Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observations, record review the facility failed to assess and monitor a Gastrostomy tube site for 1
of 2 residents (R2) reviewed for feeding tubes in a sample of 6.
Findings include:
R2's Face Sheet, not dated, documented that R2's original admission date was 9/30/3019 was readmitted
to the facility on [DATE] with a diagnosis of dysphagia and adult failure to thrive.
R2's minimum data set (MDS), dated [DATE], documented that R2 is moderately cognitively impaired. MDS
indicated that she requires assistance with activities of daily living (ADL). R2 receives a mechanically
altered diet.
R2's Care Plan, updated on 10/07/2024, documented that R2 refuses to follow mechanical diet and
chooses to eat regular textured food despite being educated on the risks of choking. Care plan dated
10/05/2024 documented that R2 receives tube feeding for support to nutritional oral intake. The goal is that
R2 will be adequately nourished and hydrated as evidenced by maintaining weight. The approaches are
flushes as ordered, keep head of bed elevated, monitor weight, notify physician of changes, observe for
signs and symptoms of aspiration, observe for tube feeding tolerance, and tube feeding as ordered.
R2's Physician Orders, dated 10/23/2024, documented to administer Nova Source Renal 2 237 milliliters
(ml) via percutaneous gastrostomy tube (PEG); to flush gastrostomy tube (G tube) with 50 ml water before
and after each tube feeding ordered at 9:00 am, 1:00 pm, 5:00 pm and 9:00 pm. R2's POS (Physician
Order Sheet) documents an order dated 11/5/2024 to consult with dietician to adjust tube feeds based on
oral intake.
R2's Physician Progress Note, dated 10/8/2024, documented that R2 receives tube feeding via peg tube
but has also passed her swallow and is able to take things by mouth but has poor intake.
R2's Progress Notes, dated 11/12/2024, documented that G tube patent, placement verified per
auscultation. Flushes as ordered without difficulty.
R2's Progress Notes, dated 11/18/2024, at 1:51 pm, documented that R2 took morning medications and
pain medications before leaving for dialysis by mouth crushed. R2 refused tube feeding stating it made her
sick on the ride there.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145465
Printed: 05/15/2026
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
145465
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/26/2024
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 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R2's Progress Notes, dated 11/18/2024 at 5:13 pm, documented Registered Nurse (RN) went to administer
evening medications and resident stated she doesn't get anything that way anymore, pulled her shirt up
and there was no g-tube present. Medical doctor (MD) made aware and R2 has been sent to hospital for
possible reinsertion. R2 had stated that it had been out for a few days.
R2's Progress Notes, dated 11/20/2024 at 2:58 pm, documented R2 returned to facility from hospital
yesterday (11/19/2024) following admission for G-tube removal observation/monitoring. Area to abdomen
where G tube was removed clean and dry. No drainage or signs and symptoms of infection.
On 11/25/2024 at 8:25 am, observed R2 in her room lying in bed, flat sleeping with oxygen on. Tube feeding
supplies are noted sitting on her windowsill. Empty enteral feeding bag hanging on intravenous pole (IV)
dated on bag of 11/4.
On 11/25/2024 at 9:20 am, R2 stated she has been eating meals the entire time she has had G tube in. R2
stated her G tube was accidentally pulled out a week or two ago. R2 stated that she was in the hospital for
3 days. R2 doesn't remember how the tube was pulled out. R2 stated that she honestly didn't know why she
ever had the G tube.
On 11/26/2024 at 9:20 am V3, Licensed Practical Nurse (LPN) stated that she did not take care of R2 on
11/15/2024. V3 stated that the day before R2 had been moved from the 400- hall to the 200 -hall. V3 did
remember that the morning of 11/15/2024, R2 had come up to V3 and had told her that her (R2) G tube
was out. V3 stated that she thought R2 was her patient. R2 had told her that she did not want the G tube
and that she had tried to pull it out in the past. V3 was asked regarding care of a G tube, and she stated
she would assess it, put a dressing on it. V3 stated that she would try to document this assessment at least
once per day in her progress notes.
On 11/25/2024 at 3:40 pm spoke with V13, Certified Nursing Assistant (CNA). V13 stated that on
11/15/2024 she was on the 400- hall. However, she did get the front door when transport returned with R2
from hemodialysis. Transport stated that R2's G tube was out. V13 told him that she would tell her nurse
and she told V3.
On 11/25/2024 at 3:30 pm spoke with V14, RN. V14 stated that on 11/16/2024 she had charted not given
for the 9:00 am and 1:00 pm entries for medications because she had followed an agency nurse who had
not given R2 medications. V14 stated that it was around 5:00 pm - 5:30 pm and she gave R2 her
medications orally. V14 planned to flush the g-tube but R2 told her it wasn't there anymore. V14 asked R2 if
it was discontinued and R2 stated that it had been because she doesn't need it anymore. R2 told V14 that
she was eating and drinking.
On 11/25/2024 at 9:30 am spoke with V5, LPN. V5 stated that Monday morning, 11/18/2024, she gave R2
her medications orally and R2 refused her tube feeding. V5 stated that she did not observe or assess the
tube feeding site and sent her to dialysis. V5 stated it was discovered Monday after dialysis that the G tube
was not in place, and R2 was sent to the hospital.
On 11/25/2024 at 3:17 PM V12, Emergency Medical Technician (EMT), stated that they received a call for
transport for resident gastrostomy (G) tube replacement. V12 stated that he asked the 2 nurses present
when it was the last flushed. V12 stated that he was informed that the G-tube was flushed on that day at
6:30 AM. V12 stated upon assessing the patient noted that the feeding site was scabbed completely over.
V12 stated that the scabbed appeared to be there longer than a few hours. It didn't look like it had just been
pulled out this morning. V12 stated that he sees this as neglect because
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145465
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
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
145465
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/26/2024
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 0693
Level of Harm - Minimal harm
or potential for actual harm
to say that a treatment was completed, and it is obvious that it wasn't is a problem. V12 stated that this is
the first time I've seen a feeding tube that scabbed over when I was told it was flushed this morning. V12
stated that I would think it would have been longer and the ER (Emergency room) physician said that R2
would have to have surgery for placement of the G-tube. V12 stated that R2 stated that the tube came out
on Friday prior. It threw up all kinds of red flags and I am obligated to report it.
Residents Affected - Few
The facility's Enteral Feeding Tubes: checking placement policy, dated July 2024, documents that It is the
policy of Helia Healthcare that enteral feeding tube placement will be checked to confirm placement.
Procedure: 1. The nurse will check enteral feeding tubes each shift and as needed.
The facility's Tube Feeding: Bolus policy, dated July 2024, documents Procedure: 1. Check physician's order
to determine type of feeding. 3. Verify placement of the tube
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145465
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
FAQ · About this visit
Common questions about this visit
What happened during the November 26, 2024 survey of JERSEYVILLE NSG & REHAB CENTER?
This was a inspection survey of JERSEYVILLE NSG & REHAB CENTER on November 26, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at JERSEYVILLE NSG & REHAB CENTER on November 26, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriat..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.