Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Gillespie Health & Rehab Ctr during CMS and state inspections, most recent first.
Failure to Implement Individualized Transfer and Fall Interventions: A resident who required a mechanical lift was transferred without a documented individualized transfer plan, and staff were observed using unsafe positioning during the lift. Other residents with cognitive impairment, repeated falls, and high fall risk had fall precautions and alarms that were not consistently in place, with observations showing missing or inactive interventions and repeated falls despite existing care plans and orders.
A resident with chronic kidney disease and a history of UTIs experienced a delay in receiving a physician-ordered antibiotic for a confirmed UTI. Although lab results and the antibiotic order were received, the medication was not started as documented in the MAR, resulting in a failure to provide timely treatment according to physician orders and facility policy.
Staff failed to follow proper incontinent and perineal care procedures for three residents, including not separating the labia during cleansing and not consistently using the front-to-back technique. These actions were not in accordance with facility policy, which requires thorough cleaning to prevent infection and skin irritation, especially for residents with a history of urinary tract infections and those requiring extensive assistance.
Surveyors found that a controlled substance bottle was stored without a resident name or physician order, and a multi-dose vial of Tuberculin was kept past its discard date without proper labeling. An LPN could not identify the owner of the controlled substance, and the DON confirmed the medication was discontinued but not disposed of as required. These failures were not in line with facility policy for medication labeling and storage.
Several residents with cognitive impairments, special diets, or poor intake were not offered substitute food choices when they disliked or could not eat the meals served. Staff did not consistently check with residents about their preferences or provide alternatives, and there was a lack of staff presence in the dining area to assist or address these needs. Facility policies regarding food preferences and substitutions were not consistently followed.
Multiple staff failed to follow infection control protocols, including improper hand hygiene, failure to change soiled gloves, not wearing required PPE during resident care, and not cleaning contaminated surfaces. The Infection Preventionist did not systematically track or document infections, and staff were sometimes unaware of residents' precaution status, leading to incomplete infection control measures.
Three residents with significant care needs did not receive timely or complete incontinent care, as staff failed to thoroughly clean all necessary perineal and genital areas after episodes of incontinence. In some cases, soiled clothing and surfaces were not addressed, and facility policy for perineal care was not consistently followed.
A resident with a J-tube for medications and feedings did not have tube placement checked prior to medication administration, as required by physician orders. Additionally, the enteral feeding bag in use was not labeled with the type of feeding or the rate. The DON confirmed the labeling omission, and the facility's policy did not address labeling procedures.
The facility did not properly justify or monitor antibiotic use for two residents, failing to use infection surveillance and the McGeer criteria as required by its antibiotic stewardship policy. In both cases, antibiotics were initiated without appropriate clinical assessment or documentation, and necessary infection screening forms and cultures were not completed prior to starting treatment.
The facility failed to ensure that residents' advance directives and physician's orders accurately reflected their wishes. One resident's care plan was not updated to reflect a DNR status, and another resident's care plan did not document advance directive wishes at all, despite the POLST indicating a DNR status.
Failure to Implement Individualized Transfer and Fall Interventions
Penalty
Summary
The facility failed to implement individualized transfer plans and appropriate interventions for residents reviewed for accidents. For one resident who was cognitively intact, dependent on staff for chair-to-bed transfers, and had limited range of motion and muscle weakness, staff used a mechanical lift without any documented instructions in the care plan for how to complete the transfer. During the observed transfer, two CNAs assisted, and one CNA placed a foot on the wheelchair bar while the lift was being operated. The resident reported that during a prior transfer two CNAs were involved, one staff member was not attentive, the wheelchair was flipped backwards during the mechanical lift transfer, and the resident was left close to the floor and later needed numbing cream for tailbone pain. The facility’s own corrective action documentation stated the wheelchair was tipping during the transfer and that the resident was too large for the wheelchair. For another resident with cognitive impairment, dependence on staff for transfers, and a high fall risk, the record showed repeated falls and interventions that were not consistently in place. The resident’s care plan and physician order included a pressure pad alarm or pull-tab alarm, with checks each shift, and the fall log documented multiple falls. On observation, the resident was found on the floor with the head and upper body under an overbed table and the feet wrapped in catheter tubing, while no dycem was observed in the wheelchair seat and no foot board was in place to the foot pedals. The DON stated the interventions were intended to prevent falls and that if they were not in place, the resident would fall, and a CNA stated staff are in-serviced on fall interventions after each fall and that the interventions are supposed to always be in place. A newly admitted resident with ALS, spinal stenosis, repeated falls, cerebral ischemia, DM, and HTN also had a care plan identifying one-person physical assistance for transfers and ambulation, but the record showed a history of falls and changing fall-risk status. The fall log documented falls on multiple dates, and the resident’s room had a visual fall-risk marker. On observation, the resident was sitting in a wheelchair with the call light in the bed. Another resident with Alzheimer’s disease, severe cognitive impairment, lack of safety awareness, and a history of falls had a care plan with alarm-based interventions and other fall precautions, but the record showed multiple falls and no new intervention after one fall. On observation, the resident’s alarm was present but not flashing, and no nonskid strips were seen on the floor by the bed or in the restroom. The DON stated staff were expected to follow fall precautions, complete fall risk assessments after every fall or change in condition, and enter a new fall intervention after each fall.
Delay in Initiation of Physician-Ordered Antibiotic for UTI
Penalty
Summary
A deficiency occurred when the facility failed to initiate a physician-ordered antibiotic in a timely manner for a resident diagnosed with a urinary tract infection (UTI). The resident, who had a history of chronic kidney disease stage 4 and recurrent UTIs, reported symptoms of a UTI and confirmed that a urine specimen had been sent to the lab. The culture report, dated 9/15/2025, showed significant growth of Escherichia coli, and the physician faxed an order for Macrobid 100 mg twice daily for 10 days on 9/16/2025. However, the medication administration records for that date did not show that the antibiotic had been started as ordered. The resident stated she was not receiving the prescribed antibiotic despite her symptoms and medical history. The facility's policies require prompt notification of test results to the physician and timely completion of ordered cultures and treatments. The administrator confirmed that the physician had been notified and the order received, but the initial dose had not been administered as expected. This lapse resulted in a delay in providing appropriate treatment according to the physician's order and the resident's needs.
Failure to Provide Complete and Proper Incontinent and Perineal Care
Penalty
Summary
Surveyors observed that staff failed to provide complete and proper incontinent and perineal care to three residents who required such care. In multiple instances, Certified Nursing Assistants (CNAs) did not separate the labia when cleansing female residents' perineal areas, contrary to facility policy. For one resident with a history of chronic kidney disease and urinary tract infections, the CNA cleansed the groin and peri area but did not separate the labia, despite the resident's care plan indicating a need for thorough incontinence care. Another resident, who was always incontinent and cognitively intact, also did not have the labia separated during peri care. In both cases, the care plans required incontinence care after each episode according to facility protocol. Additionally, for a third resident who was always incontinent and required extensive assistance, the CNA cleansed the rectal area and then used a clean cloth to rinse from the rectal area to the peri area, which is inconsistent with the expected front-to-back technique. Interviews with staff confirmed the expectation to cleanse from front to back and to separate the labia during care. The facility's perineal care policy specifically instructs staff to separate the labia and wash downward from front to back to prevent infection and skin irritation. These observed failures to follow established procedures led to the deficiency.
Improper Labeling and Storage of Medications
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications in accordance with professional standards and facility policy. During an inspection of the medication storage room and cart, a bottle of Morphine Sulfate, a controlled substance, was found in a locked box without a label indicating the resident's name or a physician's order. The LPN present was unable to identify the owner of the medication, and the DON later confirmed that the bottle belonged to a resident whose order for Morphine had been discontinued two months prior. The medication had been opened and used, but was not properly labeled or disposed of after discontinuation. Additionally, a multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) Tubersol was found in the refrigerator with no cap and a label indicating it had been opened over 30 days prior. The LPN verified the vial had been accessed, and the DON confirmed after consulting with the pharmacy that the vial should have been discarded after 30 days, as per the manufacturer's instructions. Facility policy requires that drug containers with missing or improper labels be returned to the pharmacy and that discontinued or outdated drugs be destroyed or returned, which was not followed in these instances.
Failure to Provide Substitute Food Choices and Accommodate Dietary Preferences
Penalty
Summary
The facility failed to provide appropriate substitute food choices for five residents who were reviewed for meals, resulting in unmet dietary preferences and needs. Multiple residents, including those with cognitive impairments, malnutrition, and special diet requirements, were observed not receiving alternatives when they disliked or could not eat the food served. For example, one resident with dementia and severe protein calorie malnutrition requested plain turkey but was repeatedly served turkey in a sandwich or with gravy, contrary to her stated preference. Another resident on a consistent carbohydrate diet due to diabetes and at risk for malnutrition was not offered alternatives when he disliked the processed turkey served and was unable to cut it, leading to minimal food intake. Residents with mechanical soft diets or other dietary restrictions also experienced similar issues. One resident without teeth, on a mechanical soft diet, repeatedly received grilled cheese sandwiches despite expressing dislike for them and not being offered other options. Another resident with a history of CVA and dysphagia, requiring a mechanical soft diet, was not asked about food preferences and only ate limited portions of her meal. Additionally, a resident with Parkinson's disease and low BMI reported not being asked about meal preferences and not liking the food provided, resulting in poor intake. Observations revealed a lack of staff presence in the dining room to assist or offer alternatives to residents who were not eating their meals. Interviews with staff, including the Dietary Manager and Administrator, confirmed that there was no clear policy or consistent practice for offering meal substitutions, and staff were not routinely checking with residents about their food preferences or providing alternatives when meals were refused or disliked. Facility policies referenced food preference interviews and the provision of alternate selections, but these were not consistently implemented in practice.
Failure to Implement Effective Infection Control Practices
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices for multiple residents. The Infection Preventionist did not accurately track or document infections, relying on memory rather than systematic trend analysis, and failed to record essential details such as onset dates and organism colony counts. In one instance, a resident was incorrectly listed as requiring contact precautions for a urinary tract infection, and the monthly infection tracking log lacked complete information as required by facility policy. Direct care staff were observed not following proper hand hygiene and glove use protocols. A Licensed Practical Nurse administered medication via a J-tube without performing hand hygiene before donning gloves. Certified Nurse Aides providing incontinent care to a resident on Enhanced Barrier Precautions did not wear required gowns and changed gloves multiple times without hand hygiene in between, despite clear signage and policy requirements. One CNA was unaware of the resident's precaution status, indicating a lack of communication or training. Additional lapses included a CNA using soiled gloves to assist a resident after providing perineal care, and failing to clean contaminated surfaces such as handrails after they were soiled during resident care. These actions were inconsistent with the facility's hand washing and infection control policies, which require glove changes and cleaning of contaminated equipment or surfaces to prevent the spread of infection.
Incomplete and Untimely Incontinent Care Provided to Multiple Residents
Penalty
Summary
The facility failed to provide timely and complete incontinent care for three residents who required assistance with activities of daily living due to severe cognitive or physical impairments. One resident with chronic kidney disease, hypertension, and impaired mobility was observed with saturated clothing from urine and did not receive thorough perineal cleaning, as the groin and genital areas were not properly cleansed during care. Another resident, dependent on staff for toileting and always incontinent of bowel and bladder, experienced incomplete cleaning after an episode of incontinence, with only the buttocks and anal area wiped, and no attention given to the front side or soiled handrails after the resident touched them with feces-contaminated hands. A third resident, who was cognitively intact but fully dependent on staff for toileting and always incontinent, did not receive adequate perineal care after urinating on himself during a care episode. The staff cleansed the buttocks, rectal area, inner thighs, and scrotum, but failed to clean the scrotum again or the penile head after visible urine pooled on the scrotum. Staff interviews confirmed that if urine was noticed, further cleaning would have been performed, indicating a lack of thoroughness in the care provided. Facility policy for perineal care outlines specific steps for cleaning both male and female residents, including washing and rinsing all relevant areas and changing gloves when moving from dirty to clean areas. Observations and staff interviews revealed that these procedures were not consistently followed, resulting in incomplete perineal care for the residents involved.
Failure to Check J-Tube Placement and Label Enteral Feeding Bag
Penalty
Summary
A deficiency was identified when a nurse failed to check the placement of a resident's J-tube prior to administering medications and water flushes. The nurse administered 30 ml of water, a hydroxyzine cocktail, and another 30 ml flush before measuring the tube, contrary to physician orders that required tube placement to be checked by measuring before use. The nurse acknowledged the error, stating the measurement should have been done prior to medication administration. The resident involved had a diagnosis of Multiple Sclerosis and quadriplegia and was the only resident in the facility with a feeding tube. Additionally, the disposable tube feeding bag in use for the resident was not properly labeled. The bag was dated but did not indicate the type of feeding or the rate, as required. The Director of Nursing confirmed that the bag was not labeled with the type of tube feeding and questioned whether the rate should also be included. Physician orders specified the use of Jevity 1.5 at a set rate, but this information was not documented on the feeding bag. The facility's policy on enteral tube feeding did not address procedures for labeling disposable tube feeding bags.
Failure to Justify and Monitor Antibiotic Use per Stewardship Protocols
Penalty
Summary
The facility failed to justify the use of antibiotics and did not utilize proper infection surveillance when initiating antibiotics for two residents. In one case, the Infection Preventionist was unable to effectively use the McGeer criteria to determine if a resident qualified for a true urinary tract infection (UTI), and the decision to obtain a urine culture was based on a family request rather than clinical symptoms. The resident was subsequently prescribed Levaquin for a UTI, but the infection analysis section of the screening evaluation was left blank, indicating a lack of documented clinical justification for the antibiotic order. In another instance, a resident with a history of multiple UTIs was started on prophylactic antibiotics without obtaining a urine culture prior to initiation. The Infection Preventionist admitted that infection screening forms and analyses were not completed, and the last urinalysis on record was from the previous year, which showed no growth. The nurse practitioner confirmed that prophylactic antibiotics are not typically prescribed without urology consultation and that McGeer criteria are used to guide antibiotic initiation, which was not followed in this case. The facility's own antibiotic stewardship policy requires assessment using McGeer criteria and consideration of urinalysis and cultures, which was not adhered to for these residents.
Failure to Ensure Advance Directives Reflect Resident Wishes
Penalty
Summary
The facility failed to ensure that residents' advance directives and physician's orders accurately reflected their wishes. For Resident 41, the care plan initially documented a desire for CPR in the event of cardiac arrest, but the physician's order was later changed to Do Not Resuscitate (DNR) without updating the care plan accordingly. This discrepancy was evident as the care plan was not updated to reflect the resident's DNR status until a later date, despite the POLST form indicating the resident's wish to be a DNR. For Resident 58, the care plan did not document the resident's advance directive wishes at all. Although the physician's orders initially indicated a Full Code status, the POLST form documented the resident's wish to be a DNR. The facility's process for updating the care plan and physician's orders based on the POLST was not followed, leading to a failure in accurately reflecting the resident's wishes in the medical records. The administrator acknowledged the oversight and indicated that the necessary updates would be made immediately.
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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.
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Nursing homes near Gillespie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Staunton Health And Rehab Ctr | 6.6 mi | ★★★★★ | 3 | 0 |
| Avenues At Litchfield | 10.1 mi | ★★★★★ | 2 | 0 |
| Litchfield Health & Rehab Center | 10.4 mi | ★★★★★ | 0 | 0 |
| Hallmark Hc Of Carlinville | 12.9 mi | ★★★★★ | 0 | 0 |
| Carlinville Rehab & Hcc | 12.9 mi | ★★★★★ | 3 | 0 |
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