Jerseyville Nsg & Rehab: Fall Safety Failures - IL
That is what federal inspectors found at Jerseyville Nursing & Rehab Center following a complaint inspection completed in November 2025. The citation was tagged at the highest level of actual harm.
The resident, identified in inspection records as R2, had a documented fall history serious enough that the facility's own medical director said his primary concern for her was preventing falls. She had no fingers and no toes, a physical condition the director of nursing, identified as V2, described as the resident's major health concern and the reason they wanted to keep her safe. A low bed, a fall mat, and both bed and wheelchair alarms had all been put in place before the fall occurred.
None of it worked.
V2 told inspectors that the bed alarm was not an effective intervention for R2 in the bed setting, only in her wheelchair. V2 confirmed that all of those interventions, the low bed, the mat, the alarms, had already been in place before the fall. The low bed position and the fall mat were not added to R2's formal care plan until after she fell.
The facility had thought about the alarm problem. V2 acknowledged to inspectors that hiding the alarm box inside the bedside table might have prevented R2 from being able to reach it and switch it off. It was a solution that had occurred to staff. It had not been implemented.
The medical director, V11, was interviewed on the day of the inspection at 11:50 in the morning. He told inspectors he had not yet seen R2 but was scheduled to do so that month. He said he would expect staff to be following the fall risk care plan interventions if they were able to do so, and that he would expect interventions to be progressive and resident centered. If a resident was able to turn off an alarm, he said, he would expect the facility to attempt to prevent her from doing so by hiding it. He was direct about the consequence of failing to follow interventions that had previously been working: it could pose a higher risk for R2 to fall.
That is what the inspection record shows happened.
When inspectors looked at the facility's written policies, they found the alarm guidelines were undated. The guidelines acknowledged what the facility had apparently not acted on in R2's case, that many reports describe patients deliberately deactivating their alarms and that alarms may not always be appropriate or effective. The Falls Management Policy, which did carry a date, stated the facility's obligation to assess and manage resident falls through prevention, investigation, and the implementation and evaluation of interventions.
The evaluation piece is where the record breaks down. R2 could disable her own alarm. Staff knew it. The solution, moving the alarm box out of her reach, was discussed but not carried out. The care plan was updated only after she was already on the floor.
V2 told inspectors that if they had known R2 was turning off the alarm, they would have had her more supervised or brought up to the nurse's station. The suggestion was that the facility would have acted differently with better information. But the alarm was already in place precisely because R2 was a fall risk. The question of whether she could defeat it was not a new one by the time she fell.
The medical director's thyroid comment added a layer inspectors apparently pursued. V11 said that a TSH level of 34, indicating significant hypothyroidism, would not in his clinical judgment have contributed to fall risk. That question had been raised; he answered it directly.
What remained unanswered, at least in the record inspectors produced, was why the box stayed where R2 could reach it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jerseyville Nsg & Rehab Center from 2025-11-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
JERSEYVILLE NSG & REHAB CENTER in JERSEYVILLE, IL was cited for violations during a health inspection on November 12, 2025.
That is what federal inspectors found at Jerseyville Nursing & Rehab Center following a complaint inspection completed in November 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.