Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Jerseyville Manor during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment and significant behavioral and psychiatric histories were allowed to interact in a hallway without effective protection from resident-to-resident abuse. One resident, known to pace the unit and at high risk for falls, stopped outside another resident’s room while ambulating independently. The other resident, who had documented verbal and physical behaviors, wandering, territoriality, and rejection of care, came out of her room, ran toward the pacing resident, and pushed her to the floor, causing a severe left hip fracture and head impact. Staff had prior knowledge of both residents’ behavioral patterns, including the aggressor’s tendency to become easily annoyed and to put hands on others, yet the incident occurred in an unsupervised context. Hospital and facility records linked the fracture from this push to the resident’s subsequent surgery and death, and the facility’s own abuse policy defined such willful acts causing injury as abuse, forming the basis of the deficiency for failure to prevent resident-to-resident abuse.
A resident with dementia, severe cognitive impairment, incontinence, and need for substantial/maximal assistance with mobility had documented fall-risk interventions including use of a concave mattress and other fall approaches. After being found on the floor on two separate occasions, with the second fall followed by reluctance to ambulate and lower extremity stiffness, imaging confirmed an acute transverse fracture of the left patella. During surveyor observation, the resident’s bed had a regular mattress rather than the ordered concave mattress, and multiple CNAs reported the resident had not had a special mattress, while the DON and MD indicated that interventions should be in place after each fall; the facility also lacked a specific fall-prevention policy, relying instead on an undated accident/incident prevention document.
A resident with Parkinson’s disease and a deep brain stimulator (DBS) had physician orders and a care plan directing that the DBS be charged on specific days using a chest-placed charging disk, yet the resident reported that staff did not know how to charge it and that it was sometimes not charged. Multiple LPNs and an RN stated they had not been inserviced on how to use, read, or charge the DBS, did not know how to confirm it was charging, and relied on the resident or family for guidance, while describing various Parkinson’s symptoms they observed when the DBS was not charged. The DON and ADON acknowledged there had been no formal staff education on the DBS, and although a written DBS policy existed, there was no indication it had been implemented through staff training, despite expectations from the medical director and neurologist’s office that staff would be educated on device use and related symptoms.
A resident with Alzheimer’s disease, cerebral infarction, and dysphagia, who was on a mechanically altered diet and had documented coughing and choking during meals, experienced a choking episode when a piece of bread became lodged in the throat during a meal and was later expelled before an LPN arrived. Despite a physician order for speech therapy to evaluate and treat swallowing and a referral made to the SLP, the swallow evaluation was not completed until many days after the incident, while the DON was unsure about the expected timeframe for such evaluations and the medical director stated they are normally done the next day. The facility’s therapy policy did not define a required timeframe for SLP evaluation after a choking-related referral.
Failure to Prevent Resident-to-Resident Abuse Resulting in Fatal Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to prevent resident-to-resident abuse, resulting in one resident pushing another resident to the floor and causing a left hip fracture that required surgery and was listed as the immediate cause of death. The resident who was pushed (R157) had severe cognitive impairment with a BIMS score of 3 and multiple diagnoses including dementia without behavioral disturbance, schizoaffective disorder, anxiety disorder, psychosis, repeated falls, weakness, unsteadiness on feet, reduced mobility, COPD, osteoporosis, heart failure, and depression. She was known to pace the unit, ask repetitive questions, display anxiety, and exhibit verbal/physical expressions related to rejection of care and delusions, as well as other behaviors such as pacing and picking at her skin. Her care plan identified her as at risk for falls related to cognitive deficits, altered safety awareness, need for ADL assistance, incontinence, and use of psychotropic and opioid medications. The resident who pushed her (R136) also had severe cognitive impairment with a BIMS score of 2–3 and extensive psychiatric and neurologic diagnoses including Alzheimer’s disease, paranoid schizophrenia, dementia with agitation, delusional disorders, depressive episodes, and severe dementia with psychotic disturbance. Her MDS and care plan documented a history of verbal and physical behaviors directed toward others, rejection of care, wandering, exit-seeking, and territoriality when others entered her room or personal space. Progress notes described that she might scream, curse, shove, kick, hit, or scratch staff providing care, and that she had been placed on a behavior tracking program for increased wandering and exit-seeking. Staff notes also documented an incident where she was kissing a relative in the dining room and became verbally upset when separated, and that she had verbal/physical behaviors related to rejection of care, with formal behavioral programming in place. On the day of the incident, R157 was walking laps on the unit, consistent with her usual pacing behavior, and walked past the doorway of R136’s room, stopping approximately 5–6 feet outside the doorway while saying something and pointing her finger. A CNA (V19) witnessed R136 come out of her room running with both arms extended and push R157 to the floor, then run back into her room laughing and shut the door. The CNA reported that R157’s head hit the floor very hard, and she was bleeding, crying in pain, and complained of severe pain everywhere. The nurse’s fall event documentation and progress note recorded that a loud noise was heard, R157 was found on the floor on her left side with painful and limited ROM in the left lower extremity, shallow skin tears to the left eyebrow and forearm, and severe pain. The fall safety event and hospital ER note both documented that another resident pushed her in an unsupervised context. Hospital records confirmed a proximal left femur fracture requiring ORIF, and the death certificate listed the acute displaced left femur intertrochanteric fracture, status post intramedullary nail insertion, with underlying dementia and contributing pulmonary edema and schizoaffective disorder, as the causes of death. Staff interviews indicated that some staff were aware that both residents had behavioral issues, though they generally described R157’s behaviors as not directed toward other residents and R136’s behaviors as primarily verbal toward staff. However, the CNA who witnessed the event stated that prior to this incident, R136 had “a few issues” at the supper table where she would put her hands on residents who annoyed her and that she was easily annoyed by other residents. Another CNA reported that R136 stayed in her room most of the time but would verbally curse or tell other residents to stay away, and staff would attempt to redirect her with snacks, TV, or diversion. The facility’s Abuse Prohibition and Reporting Policy stated that special attention would be given to identifying behaviors that increase a resident’s potential for abusing others or being a victim of abuse, including residents with a history of aggressive behaviors and those who enter other residents’ rooms. Despite documented behavioral histories and risk factors for both residents, the incident occurred when R157 was walking independently on the unit and R136 was able to leave her room and physically push R157 in the hallway, resulting in the injury and subsequent death. The facility’s internal investigation concluded that the root cause of the fall was directly linked to the actions of R136, who pushed R157, and that due to R136’s cognitive status she was unable to account for or explain her actions. The investigation noted that neither resident could provide credible details of the fall or what led up to it, and that staff who were nearby did not witness any behaviors immediately beforehand that would indicate the event would occur. The investigation also stated that R136 had no prior physical incidents since admission and that there was no sufficient evidence to suggest the actions were intentional. Nonetheless, the event met the facility’s own definition of abuse as the willful infliction of injury with resulting physical harm, pain, or mental anguish, where “willful” means the individual acted deliberately, regardless of intent to cause harm. The deficiency centers on the facility’s failure to prevent this resident-to-resident abuse, despite known behavioral risks and documented patterns of wandering, territoriality, and behavioral expressions in both residents. The Medical Director later stated that, in her opinion, the incident between the two residents was unexpected and that neither resident had displayed physical behaviors toward others, and she attributed the resident’s death to poor postoperative monitoring at the hospital. However, the death certificate and hospital documentation directly linked the acute displaced left femur fracture, caused by the push and fall, to the resident’s death. The facility’s abuse policy emphasized protecting residents from all types of abuse and giving special attention to residents with aggressive behaviors or those who enter other residents’ rooms, but the events described show that R157 was able to ambulate independently in the hallway near R136’s room and that R136 was able to exit her room and physically push her, resulting in serious injury. These facts and observations form the basis of the cited deficiency for failure to protect residents from abuse, specifically resident-to-resident abuse.
Failure to Implement Fall-Prevention Interventions Resulting in Patellar Fracture
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain current fall-prevention interventions for one resident, resulting in a left patellar fracture. The resident had dementia, Alzheimer’s disease, weakness, severe cognitive impairment, used a walker, and required substantial to maximal assistance with bed mobility, transfers, and ambulation. The care plan identified the resident as at risk for falls due to diagnoses, cognitive deficits affecting safety awareness, need for ADL assistance, bowel and bladder incontinence, and use of psychotropic and potential opioid medications. The care plan documented fall interventions including a concave mattress, neon tape to the walker, keeping the walker at bedside, encouraging the resident to ask for assistance when ambulating, alternating call rounds with toileting offers, and using lighter weight pajamas at bedtime. On one date, facility documentation shows the resident was previously resting in bed in the lowest locked position and was later found on the floor lying on her left side with her head against the closet door, incontinent of bladder, with disheveled blankets suggesting she slid out of bed. The fall investigation identified that the resident slid out of bed and noted that a concave mattress was to be used as an intervention. A subsequent fall occurred days later, when the resident was again found on the floor on her left side near the closet, with a small hematoma to the back of the head and an abrasion to the left knee. Staff documented that the resident was able to bear weight but had an unsteady gait with a slight limp, and that she commonly attempted to get up on her own despite requiring assistance to get out of bed and ambulate. Following the second fall, nursing notes describe the resident as reluctant to ambulate, with stiff lower extremity ROM and inconsistent reports of pain location. An x-ray report initially mentioned a patellar fracture without clarifying whether it was old or new, and a reread by the radiologist confirmed an acute left patellar fracture, later specified as a transverse fracture of the patella with apex anterior angulation and articular surface step-off. Surveyor observations on a later date found that no concave mattress was on the resident’s bed; staff CNAs reported that the resident had a regular mattress and denied that a special mattress had been in place. The DON stated that interventions are to be implemented and care plans updated after every fall, and the MD stated that if a concave mattress was ordered after a fall, she would expect it to be in place. The DON also stated the facility did not have a fall prevention policy and provided an undated Accident/Incident Prevention document without a facility name, which generally stated that interventions are to be put in place when a resident is identified as high risk for accidents/incidents.
Lack of Staff Competency in Managing Resident’s Deep Brain Stimulator
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were knowledgeable and competent in the use and monitoring of a deep brain stimulator (DBS) for a resident with Parkinson’s disease. The resident’s face sheet documented diagnoses of Parkinson’s disease and a DBS, and the care plan included an approach to charge the DBS on specified days by placing a round disk on the right side of the chest for approximately two hours or until fully charged. The physician’s orders and the treatment administration record also directed that the DBS be charged three times weekly on night shift. Despite these written directions, the resident reported that staff were supposed to charge his DBS but did not know what they were doing and that sometimes his DBS was not charged. Multiple staff interviews confirmed a lack of formal in-service training and inconsistent knowledge about how to operate the DBS charger, how to verify that it was charging, and what symptoms the resident would exhibit if the DBS was not charged. Several LPNs and an RN stated they had not been inserviced on how to use, read, or charge the DBS device and did not know how to tell if it was charging or what symptoms to look for when it was not charged. One LPN reported learning from the resident’s family and the resident himself, rather than from facility training, and others stated that the family or the resident handled the charging. Staff described various observations when the DBS was not charged, including increased tremors, difficulty swallowing, coughing while eating, delayed or slurred speech, and slow movements, but this knowledge was informal and not based on structured education. Leadership interviews further demonstrated the absence of a systematic training process. The DON, who had been in the role for over ten years, acknowledged she had not inserviced staff on how to use the resident’s DBS and did not know the full extent of symptoms that could occur if it was not charged. The ADON recalled being shown how to charge and read the device by the resident’s family at the time of admission, rather than through a facility-led process. The neurologist’s medical assistant and the medical director both stated that when the DBS is not charged, the resident’s Parkinson’s symptoms increase, such as tremors, slurred speech, shuffling gait, and out-of-control tremors, and both expected staff to be educated on device use and symptoms. A DBS policy dated 1/2013 referenced following manufacturer’s instructions and charging as recommended by the doctor but did not bear the facility’s name, and there was no evidence in the report that this policy had been implemented through staff training.
Delayed Swallow Evaluation After Choking Episode in Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to timely evaluate the swallowing function of a resident with known dysphagia after a choking episode. The resident was admitted with diagnoses including Alzheimer’s disease, cerebral infarction, and dysphagia, and the MDS documented severe cognitive impairment, need for setup or clean-up assistance with eating, a mechanically altered therapeutic diet, food holding in the mouth/cheeks, and coughing or choking during meals or when swallowing medications. The care plan identified dysphagia with increased risk of aspiration, choking, and swallowing difficulties, and the diet order specified a mechanical soft diet. During a noon meal, the resident experienced an episode in which a piece of bread became lodged in the throat; by the time the LPN arrived in response to staff notification, the resident had already expelled the bread. Following this choking event, a physician order was written for speech therapy to evaluate and treat as indicated, and the SLP reported that the LPN had made a referral for a swallow evaluation after the episode. However, the SLP stated that the evaluation had not yet been completed and was only planned for sometime later in the week, and the DON was unsure how soon residents should be evaluated after choking. The medical director stated awareness of the choking incident and was unsure why it took the SLP so long to evaluate, noting that such evaluations are normally done the next day. The resident’s swallowing function was ultimately evaluated 11 days after the choking episode. The facility’s Therapy Evaluation/Reassessment Policy did not specify a timeframe for conducting a speech therapy evaluation following a referral for choking.
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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 Jerseyville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evercare Of Jerseyville | 1.9 mi | ★★★★★ | 16 | 1 |
| Jerseyville Nsg & Rehab Center | 2.3 mi | ★★★★★ | 3 | 1 |
| Robings Manor Rhc | 12.5 mi | — | 0 | 0 |
| Bria Of Godfrey | 13.8 mi | ★★★★★ | 5 | 0 |
| Evercare Of Calhoun | 15.3 mi | ★★★★★ | 3 | 0 |
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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.