prior convictions, yet no risk level or criminal risk assessment was documented, and the DON/Administrator did not notify the Identified Offender Program.
Incomplete and delayed incontinent care was observed for multiple residents with bowel and bladder incontinence. A resident sat in urine for hours despite stating she needed cleaning, and when care was finally provided it was incomplete; she later said she felt angry, embarrassed, depressed, and like a burden. Other residents also received partial peri-care, with staff failing to cleanse all required areas and, in one case, failing to rinse and dry after using body wash.
Failure to post daily staffing information was observed when surveyors did not see staffing posted in the lobby or halls, and the ADON stated she had not posted it that week. The Administrator said there was no policy on staffing postings, while the RDO stated the facility would follow State and Federal guidelines for daily staffing postings. The facility had 55 residents.
Expired and improperly labeled medications were found in the med room refrigerator and on a C-Hall med cart. Surveyors observed expired influenza vaccine, an open Aplisol vial beyond the allowed use period, and multiple open meds without open dates, while an LPN, DON, ADON, RN, and Administrator all acknowledged that open meds should be dated and expired meds discarded.
Dietary staff were observed failing to follow food safety and infection control practices during kitchen operations and meal service. The Dietary Manager and other dietary staff were seen without proper hair coverage or with hair exposed outside hair nets, expired and undated food items were found in storage and in a refrigerator, and staff handled food, utensils, gloves, and resident meal trays without proper hand hygiene. A Cook also used bare hands to handle a utensil that fell into food and then continued serving meals.
Failure to perform hand hygiene and use PPE during resident care and laundry handling. A CNA fed two residents and assisted others at the table without hand hygiene between tasks, a laundry aide handled isolation linen without gown or gloves, a CNA provided care to a resident on EBP without donning gown or gloves, and two CNAs used a soiled overbed table during incontinent care. Facility policies required hand hygiene before and after resident contact and PPE for high-contact care and soiled linen handling.
The facility failed to ensure CNAs completed the required 12 hours of annual education, including dementia care and abuse prevention training. Interviews with the ADON, DON, Administrator, and CNAs showed training was mainly orientation and floor training, with monthly in-services, but the training binder did not track hours and several CNAs did not recall abuse or dementia training. Record review showed the sampled CNAs had only 0.0 to 10.5 hours of training, with multiple CNAs missing abuse prevention and dementia education.
Delayed response to resident call lights. Four cognitively intact residents stated that call lights were not answered timely, and resident council minutes repeatedly documented the same concern over several months. A CNA reported that some days there is not enough staff and that call lights are answered when staff can get to them, with delays occurring while providing care to someone else. Facility policy required timely, courteous response to call lights and for all staff to assist.
Failure to implement documented fall interventions for multiple residents with high fall risk and severe cognitive impairment. Surveyors observed missing recliner mats, a resident eating lunch in a wheelchair instead of the ordered regular chair, and missing bed supports and other care plan interventions for residents with repeated falls, while an RN and ADON confirmed the interventions were not in place as documented.
Failure to identify and monitor lap tray use as a restraint: Two residents were observed with lap trays attached across their laps in reclining wheelchairs, and one could not remove the tray on request while the other was lethargic and unable to respond. The facility had no restraint assessment, care plan, or physician order for the lap trays, and staff stated the devices were being used routinely, including at the request of a family member and with hospice involvement.
Failure to Provide Eating Assistance: A resident with poor food intake and documented weight loss was observed eating in the dining room without needed touch assistance or encouragement. The resident ate cereal and drank fluids, but later handled scrambled eggs with his hands and left part of the meal uneaten while a CNA only asked about drinks and coffee. Records showed a regular diet, a care plan for unplanned weight loss, MDS coding for eating supervision or touch assistance, and a significant drop in weight.
Failure to provide feeding assistance for a resident with weight loss. A resident was observed in the dining room eating breakfast, but a CNA only offered more to drink and coffee and did not provide touch assistance or encouragement to finish the remaining eggs and biscuit. The resident’s record documented unplanned weight loss, RD follow-up for weight variance, a regular diet order, and an MDS indicating supervision or touch assistance for eating.
A resident with multiple medical conditions and a moderate risk for pressure ulcers developed a new Stage 2 pressure ulcer after staff failed to consistently implement care plan interventions, such as providing a pressure-relieving cushion and regular repositioning. The resident was observed in a wheelchair without appropriate pressure-relieving devices, and staff did not ensure interventions were in place as required by facility policy.
The facility failed to employ a Registered Nurse as the Director of Nursing (DON), affecting all 41 residents. The position has been vacant since 6/28/24, with duties split between the Administrator and an LPN/MDS Nurse. Despite efforts to fill the role, including job ads and interviews, the facility remains without a DON, lacking a dedicated full-time nurse to oversee operations.
The facility failed to maintain food safety and sanitation standards, affecting all 41 residents. Observations included unlabeled and undated food items, improper hand hygiene by a cook, and unclean cooling units in the kitchen. The Dietary Manager acknowledged the need for labeling and cleaning but had not implemented these practices.
The facility failed to appoint a qualified individual for the Infection Prevention and Control Program, affecting 41 residents. After the DON left, the Administrator and an LPN shared infection control duties, but the LPN lacks certification, and the Administrator has limited medical knowledge. This arrangement does not meet the facility's policy requiring a part-time Infection Preventionist.
The facility failed to provide adequate incontinent care, resulting in multiple residents developing UTIs. Residents were not assisted with toileting in a timely manner, and proper cleaning techniques were not followed. Care plans requiring regular checks and thorough cleaning were not adhered to, contributing to the residents' conditions. The facility's perineal cleansing policy was not consistently implemented, leading to deficiencies in care.
A long-term care facility failed to adhere to infection control protocols, including inadequate hand hygiene, improper use of PPE, and lack of isolation signage. Staff members were observed not changing gloves between tasks and not performing hand hygiene, increasing the risk of cross-contamination. Residents with indwelling medical devices and infections were not properly isolated, and staff were unaware of Enhanced Barrier Precautions requirements.
A resident reported being kicked by a prior DON, causing a fall and requiring a mechanical lift. Despite the resident's cognitive intactness and reporting the incident to her doctor and staff, the facility failed to document or report the incident to IDPH. The administrator, unaware of the allegations until informed by surveyors, did not investigate further or report the incident, violating the facility's Resident Rights Policy.
A cognitively intact resident reported being kicked by a prior DON, causing a fall and requiring a mechanical lift. Despite the report, the facility failed to document or investigate the incident, violating its Resident Rights Policy.
A resident experiencing gradual weight loss did not receive prescribed nutritional supplements during a meal, and staff failed to intervene or document the refusal to eat. Despite specific dietary orders to add ice cream to meals, the resident did not receive it, and staff did not follow the care plan interventions to address poor intake.
A facility failed to manage a resident's G-tube care properly, as an LPN administered water and medications without checking for residuals, contrary to policy. Additionally, CNAs lowered the resident's bed to a flat position while the feeding pump was running, unaware of the requirement to stop the pump. The resident was severely cognitively impaired with a diagnosis of Chromosomal abnormality and Gastrostomy.
A facility failed to provide assistive eating devices for a resident, leading to the resident using their hands to eat. Observations showed the resident using a regular spoon and their hand to scoop food, with food falling onto the table and bib. The care plan noted a self-care deficit but did not specify adaptive equipment. The therapy director was unaware of the issue.
The facility did not post ombudsman contact information, as required, affecting all 41 residents. Several residents were unaware of this information, and a surveyor confirmed its absence. The administrator admitted there was no specific policy for posting this information, despite following state guidelines.
The facility failed to post survey results, affecting all 41 residents. During a resident council meeting, several residents were unaware of the survey results' availability. The Administrator confirmed the results were not available and acknowledged the absence of a policy for posting them, despite following Illinois Department of Public Health guidelines.
Failure to Screen and Track Resident Criminal History Led to Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse and resident background check policies by not screening for potentially abusive residents during the admission process, not reporting and tracking residents with qualifying criminal offenses, not completing a risk assessment, and not putting protective measures in place to prevent abuse. The deficiency involved one resident reviewed for abuse in a sample of 35 and was identified as an Immediate Jeopardy after a resident with a criminal history was admitted without appropriate screening, referrals, or interventions and later sexually abused another resident. The Immediate Jeopardy was identified as affecting all 55 residents in the facility. One resident involved in the incident had diagnoses including Parkinsonism, dementia, osteoporosis, atherosclerotic heart disease, polyneuropathy, and cognitive communication deficit. His MDS documented severe cognitive impairment and dependence on staff for ADLs and mobility. Another resident involved in the incident had diagnoses including major depressive disorder, morbid obesity, hypertension, restlessness and agitation, panic disorder, psychophysiologic insomnia, and anxiety disorder, and was documented as cognitively intact and able to propel himself in a wheelchair. The incident occurred when staff observed the resident with the criminal history expose his genitals to the other resident and then grab her breast. Staff removed him from the area, and the other resident was returned to sleep with no immediate injury noted. Witness statements described the resident continuing to expose himself, grabbing the other resident’s breast, and later attempting to bite staff. The facility’s records showed the resident had multiple criminal convictions, including retail theft, battery, aggravated battery, burglary, criminal trespass to buildings, and violations of order of protections, but the facility did not notify the Identified Offender Program, did not complete a criminal risk assessment, and did not document the resident’s risk level in the care plan.
Call Light Left Out of Reach for Resident Needing Assistance
Penalty
Summary
The facility failed to ensure that R24’s call light was within reach, despite care plan interventions stating that R24 needed a working and reachable call light and could use the bell to call for assistance. R24’s care plan documented dementia, impaired balance, limited mobility, limited range of motion, stroke with left-sided weakness, confusion, gait and balance problems, incontinence, and dependence on staff for activities of daily living. The MDS documented that R24 was cognitively impaired, always incontinent of bowel and bladder, and dependent on staff for ADLs. On 12/8/2025, R24 was transported from the dining room to her room and placed at the foot of the bed, where she was observed slumped and leaning forward and to the right side. R24 stated she had used the bathroom on herself and needed to be cleaned, while her call light was located at the top of the bed and remained out of reach. R24 was heard calling for the call light and was later observed reaching for it, but from 10:00 AM to 11:00 AM she remained in her wheelchair with the call light still out of reach and not on. At 1:28 PM, R24 was assisted to bed and placed on a bedpan, and at 1:56 PM the call light was on and staff responded to provide incontinent care. On 12/10/2025, R24 stated she had sat wet for hours, said it happens all the time, and reported feeling angry, embarrassed, like a burden, and depressed. Staff and the physician stated R24 could use her call light when it was in reach, and the physician stated it should always be in reach when she was in the room.
Failure to Protect Resident from Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a severely cognitively impaired resident from physical and sexual abuse by another resident with a documented criminal felony background. R54 had diagnoses including Parkinsonism, dementia, osteoporosis, atherosclerotic heart disease, polyneuropathy, and cognitive communication deficit, and was dependent on staff for activities of daily living and mobility. R62 had diagnoses including major depressive disorder, morbid obesity, hypertension, restlessness and agitation, panic disorder, psychophysiologic insomnia, and anxiety disorder, and was cognitively intact and able to ambulate with supervision or touching assistance. R62’s care plan noted a criminal felony background including retail theft, battery, and aggravated battery, but did not document a risk level. During the incident, staff observed R62 exposing his genitals in the hall near the nurse’s station and then moving toward R54. Staff told R62 the behavior was inappropriate, but he laughed and continued. R62 then reached out and grabbed R54’s breast. Staff removed R62 from the situation and took him to another room. The record also documented that R62 later entered female residents’ rooms and continued disruptive behavior, including grabbing at staff and attempting to bite a CNA. The facility’s investigation documented witness statements from CNAs who saw R62 expose himself to R54 and grab her right breast. Despite these statements, the facility concluded the allegation was unsubstantiated and stated there was no serious injury or harm, no redness, discoloration, or pain. The Administrator stated the facility did not notify the Identified Offender Program of R62’s criminal convictions, no criminal risk assessment was completed, and no police report was made for the resident-to-resident abuse incident.
Incomplete and Delayed Incontinent Care
Penalty
Summary
The facility failed to provide timely and complete incontinent care for multiple residents who were incontinent of bowel and/or bladder. R24’s care plan directed staff to change briefs every 2 hours and as needed, clean the peri-area with each incontinence episode, and check the resident every 2 hours. On 12/8/2025, R24 was observed sitting in urine for several hours after stating she had used the bathroom on herself and needed to be cleaned. Staff did not provide toileting or incontinent care during that period, and when care was finally provided, the cleansing was incomplete because the left buttock, inner thighs, and suprapubic area were not cleansed. R24 was documented as alert, oriented, and able to communicate her needs, and later stated she sat wet for hours, felt angry, embarrassed, depressed, and like a burden. R7’s care plan directed staff to change briefs every 2 hours and clean the peri-area after each incontinent episode. During observed incontinent care, R7 was incontinent of urine and stool, and staff cleansed the groin and part of the buttocks but did not cleanse the inner thighs, suprapubic area, outer labia, or the entire right buttock. R8’s care plan directed peri-care after each incontinent episode. During observed care, staff cleansed the groin, scrotum, penis, and rectal area, but did not retract the foreskin to cleanse, did not cleanse the inner thighs or buttocks, and did not dry the resident before applying a clean brief. R22’s MDS documented that the resident was cognitively intact, always incontinent, and dependent on staff for toileting hygiene, but the care plan did not address incontinence needs. During observed care, staff removed a urine-saturated brief and cleansed only part of the labia and buttock, without cleansing the inner labia or outer hip region. The CNA used body wash but did not rinse or dry the resident after cleansing. The ADON stated staff should cleanse the inner labia and buttocks during peri-care and that the facility body wash was not a no-rinse wash, so it should have been rinsed and dried.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information each day. On 12/8/25 at 8:00 AM, surveyors entered the facility and did not see daily staffing posted on the boards or walls in the front lobby or halls. On 12/9/25 at 4:30 PM, the daily staffing was still not posted, and on 12/10/25 at 8:00 AM it remained unposted. At 8:30 AM on 12/10/25, the ADON stated that she was the person who posts the daily staffing and had not done it that week. She said she usually posts it by the front door or by the DON's office. Later that day, the Administrator stated there was no policy on posting staffing and that staff would be expected to post it daily. The Regional Director of Operations stated the facility would follow State and Federal guidelines for posting daily staffing. The CMS 671 dated 10/8/25 documented that 55 residents resided in the facility.
Expired and Undated Medications Found in Storage
Penalty
Summary
Medication storage and labeling were not maintained in accordance with accepted professional principles. During inspection of the medication room refrigerator, surveyors observed 3 boxes of influenza vaccine with an expiration date of 6/2025 and one open, partially used multidose vial of Aplisol with a handwritten open date of 11/1/25. The package insert for Tuberculin (Aplisol) documented that a vial entered and in use for 30 days should be discarded. A Licensed Practical Nurse stated the facility did administer influenza, confirmed the influenza vaccine was expired and should not have been in the refrigerator, and verified the Aplisol vial should have been destroyed. The nurse also stated both products were stock medications used for residents with an order and no allergy. Surveyors also observed the C-Hall medication cart with expired and improperly labeled medications. Aspirin 325 mg had an expiration date of 10/2025 and an open date of 8/12/24, CoQ10 100 mg had an expiration date of 10/2025 and no open date, and multiple other open medications in the cart did not have an open date written on the bottle, including Tylenol 500 mg, Vitamin C 500 mg, Tylenol 325 mg, Vitamin B12, Arthritis Pain/Tylenol 650 mg, Vitamin B Complex, Magnesium Oxide 400 mg, MVI with Iron, Ibuprofen 200 mg, Tums, Mucous Relief 600 mg, Calcium 500 mg, Iron Tabs, Geri-Kot 8.6 mg, Iron 27 mg, Melatonin 3 mg, Loratadine 10 mg, and Docusate 100 mg. The DON, ADON, RN, and Administrator each stated that open medications should be dated when opened and expired medications should be discarded. The facility policy also required expired medications and biologicals to be removed from use and opened medications to follow manufacturer or supplier expiration guidance.
Food Storage, Hair Covering, and Hand Hygiene Failures During Meal Service
Penalty
Summary
The facility failed to dispose of expired food items, failed to ensure dietary staff wore proper hair nets and beard coverings, and failed to follow infection control practices during food preparation and service. During kitchen observations, the Dietary Manager was seen in the kitchen without a hair net, with short hair, a mustache, and a beard. Other dietary staff were observed with hair nets on, but with large amounts of hair coming out from the front, sides, and back of the hair nets while working in the kitchen, assisting with food, and serving meals. Expired and improperly stored food items were found in the kitchen and storage areas. In the main kitchen refrigerator, there was a gallon jug of Aloe Gel marked "Do Not Eat" and "Not for Internal Use." A bag of dried au gratin potato slices dated 10/28/24 was also found, and the Dietary Manager stated the item was left over from the previous company. In the storage room, resident food items brought in by family were kept in a plastic container on a shelf, and the Cook stated that expiration dates were not checked on any food brought in by family. Items found included a soup mix with an expiration date of 9/19/25, an opened bag of French dried onions with an expiration date of 12/2/25, and multiple ranch dressing mix packets with no visible expiration or use-by date and no date written on them. During lunch service, staff were observed handling food and utensils without proper hand hygiene and with unsafe glove use. One Cook used bare hands to handle utensils, removed a scoop from pureed stew with bare hands after it fell into the food, wiped it off, left it in the pan, and then used it to serve residents. The same Cook then donned gloves without hand hygiene and continued serving food while touching lids, utensils, dishes, and desserts, and also served cornbread with her hands. Another Dietary Aide donned gloves, handled food packages, assembled a sandwich, removed gloves, and put on new gloves without hand hygiene before assisting with lunch trays. Multiple staff were also observed taking trays to residents in the dining room without hand hygiene. The Administrator stated dietary staff should keep hair inside hairnets and perform hand hygiene and infection control practices while serving food.
Failure to Perform Hand Hygiene and Use PPE During Resident Care and Laundry Handling
Penalty
Summary
The facility failed to perform hand hygiene and to use appropriate PPE during resident care and laundry handling. On 12/9/25, a CNA was observed feeding two residents while seated between them, turning from one resident to the other without performing hand hygiene between feeding tasks and while also assisting other residents at the table with drinks. The DON later stated that staff should perform hand hygiene when assisting residents with feeding and should not feed one resident after another without hand hygiene in between. The facility also failed to ensure PPE was worn during isolation laundry handling. The Housekeeping/Laundry Supervisor described that isolation linen and trash are placed in red bags, transported in a yellow barrel to the laundry room, washed using the washer's isolation setting, and that staff handling this laundry should wear PPE including gown and gloves. However, the Laundry Aide stated she wore only what she had on and that no gowns or other PPE were available in the laundry room. The supervisor stated she had not been aware PPE was unavailable and would make sure it was provided. The facility further failed to follow enhanced barrier precautions and infection control practices during resident care. A CNA entered a resident's room, pushed the resident in a wheelchair, transferred the resident to bed, and pulled the resident's pants down without donning gown or gloves, despite signage outside the room indicating enhanced barrier precautions and the resident having a pressure sore to the right hip. In another observation, two CNAs performed incontinent care for a resident while using a soiled overbed table to wet washcloths, place wipes, and cleanse the resident's peri area. The facility's policies stated that hand hygiene should be performed before and after resident contact and after contact with resident equipment, and that gown and gloves are required for high-contact care activities such as dressing, hygiene, linen changes, incontinence care, medical device care, and wound care.
CNA Annual Training and Required Dementia and Abuse Education Not Maintained
Penalty
Summary
The facility failed to ensure the continuing competence of Certified Nursing Assistants by not providing the required 12 hours of annual education and training, including dementia management and resident abuse prevention training, for the sampled CNAs. During interview, the ADON stated new CNAs receive orientation, at least 3 days of floor training with a peer, monthly in-services, and yearly competencies, and the Administrator stated the training binder did not list training hours and that hours would have to be added up from each in-service. The DON stated staff training, including CNA annual training for abuse and dementia, is done by the DON or ADON. Record review showed that none of the reviewed CNAs had completed a total of 12 hours of annual training. Of the nine CNAs reviewed, only three had abuse training and four had dementia training. Individual CNA in-service records documented multiple staff with limited training hours, including one CNA with 10.5 hours and missing dementia training, another with 3.0 hours and missing abuse prevention and dementia training, another with 8.5 hours and missing both, another with 5.0 hours, another with 3.0 hours and missing abuse prevention training, another with 3.0 hours and missing abuse prevention training, another with 3.5 hours and missing both, another with 0.5 hours and missing both, and another with 0.0 hours and missing both. The facility policy dated 11/1/25 stated CNAs are required to obtain 12 hours of continuing education provided by the facility during in-services and 1:1 interaction, and the CMS 671 documented 55 total residents in the facility.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to answer call lights in a timely manner for 4 of 24 residents reviewed for call lights in a sample of 35. During a resident group meeting on 12/9/2025, R2, R6, R12, and R30 all stated that call lights were not being answered timely. The MDS for each of these residents documented that they were cognitively intact. Resident council minutes from 6/2/2025, 8/4/2025, 10/6/2025, and 12/2/2025 documented repeated resident concerns that call lights were taking too long to be answered. On 12/10/2025, a CNA stated that some days there is not enough staff and that call lights are answered when staff can get to them; the CNA also stated that delays occur when providing care to someone else. The facility policy stated that resident call lights are to be answered in a timely and courteous manner, that all staff should assist in answering call lights, and that nursing staff should promptly cancel the call light when entering the room.
Failure to Implement Documented Fall Interventions
Penalty
Summary
The facility failed to implement fall interventions that were documented in the care plans for 4 of 9 residents reviewed for accidents. Surveyors observed that interventions listed for residents with high fall risk, severe cognitive impairment, and significant transfer assistance needs were not in place as documented, including missing equipment and missing environmental supports intended to reduce falls. For one resident with stroke-related right-sided weakness, confusion, gait and balance problems, and severe cognitive impairment, the care plan directed staff to place Dycem in the recliner chair, but surveyors observed the recliner without the mat on two separate occasions. The resident had a history of multiple falls and required substantial to maximal assistance for transfers. For another resident with flaccid hemiplegia and severe cognitive impairment, the care plan directed that the resident be placed in a regular chair at meals after a fall review, but the resident was observed eating lunch in a wheelchair. An RN stated the resident should have been in a regular chair at lunch and not in the wheelchair. For a third resident with pulmonary fibrosis, dementia, aphasia, dysphagia, bipolar disorder, depression, malnutrition, and severe cognitive impairment, the care plan documented a bolster mattress intervention, but surveyors observed no bolsters on the mattress and the ADON agreed the bed did not have bolsters. For a fourth resident with epilepsy, dementia, moderate intellectual disabilities, glaucoma, anxiety, severe cognitive impairment, and repeated falls, the care plan included multiple fall interventions such as a bolster mattress, floor bed, and signs to prompt assistance, but surveyors observed the bed without a bolster mattress, not in the lowest position, and without the documented sign in the room. The ADON stated the resident was high risk for falls, was confused and unaware of safety problems, and that the care plan interventions were supposed to be in place.
Failure to Identify and Monitor Lap Tray Use as a Restraint
Penalty
Summary
The facility failed to identify and monitor the use of lap trays for 2 residents reviewed for restraints. The report states that the facility did not complete a restraint assessment on one resident’s lap tray, did not care plan the lap tray, and did not document its use. The facility’s restraint policy defined a physical restraint as equipment attached or adjacent to the resident’s body that the individual cannot remove easily and that restricts freedom of movement, and it also identified lap trays as a form of postural support when used for positioning rather than restriction. One resident had diagnoses including vascular dementia, anxiety, and depression. The resident’s care plan did not address the lap tray or restraint use, the MDS documented cognitive impairment and dependence on staff for care, and the physician orders did not include an order for a lap tray or restraint. During observation, the resident was sitting in a reclining wheelchair with a lap tray attached and secured across the lap and was not able to remove it upon request. A second resident was observed in a reclining wheelchair with a lap tray in place and was lethargic and did not respond to questions during the observation. Nursing staff stated that the resident used the lap tray when up except while eating, that the resident’s daughter insisted on its use because the resident slid out of the chair, and that hospice provided the lap tray. The nurse stated the resident could sometimes remove the lap tray but other times could not. The ADON stated the facility had not completed a restraint assessment, had not care planned the lap tray, and had not been documenting its use.
Failure to Provide Eating Assistance
Penalty
Summary
The facility failed to provide eating assistance for 1 of 24 residents reviewed for assistance with eating. On 12/09/2025, the resident was observed in a wheelchair in the dining room eating cooked cereal, with orange juice and water in front of him and a plate of scrambled eggs and biscuit with jelly on the table. At 8:47 AM, he was observed eating scrambled eggs with his hands. He finished the cereal and water, drank all of the orange juice, and later turned the plate clockwise and touched the eggs with his hands while the biscuit and eggs remained on the plate. At 9:03 AM, a CNA approached the table and asked if the resident wanted more to drink and requested coffee, but did not provide touch assistance or encouragement to eat the scrambled eggs or biscuit. The resident had 50% of the scrambled eggs and one-half of the biscuit remaining. Records showed the resident had a regular diet and a care plan for unplanned weight loss related to poor food intake. The MDS documented eating supervision or touch assistance, and the weight summary showed a decline from 169.6 pounds on 8/29/2025 to 152 pounds on 12/5/2025. The RD note documented a 5% weight loss over 30 days and a goal for intake to remain greater than 50% with no significant weight change.
Failure to Provide Feeding Assistance for Resident With Weight Loss
Penalty
Summary
The facility failed to provide feeding assistance for a resident with documented weight loss. On 12/09/2025 at 8:00 AM, the resident was observed sitting in a wheelchair in the dining room eating cooked cereal from a bowl, with orange juice and water in front of him and scrambled eggs and a biscuit with jelly on the table. By 8:47 AM, the resident was observed eating scrambled eggs with his hands. He consumed all of the cooked cereal and water, and by 8:55 AM he drank all of the orange juice. At 8:58 AM, he turned the plate clockwise with the biscuit, jelly, and scrambled eggs, and touched the eggs with his hands. At 9:03 AM, a CNA approached and asked if he wanted more to drink and requested coffee, but did not provide touch assistance or encouragement to eat the scrambled eggs or biscuit. At that time, 50% of the scrambled eggs and one-half of the biscuit remained on the plate. The resident’s record showed a dietary note dated 11/11/2025 documenting RD follow-up for weight variance. The note stated he was on a regular diet with intake noted as 51-100% of meals, and his weight on 11/6/2025 was 151 pounds. The note also documented a 5% loss over 30 days, or 8 pounds, with a goal for intake to remain greater than 50% and no significant weight change. The physician order dated 8/29/2025 ordered a regular diet, regular texture, and thin consistency. The care plan dated 9/2/2025 documented unplanned/unexpected weight loss related to poor food intake, and the MDS documented eating supervision or touch assistance. The weight summary showed a weight of 169.6 pounds on 8/29/2025 and 152 pounds on 12/5/2025. The Administrator stated the resident weighed 169 pounds on admission from the hospital, and the ADON stated staff would be expected to provide assistance and cueing if needed during meals.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident with multiple complex medical diagnoses, including hypertensive heart disease with heart failure, HIV, COPD, acute myocardial infarction, and cerebral infarction, was admitted to the facility and assessed as being at moderate risk for pressure ulcer development. The resident's care plan identified the potential for pressure ulcer development and included interventions such as keeping the bed as flat as possible, using a pressure-relieving device on the bed and chair, and repositioning with assistance. Despite these documented interventions, staff failed to implement them consistently. On assessment, a new Stage 2 pressure ulcer was discovered on the resident's left buttock, which was determined to be acquired in-house. Staff interviews and observations revealed that the resident was often up in a wheelchair without a pressure-relieving cushion or device, contrary to the care plan. The resident reported having had a cushion previously but was unsure of its current whereabouts and stated that no action had been taken regarding the new pressure ulcer. Staff acknowledged encouraging the resident to use a recliner or cushion but did not ensure these interventions were in place. Facility policy required regular assessment and implementation of interventions for pressure ulcers, but these were not followed, resulting in the development of a new pressure ulcer for the resident.
Facility Lacks Director of Nursing
Penalty
Summary
The facility failed to employ a Registered Nurse as the Director of Nursing (DON), which has the potential to affect all 41 residents residing in the facility. The deficiency was identified through interviews and record reviews. On multiple occasions, the facility's Administrator, identified as V1, confirmed that the facility had been without a DON for over a month, with the last DON's day being on 6/28/24. Despite efforts to fill the position, including running and refreshing job advertisements weekly and conducting interviews, the position remained vacant. The facility's schedule for August 2024 did not list any hours for a DON, and there was no staffing policy in place, with the facility following the Illinois Department of Public Health guidelines instead. In the absence of a DON, the duties were being divided between the Administrator (V1) and a Licensed Practical Nurse/Minimum Data Set (MDS) Nurse (V11). V11 reported handling most of the DON's responsibilities, including investigating incidents, scheduling for Certified Nursing Assistants (CNAs) and nurses, and maintaining the infection book. V1, a salaried employee, incorporated DON duties into their 40-hour workweek without specific hours allocated for these tasks. This arrangement was confirmed by both V1 and V11, indicating a lack of a dedicated full-time DON to oversee nursing operations, which is a requirement for the facility.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards, which could potentially affect all 41 residents. During an inspection, it was observed that the kitchen's stand-up freezer contained a box of pre-made omelets that were not sealed and had freezer burn. The walk-in refrigerator had several items that were not labeled or dated, including a storage container of red liquid, opened cartons of tomato juice, an opened package of hot dogs, a plastic container of mandarin oranges, a stainless steel container of tomatoes, and storage bags of meat. The Dietary Manager acknowledged that all items should be labeled and dated with an open and expiration date. Additionally, a cook was observed donning gloves without performing hand hygiene before serving the noon meal. The facility also had issues with cleanliness, as the cooling unit fan cover in the walk-in refrigerator and the wall-mounted kitchen air conditioner were covered in a thick black layer of debris. These units blow air onto food preparation areas, potentially contaminating the food. The Dietary Manager admitted awareness of the need to clean the cooling unit grate but had not done so due to its continuous operation. The facility's policy requires labeling and dating of food, but these practices were not followed, leading to the deficiency.
Inadequate Infection Preventionist Designation
Penalty
Summary
The facility failed to designate a qualified individual responsible for the Infection Prevention and Control Program, which has the potential to affect all 41 residents. The Director of Nursing (DON) left the facility on 6/28/24, and since then, the Administrator (V1) and an LPN/MDS Nurse (V11) have been covering the DON's duties, including infection control. The Administrator, who is a certified Infection Preventionist but lacks a medical background beyond a Basic Life Support course, collaborates with the LPN to manage infection control tasks. However, the LPN does not have an Infection Preventionist Certification and primarily handles the infection log and antibiotic reviews. The facility's policy requires at least a part-time Infection Preventionist, which can be the DON with an approved certification. Despite this, the Administrator and LPN are sharing the infection control responsibilities without dedicated hours for these duties. The Administrator relies on the LPN for medical insights, such as understanding lab results and appropriate antibiotic use, due to her lack of nursing qualifications. The report highlights that the facility's current infection control practices do not align with their policy, as there is no qualified individual solely responsible for the program.
Inadequate Incontinent Care Leading to UTIs
Penalty
Summary
The facility failed to provide adequate incontinent care to prevent urinary tract infections (UTIs) for several residents. One resident, who was frequently incontinent of bladder and occasionally incontinent of bowel, was not assisted with toileting in a timely manner. The resident was left waiting in the bathroom, and when finally assisted, it was noted that her brief was wet, and she expressed discomfort while urinating. Her care plan required checks every two hours and as needed, but this was not adhered to, contributing to her UTI diagnosis. Another resident, who was severely cognitively impaired and frequently incontinent, was found with a soiled brief. The care provided did not include proper cleansing and drying of the perineal area, which is essential to prevent infections. The resident had recently been diagnosed with a UTI and had been to the emergency room. The care plan for this resident also required regular checks and thorough cleaning, which were not followed, potentially exacerbating her condition. Additional deficiencies were observed in the care of other residents, including improper cleaning techniques and failure to use soap during perineal care. One resident was not properly cleaned, and the foreskin was not retracted during care, which is necessary for thorough cleaning. Another resident, who was cognitively intact, reported frequent UTIs and expressed that the urgency of urination often left no time for staff assistance. The facility's perineal cleansing policy outlines specific procedures to prevent infections, but these were not consistently followed, leading to multiple cases of UTIs among residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by multiple instances of inadequate hand hygiene, improper use of personal protective equipment (PPE), and failure to post necessary isolation signs. For instance, a Licensed Practical Nurse (LPN) was observed preparing medications for a resident with a feeding tube without performing hand hygiene before or after donning and doffing gloves. Additionally, the LPN entered the resident's room without wearing a gown, despite the need for Enhanced Barrier Precautions due to the resident's indwelling medical device. The facility's policy on Enhanced Barrier Precautions was not followed, and staff members were unaware of the requirements. In another instance, a resident diagnosed with Extended Spectrum Beta Lactamase (ESBL) was not placed on isolation as required. The resident was observed using a community bathroom, and staff members failed to perform hand hygiene before donning gloves. The facility's policy on contact precautions was not adequately implemented, as evidenced by the lack of signage and improper handling of resident care equipment. Staff members were also observed using the same gloves for multiple tasks, increasing the risk of cross-contamination. Additional deficiencies were noted in the care of other residents, where staff members failed to change gloves between tasks and did not perform hand hygiene. For example, a Certified Nurse's Aide (CNA) was seen using the same gloves to provide incontinent care, apply barrier cream, and handle a mechanical lift sling. Another CNA assisted a resident to the restroom without wearing PPE and used the same gloves for multiple tasks, including wiping the resident and adjusting equipment. These actions demonstrate a systemic failure in adhering to infection control protocols, as outlined in the facility's policies.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the Illinois Department of Public Health (IDPH). The resident, who is cognitively intact and has a medical history including hypertension, arthritis, osteoarthritis, spinal stenosis, and chronic heart failure, reported that a prior Director of Nursing (DON) kicked the back of her legs, causing her to fall and require a full body mechanical lift. The resident also mentioned that the DON threatened to repeat the action. Despite the resident's report to her doctor and other staff members, there was no documentation of the incident in her chart. Upon review, the facility's administrator was unaware of the allegations until informed by surveyors. The administrator admitted to speaking with both the resident and the accused DON but did not conduct a further investigation or report the incident to IDPH. The facility's Resident Rights Policy mandates reporting such incidents to IDPH within specific timeframes, which was not adhered to in this case.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was cognitively intact and had been admitted with diagnoses including hypertension, arthritis, osteoarthritis, spinal stenosis, and chronic heart failure. The resident reported that a prior Director of Nursing (DON) kicked the back of her legs, causing her to fall and subsequently require a full body mechanical lift. The resident also mentioned that the DON threatened to repeat the action. Despite the resident's report to her doctor and other staff members, there was no documentation of the incident in her chart, and the facility's reported abuse investigations did not include this incident. The facility's Administrator was informed of the allegations but stated it was the first time hearing of the report. Although the Administrator spoke with both the resident and the DON about the incident, no further investigation was conducted, nor was any documentation created. This inaction was contrary to the facility's Resident Rights Policy, which mandates a thorough investigation process, including obtaining documentation and conducting interviews. The lack of adherence to these procedures resulted in a deficiency in handling the abuse allegation.
Failure to Provide Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to follow the plan of care and provide nutritional supplements as ordered for a resident, leading to a deficiency in maintaining acceptable nutritional parameters. The resident, who had been experiencing gradual weight loss over six months, was on a regular diet with specific dietary instructions, including the addition of ice cream to lunch and supper meals to increase caloric intake. Despite these orders, the resident did not receive the prescribed ice cream during a noon meal observation, and staff did not intervene or offer substitutes when the resident did not eat the meal provided. The resident's care plan highlighted the risk of weight loss due to poor oral intake, with interventions such as alerting the dietitian if consumption was poor for more than 48 hours and contacting the physician and dietitian in case of weight decline. However, during the observed meal, the staff failed to follow these interventions, as they did not document the resident's refusal to eat or poor intake, nor did they inform the nurse as per facility policy. Interviews with staff revealed that while substitutes were offered, the resident often refused them, yet there was no documentation or further action taken to address the resident's nutritional needs effectively.
Deficiency in G-tube Management and Resident Positioning
Penalty
Summary
The facility failed to properly manage the care of a resident with a Gastrostomy tube (G-tube), leading to deficiencies in the administration of water flushes and medications. On one occasion, a Licensed Practical Nurse (LPN) administered 65 milliliters of water and medications through the resident's G-tube without checking for residuals, which is against the facility's policy. The policy requires confirmation of tube placement via aspiration of residuals before administering flushes or medications. The LPN stated that the past Director of Nurses had informed them that checking for residuals was unnecessary. Additionally, the facility did not adhere to the protocol of maintaining the resident's head of the bed at a minimum of 30-40 degrees during and after feeding. A Certified Nurse's Aide (CNA) lowered the resident's bed to a flat position while the feeding pump was running, which is contrary to the facility's policy. The CNA was unaware of the requirement to turn off the feeding pump when the resident is lying flat, and another CNA confirmed that they were instructed not to stop the pump. The resident involved was severely cognitively impaired and had a diagnosis of Chromosomal abnormality and Gastrostomy.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive devices or adaptive eating equipment for a resident, resulting in the resident's inability to use eating utensils effectively and resorting to eating with hands. Observations on two separate occasions showed the resident using a regular spoon and their left hand to scoop food onto the spoon and then into their mouth. The resident was also seen picking up food that had fallen onto the table and their bib. The resident's care plan indicated a self-care deficit and required supervision or assistance with activities of daily living, including feeding. However, the care plan did not specify the need for adaptive eating equipment. The therapy director was unaware of the resident's use of hands to assist with eating and stated she would screen the resident.
Failure to Post Ombudsman Contact Information
Penalty
Summary
The facility failed to post ombudsman contact information, which is a requirement to ensure residents are aware of their rights and have access to advocacy services. This deficiency was identified through observations, interviews, and record reviews. On August 27, 2024, several residents stated they were not aware of the ombudsman contact information being posted. A surveyor confirmed the absence of this information within the facility. The facility's administrator acknowledged the lack of a specific policy for posting ombudsman information, although the facility follows Illinois Department of Public Health guidelines. The facility's Long-Term Care Application for Medicare and Medicaid documented a census of 41 residents, all potentially affected by this oversight.
Failure to Post Survey Results
Penalty
Summary
The facility failed to post survey results, which has the potential to affect all 41 residents residing at the facility. During a resident council meeting, several residents expressed that they were unaware of the availability of survey results. Throughout the survey, it was observed that the results of the last standard survey were not available. The Administrator confirmed that the state inspection results were not available for residents to read and acknowledged that there was no policy in place regarding the posting of survey results. The Administrator mentioned that the facility follows Illinois Department of Public Health guidelines, but the lack of a policy led to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 225 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jerseyville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Jerseyville Nsg & Rehab Center | 0.5 mi | ★★★★★ | 3 | 1 |
| Jerseyville Manor | 1.9 mi | ★★★★★ | 5 | 0 |
| Robings Manor Rhc | 11.1 mi | — | 0 | 0 |
| Bria Of Godfrey | 12 mi | ★★★★★ | 5 | 0 |
| La Bella Of Alton | 16 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.