Jerseyville Nsg & Rehab Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
isn't a lot of time in between when staff aren't there. On 9/16/25 at 1:33 PM, V10, Resident R2's Physician, stated Resident R2 is confused and has Alzheimer's Disease, the plan would not be to have her outside by herself. V10 stated V3 was at the facility and then went outside, so this could have caused Resident R2 to go searching for V3. V10 stated Resident R2 was found and returned to the facility pretty quickly.The Elopement Prevention Policy, dated 5/16/24, documents the following: It is the policy of this facility to provide a safe and secure environment for all residents. To ensure this process, the staff will assess all residents for the potential for elopement.
Determination of risk will be assigned for each individual resident and interventions for prevention be established in the plan of care to minimize the risk for elopement. A licensed nurse will complete the Elopement Risk Assessment upon admission to the facility. An interim plan of care for minimizing the risk for elopement will be initiated upon the risk determination. Revision of the Elopement Risk Assessment will be completed quarterly, upon a resident's significant change of condition, when elopement behaviors occur and as needed, determined by the IDT (Interdisciplinary Team). The Immediate Jeopardy that began on 8/22/25 was removed on 9/16/25, when the facility took the following actions to remove the immediacy:IMMEDIATE JEOPARDY REMOVAL OF IMMEDIACY PLANDeficiency Summary:The facility failed to ensure door alarms were loud enough to be heard from nursing stations and failed to ensure the exit gate latch was in working order to prevent elopement. This resulted in Resident R2, with a diagnosis of Alzheimer's Disease, eloping from the facility and being found in the roadway, creating risk for serious harm.1. Corrective Action for Residents Affected Resident R2 was immediately returned safely to the facility and assessed for injury by nursing staff; no injuries were noted. Completed on 8/22/2025 V4, LPN. Thorough body assessment completed for any injury 8/22/2025 V4, LPN. The physician and family were notified immediately of the incident. 8/22/2025 V4, LPN. All door alarms were checked 8/22/2025 V4, LPN and 9/16/2025 V7, Maintenance Director. All facility gates were checked 8/22/2025 V4, LPN and 9/16/2025 V7, Maintenance Director. Door alarms checked by outside vendor All components for the door monitor voice announcement system ordered on August 28th. 2. Identification of Other Residents at Risk Elopement
observations for residents at risk were completed: care plans reviewed and if updated if needed. 9/16/2025 V2, DON. All exit doors and alarms were tested for sound, function, and audibility from all nursing stations; any malfunctioning or inaudible alarms were immediately ordered to be repaired or replaced. 9/16/2025 V7, Maintenance Director. All exterior gate latches were inspected and repaired to ensure secure closure. 8/26/2025 V7, Maintenance Director.3. Systemic Changes to Prevent Recurrence Staff will be positioned by
the door alarm until scheduled maintenance is completed. All components for the door monitor voice announcement system are assembled, programmed, and ready to install. This will be interconnected to the 200/400 Patio door to this new system. The installation of this system is scheduled for tomorrow, September 17. A policy review of missing residents completed without any changes 9/16/2025 V1, Administrator Policy review on elopement policy without any revision 9/16/2025 V1 Administrator A policy
review of door alarm policy reviewed without any revision 9/16/2025 V1, Administrator Education provided to all staff (nursing, maintenance, ancillary staff) on elopement policy, missing resident policy and door alarm policy on 9/16/2025, including response procedures when an alarm sounds. V2, DON, V1, Administrator and V15, Dietary Manager.4. Monitoring to Ensure Compliance Administrator or designee will conduct weekly audits of door alarm function and audibility for four weeks, then monthly for three months.
Maintenance Director will maintain daily door alarm checks when on duty Results will be reported monthly to the QAPI committee for review and ongoing oversight. Any alarm malfunction identified will result in immediate repair and staff re-education if necessary.5. Completion Date All corrective actions will be completed 9/16/2025
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If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Jerseyville Nsg & Rehab Center
1001 South State Street Jerseyville, IL 62052
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0908
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to ensure its courtyard gait latch was in proper working order when reviewing for mechanical equipment in working order. This failure has the potential to affect all 50 residents residing in the facility.Findings Include:On 9/12/25 at 11:20 AM, V3, Resident R2's Son, stated
on that Friday 8/22/25, Resident R2 had exited the facility without staff and he and V4, LPN (Licensed Practical Nurse) went outside to the fenced in courtyard and did not see her. A young lady called and stated the facility had a patient out on the road behind the facility. V3 stated the courtyard gate to the fenced in area outside the 200-hall door was not locked or latched. V3 stated when he asked about this, he was told that
they could not lock/latch it because it was illegal because it could prevent residents from exiting in the event of a fire. V3 stated he had decided at that time to take Resident R2 home to live with him, they had several care concerns and this just placed it over the top. On 9/12/25 at 1:10 PM, V2, DON (Director of Nurses), stated
the latch to the gait off of the 200-hall exit door was broken and has been fixed. V2 stated V3 asked her why
it wasn't latched, and she told him because they weren't required to.Resident R2's Progress Note, dated 9/3/25 at 2:32 PM, documents the following: This nurse spoke to (V3), and he stated he was going to discharge his mother home to his house on 9/5/25. (V3) stated he feels that if he takes her home, she would be safer, and
he wouldn't have to worry about her. (V3) stated he didn't feel safe with the facilities back fence being open.The Safety and Supervision of Residents Policy, dated 12/31/25, documents the following: Our facility strives to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. Safety risks and environmental hazards are identified in an ongoing basis through a combination of employee training, employee monitoring, and reporting processes, reviews of safety and incident/accident report, and a facility-wide commitment to safety at all levels of the organization.The Resident Census Report, dated 9/12/25, documents there are 50 residents residing in the facility.
Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
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If continuation sheet
JERSEYVILLE NSG & REHAB CENTER in JERSEYVILLE, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in JERSEYVILLE, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from JERSEYVILLE NSG & REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.