Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evercare Of Jerseyville during CMS and state inspections, most recent first.
A resident with multiple medical conditions and a moderate risk for pressure ulcers developed a new Stage 2 pressure ulcer after staff failed to consistently implement care plan interventions, such as providing a pressure-relieving cushion and regular repositioning. The resident was observed in a wheelchair without appropriate pressure-relieving devices, and staff did not ensure interventions were in place as required by facility policy.
The facility failed to employ a Registered Nurse as the Director of Nursing (DON), affecting all 41 residents. The position has been vacant since 6/28/24, with duties split between the Administrator and an LPN/MDS Nurse. Despite efforts to fill the role, including job ads and interviews, the facility remains without a DON, lacking a dedicated full-time nurse to oversee operations.
The facility failed to maintain food safety and sanitation standards, affecting all 41 residents. Observations included unlabeled and undated food items, improper hand hygiene by a cook, and unclean cooling units in the kitchen. The Dietary Manager acknowledged the need for labeling and cleaning but had not implemented these practices.
The facility failed to appoint a qualified individual for the Infection Prevention and Control Program, affecting 41 residents. After the DON left, the Administrator and an LPN shared infection control duties, but the LPN lacks certification, and the Administrator has limited medical knowledge. This arrangement does not meet the facility's policy requiring a part-time Infection Preventionist.
The facility failed to provide adequate incontinent care, resulting in multiple residents developing UTIs. Residents were not assisted with toileting in a timely manner, and proper cleaning techniques were not followed. Care plans requiring regular checks and thorough cleaning were not adhered to, contributing to the residents' conditions. The facility's perineal cleansing policy was not consistently implemented, leading to deficiencies in care.
A long-term care facility failed to adhere to infection control protocols, including inadequate hand hygiene, improper use of PPE, and lack of isolation signage. Staff members were observed not changing gloves between tasks and not performing hand hygiene, increasing the risk of cross-contamination. Residents with indwelling medical devices and infections were not properly isolated, and staff were unaware of Enhanced Barrier Precautions requirements.
A resident reported being kicked by a prior DON, causing a fall and requiring a mechanical lift. Despite the resident's cognitive intactness and reporting the incident to her doctor and staff, the facility failed to document or report the incident to IDPH. The administrator, unaware of the allegations until informed by surveyors, did not investigate further or report the incident, violating the facility's Resident Rights Policy.
A cognitively intact resident reported being kicked by a prior DON, causing a fall and requiring a mechanical lift. Despite the report, the facility failed to document or investigate the incident, violating its Resident Rights Policy.
A resident experiencing gradual weight loss did not receive prescribed nutritional supplements during a meal, and staff failed to intervene or document the refusal to eat. Despite specific dietary orders to add ice cream to meals, the resident did not receive it, and staff did not follow the care plan interventions to address poor intake.
A facility failed to manage a resident's G-tube care properly, as an LPN administered water and medications without checking for residuals, contrary to policy. Additionally, CNAs lowered the resident's bed to a flat position while the feeding pump was running, unaware of the requirement to stop the pump. The resident was severely cognitively impaired with a diagnosis of Chromosomal abnormality and Gastrostomy.
A facility failed to provide assistive eating devices for a resident, leading to the resident using their hands to eat. Observations showed the resident using a regular spoon and their hand to scoop food, with food falling onto the table and bib. The care plan noted a self-care deficit but did not specify adaptive equipment. The therapy director was unaware of the issue.
The facility did not post ombudsman contact information, as required, affecting all 41 residents. Several residents were unaware of this information, and a surveyor confirmed its absence. The administrator admitted there was no specific policy for posting this information, despite following state guidelines.
The facility failed to post survey results, affecting all 41 residents. During a resident council meeting, several residents were unaware of the survey results' availability. The Administrator confirmed the results were not available and acknowledged the absence of a policy for posting them, despite following Illinois Department of Public Health guidelines.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A resident with multiple complex medical diagnoses, including hypertensive heart disease with heart failure, HIV, COPD, acute myocardial infarction, and cerebral infarction, was admitted to the facility and assessed as being at moderate risk for pressure ulcer development. The resident's care plan identified the potential for pressure ulcer development and included interventions such as keeping the bed as flat as possible, using a pressure-relieving device on the bed and chair, and repositioning with assistance. Despite these documented interventions, staff failed to implement them consistently. On assessment, a new Stage 2 pressure ulcer was discovered on the resident's left buttock, which was determined to be acquired in-house. Staff interviews and observations revealed that the resident was often up in a wheelchair without a pressure-relieving cushion or device, contrary to the care plan. The resident reported having had a cushion previously but was unsure of its current whereabouts and stated that no action had been taken regarding the new pressure ulcer. Staff acknowledged encouraging the resident to use a recliner or cushion but did not ensure these interventions were in place. Facility policy required regular assessment and implementation of interventions for pressure ulcers, but these were not followed, resulting in the development of a new pressure ulcer for the resident.
Facility Lacks Director of Nursing
Penalty
Summary
The facility failed to employ a Registered Nurse as the Director of Nursing (DON), which has the potential to affect all 41 residents residing in the facility. The deficiency was identified through interviews and record reviews. On multiple occasions, the facility's Administrator, identified as V1, confirmed that the facility had been without a DON for over a month, with the last DON's day being on 6/28/24. Despite efforts to fill the position, including running and refreshing job advertisements weekly and conducting interviews, the position remained vacant. The facility's schedule for August 2024 did not list any hours for a DON, and there was no staffing policy in place, with the facility following the Illinois Department of Public Health guidelines instead. In the absence of a DON, the duties were being divided between the Administrator (V1) and a Licensed Practical Nurse/Minimum Data Set (MDS) Nurse (V11). V11 reported handling most of the DON's responsibilities, including investigating incidents, scheduling for Certified Nursing Assistants (CNAs) and nurses, and maintaining the infection book. V1, a salaried employee, incorporated DON duties into their 40-hour workweek without specific hours allocated for these tasks. This arrangement was confirmed by both V1 and V11, indicating a lack of a dedicated full-time DON to oversee nursing operations, which is a requirement for the facility.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards, which could potentially affect all 41 residents. During an inspection, it was observed that the kitchen's stand-up freezer contained a box of pre-made omelets that were not sealed and had freezer burn. The walk-in refrigerator had several items that were not labeled or dated, including a storage container of red liquid, opened cartons of tomato juice, an opened package of hot dogs, a plastic container of mandarin oranges, a stainless steel container of tomatoes, and storage bags of meat. The Dietary Manager acknowledged that all items should be labeled and dated with an open and expiration date. Additionally, a cook was observed donning gloves without performing hand hygiene before serving the noon meal. The facility also had issues with cleanliness, as the cooling unit fan cover in the walk-in refrigerator and the wall-mounted kitchen air conditioner were covered in a thick black layer of debris. These units blow air onto food preparation areas, potentially contaminating the food. The Dietary Manager admitted awareness of the need to clean the cooling unit grate but had not done so due to its continuous operation. The facility's policy requires labeling and dating of food, but these practices were not followed, leading to the deficiency.
Inadequate Infection Preventionist Designation
Penalty
Summary
The facility failed to designate a qualified individual responsible for the Infection Prevention and Control Program, which has the potential to affect all 41 residents. The Director of Nursing (DON) left the facility on 6/28/24, and since then, the Administrator (V1) and an LPN/MDS Nurse (V11) have been covering the DON's duties, including infection control. The Administrator, who is a certified Infection Preventionist but lacks a medical background beyond a Basic Life Support course, collaborates with the LPN to manage infection control tasks. However, the LPN does not have an Infection Preventionist Certification and primarily handles the infection log and antibiotic reviews. The facility's policy requires at least a part-time Infection Preventionist, which can be the DON with an approved certification. Despite this, the Administrator and LPN are sharing the infection control responsibilities without dedicated hours for these duties. The Administrator relies on the LPN for medical insights, such as understanding lab results and appropriate antibiotic use, due to her lack of nursing qualifications. The report highlights that the facility's current infection control practices do not align with their policy, as there is no qualified individual solely responsible for the program.
Inadequate Incontinent Care Leading to UTIs
Penalty
Summary
The facility failed to provide adequate incontinent care to prevent urinary tract infections (UTIs) for several residents. One resident, who was frequently incontinent of bladder and occasionally incontinent of bowel, was not assisted with toileting in a timely manner. The resident was left waiting in the bathroom, and when finally assisted, it was noted that her brief was wet, and she expressed discomfort while urinating. Her care plan required checks every two hours and as needed, but this was not adhered to, contributing to her UTI diagnosis. Another resident, who was severely cognitively impaired and frequently incontinent, was found with a soiled brief. The care provided did not include proper cleansing and drying of the perineal area, which is essential to prevent infections. The resident had recently been diagnosed with a UTI and had been to the emergency room. The care plan for this resident also required regular checks and thorough cleaning, which were not followed, potentially exacerbating her condition. Additional deficiencies were observed in the care of other residents, including improper cleaning techniques and failure to use soap during perineal care. One resident was not properly cleaned, and the foreskin was not retracted during care, which is necessary for thorough cleaning. Another resident, who was cognitively intact, reported frequent UTIs and expressed that the urgency of urination often left no time for staff assistance. The facility's perineal cleansing policy outlines specific procedures to prevent infections, but these were not consistently followed, leading to multiple cases of UTIs among residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by multiple instances of inadequate hand hygiene, improper use of personal protective equipment (PPE), and failure to post necessary isolation signs. For instance, a Licensed Practical Nurse (LPN) was observed preparing medications for a resident with a feeding tube without performing hand hygiene before or after donning and doffing gloves. Additionally, the LPN entered the resident's room without wearing a gown, despite the need for Enhanced Barrier Precautions due to the resident's indwelling medical device. The facility's policy on Enhanced Barrier Precautions was not followed, and staff members were unaware of the requirements. In another instance, a resident diagnosed with Extended Spectrum Beta Lactamase (ESBL) was not placed on isolation as required. The resident was observed using a community bathroom, and staff members failed to perform hand hygiene before donning gloves. The facility's policy on contact precautions was not adequately implemented, as evidenced by the lack of signage and improper handling of resident care equipment. Staff members were also observed using the same gloves for multiple tasks, increasing the risk of cross-contamination. Additional deficiencies were noted in the care of other residents, where staff members failed to change gloves between tasks and did not perform hand hygiene. For example, a Certified Nurse's Aide (CNA) was seen using the same gloves to provide incontinent care, apply barrier cream, and handle a mechanical lift sling. Another CNA assisted a resident to the restroom without wearing PPE and used the same gloves for multiple tasks, including wiping the resident and adjusting equipment. These actions demonstrate a systemic failure in adhering to infection control protocols, as outlined in the facility's policies.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the Illinois Department of Public Health (IDPH). The resident, who is cognitively intact and has a medical history including hypertension, arthritis, osteoarthritis, spinal stenosis, and chronic heart failure, reported that a prior Director of Nursing (DON) kicked the back of her legs, causing her to fall and require a full body mechanical lift. The resident also mentioned that the DON threatened to repeat the action. Despite the resident's report to her doctor and other staff members, there was no documentation of the incident in her chart. Upon review, the facility's administrator was unaware of the allegations until informed by surveyors. The administrator admitted to speaking with both the resident and the accused DON but did not conduct a further investigation or report the incident to IDPH. The facility's Resident Rights Policy mandates reporting such incidents to IDPH within specific timeframes, which was not adhered to in this case.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who was cognitively intact and had been admitted with diagnoses including hypertension, arthritis, osteoarthritis, spinal stenosis, and chronic heart failure. The resident reported that a prior Director of Nursing (DON) kicked the back of her legs, causing her to fall and subsequently require a full body mechanical lift. The resident also mentioned that the DON threatened to repeat the action. Despite the resident's report to her doctor and other staff members, there was no documentation of the incident in her chart, and the facility's reported abuse investigations did not include this incident. The facility's Administrator was informed of the allegations but stated it was the first time hearing of the report. Although the Administrator spoke with both the resident and the DON about the incident, no further investigation was conducted, nor was any documentation created. This inaction was contrary to the facility's Resident Rights Policy, which mandates a thorough investigation process, including obtaining documentation and conducting interviews. The lack of adherence to these procedures resulted in a deficiency in handling the abuse allegation.
Failure to Provide Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to follow the plan of care and provide nutritional supplements as ordered for a resident, leading to a deficiency in maintaining acceptable nutritional parameters. The resident, who had been experiencing gradual weight loss over six months, was on a regular diet with specific dietary instructions, including the addition of ice cream to lunch and supper meals to increase caloric intake. Despite these orders, the resident did not receive the prescribed ice cream during a noon meal observation, and staff did not intervene or offer substitutes when the resident did not eat the meal provided. The resident's care plan highlighted the risk of weight loss due to poor oral intake, with interventions such as alerting the dietitian if consumption was poor for more than 48 hours and contacting the physician and dietitian in case of weight decline. However, during the observed meal, the staff failed to follow these interventions, as they did not document the resident's refusal to eat or poor intake, nor did they inform the nurse as per facility policy. Interviews with staff revealed that while substitutes were offered, the resident often refused them, yet there was no documentation or further action taken to address the resident's nutritional needs effectively.
Deficiency in G-tube Management and Resident Positioning
Penalty
Summary
The facility failed to properly manage the care of a resident with a Gastrostomy tube (G-tube), leading to deficiencies in the administration of water flushes and medications. On one occasion, a Licensed Practical Nurse (LPN) administered 65 milliliters of water and medications through the resident's G-tube without checking for residuals, which is against the facility's policy. The policy requires confirmation of tube placement via aspiration of residuals before administering flushes or medications. The LPN stated that the past Director of Nurses had informed them that checking for residuals was unnecessary. Additionally, the facility did not adhere to the protocol of maintaining the resident's head of the bed at a minimum of 30-40 degrees during and after feeding. A Certified Nurse's Aide (CNA) lowered the resident's bed to a flat position while the feeding pump was running, which is contrary to the facility's policy. The CNA was unaware of the requirement to turn off the feeding pump when the resident is lying flat, and another CNA confirmed that they were instructed not to stop the pump. The resident involved was severely cognitively impaired and had a diagnosis of Chromosomal abnormality and Gastrostomy.
Failure to Provide Assistive Eating Devices
Penalty
Summary
The facility failed to provide assistive devices or adaptive eating equipment for a resident, resulting in the resident's inability to use eating utensils effectively and resorting to eating with hands. Observations on two separate occasions showed the resident using a regular spoon and their left hand to scoop food onto the spoon and then into their mouth. The resident was also seen picking up food that had fallen onto the table and their bib. The resident's care plan indicated a self-care deficit and required supervision or assistance with activities of daily living, including feeding. However, the care plan did not specify the need for adaptive eating equipment. The therapy director was unaware of the resident's use of hands to assist with eating and stated she would screen the resident.
Failure to Post Ombudsman Contact Information
Penalty
Summary
The facility failed to post ombudsman contact information, which is a requirement to ensure residents are aware of their rights and have access to advocacy services. This deficiency was identified through observations, interviews, and record reviews. On August 27, 2024, several residents stated they were not aware of the ombudsman contact information being posted. A surveyor confirmed the absence of this information within the facility. The facility's administrator acknowledged the lack of a specific policy for posting ombudsman information, although the facility follows Illinois Department of Public Health guidelines. The facility's Long-Term Care Application for Medicare and Medicaid documented a census of 41 residents, all potentially affected by this oversight.
Failure to Post Survey Results
Penalty
Summary
The facility failed to post survey results, which has the potential to affect all 41 residents residing at the facility. During a resident council meeting, several residents expressed that they were unaware of the availability of survey results. Throughout the survey, it was observed that the results of the last standard survey were not available. The Administrator confirmed that the state inspection results were not available for residents to read and acknowledged that there was no policy in place regarding the posting of survey results. The Administrator mentioned that the facility follows Illinois Department of Public Health guidelines, but the lack of a policy led to the deficiency.
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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) |
|---|---|---|---|---|
| Jerseyville Nsg & Rehab Center | 0.5 mi | — | 3 | 1 |
| Jerseyville Manor | 1.9 mi | — | 4 | 0 |
| Robings Manor Rhc | 11.1 mi | — | 0 | 0 |
| Bria Of Godfrey | 12 mi | — | 3 | 0 |
| La Bella Of Alton | 16 mi | — | 3 | 0 |
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