Jerseyville Manor

In the surveyor’s words

From the most serious findings on record at Jerseyville Manor, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 23, 2026

  Based on interview and record review, the facility failed to prevent resident to resident abuse in 1 of 5 residents (R157) reviewed for abuse in the sample of 42. This failure resulted in R157 fracturing her left hip which required surgical intervention and subsequently led to R157's death.Findings Include:The Facility Investigation, undated, documents the following: R136 pushed R157 causing her to fall to the floor. R157, an alert and confused female. Her BIMS (Brief Interview for Mental Status) score is 3 indicating severe cognitive impairment and her primary diagnosis is Unspecified Dementia. R157 walks independently on the unit with staff supervision. After the fall R157 complained of pain during assessment. Family and physician were notified. […]

• Actual harm, isolatedF689Jan 23, 2026

  Based on the facility failed to implement current fall interventions for 1 (R118) of 9 resident reviewed for accidents in a sample of 42. This failure resulted in R118 sustaining a Left Patellar Fracture.Findings Include:R118's Undated Face Sheet documents R118 was admitted to the facility on [DATE] and has a medical diagnosis of Dementia, Weakness, and Alzheimer's Disease.R118's Minimum Data Set, dated [DATE] documents R118 is severely cognitively impaired, uses a walker, and needs substantial/maximal assistance with lying to sitting on side of bed, sitting to standing, chair/bed to chair transfers, and walking 10 feet.R118's Care Plan Last Reviewed/Revised 1/15/2026 documents Problem: R118 is at risk for falls related to diagnoses, cognitive deficits which may alter safety awareness,… […]

• Actual harm, isolatedF689Dec 19, 2022

  Based on observation, interview and record review, the facility failed to ensure appropriate fall interventions were in place, monitor and provide safe transfers for 6 of 7 residents (R14, R28, R72, R63, R280, R297) reviewed for falls and transfers in the sample of 57. This failure resulted in R63's fall sustaining a right hip fracture. Findings include: 1. R63's Resident Face Sheet, undated, documented diagnoses of Cerebral Infarction due to thrombosis of unspecified precerebral artery-CVA with right sided hemi, Unsteadiness on feet and other lack of coordination. R63's Minimum Data Assessment (MDS) dated [DATE], documented that his cognition was severely impaired and that he was totally dependent upon staff for bathing. […]

• Actual harm, isolatedF689Oct 6, 2022

  Based on observation, interview and record review, the facility failed to supervise residents to prevent falls for 1 of 3 residents (R6) reviewed for falls in the sample of 12. This failure resulted in R6 sustaining a broken finger and facial bruising around the eye, cheek and chin. Findings include: On 9/22/22 at 11:08 AM, R6 was sleeping in her wheelchair. R6 had purple and fading yellow bruising around her right eye, cheek and chin. R6 has an ace bandage on her right hand. R6's Physician Order Report, dated 9/1/22 - 9/22/22 documents R6 was admitted on [DATE] with diagnoses of Congestive Heart Failure, Type 2 Diabetes, Dementia and depression. […]

• No harm, potential for more than minimal, widespreadF812Feb 15, 2024

  Based on observation, and interview the facility failed to ensure there was an air gap in the ice machine between the ice storage bin and floor sewage drain in the kitchen and that food was stored, prepared, and served under sanitary conditions. This has the potential to affect the 138 residents living in this facility. Findings include: On 2/13/2024 at 9:12 AM, in the refrigerator there were 12 cases of milk stacked in crates containing 4 gallons in each milk in each container stacked 3 crates high. The milk was sitting directly on the floor. On 2/13/2024 at 9:15 AM, in the refrigerator, next to the milk was a pull-out cart that had a large clear container of cabbage and a clear plastic bag of green onions. Both items were cut into small pieces, and there was no date and/or label. […]