Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to provide preventative measures for a safe transfer, free of
hazards from one level to the next for 2 out of 8 residents (R39, R59) for falls in a sample of 43.
1. R59's Face Sheet undated documents her pertinent diagnosis as age related physical debility and
repeated falls.
R59's Minimum Data Set (MDS) dated [DATE] documents R59 has moderate cognitive impairment and is
dependent in transferring from sit to stand, chair to bed, toilet, and tub transfer.
R59's Fall Risk admission dated 7/26/24 documents High Risk for Falls.
Nurse Progress notes dated 11/6/24 documents R59 lost her balance during a transfer from wheelchair to
recliner and fell to her right side, staff was present with her.
Medical records from an area hospital dated 11/6/24 documents R59 presenting with a ground level fall
during transferring a patient, head injury, bruising to forehead, forehead hematoma. 11/6/24 CT with spine
obtained documents no acute abnormality, no acute intracranial finding.
On 11/21/24 at 12:23 PM, V27 (Certified Nursing Assistant/CNA) stated she was the CNA involved in the
transfer of R59 on 11/6/24. V27 stated it was after lunch and she was in the process of transferring R59 to
her recliner, she stood R59 up using a gait belt and R59 fell forward. R59 is top heavy. V27 stated she did
use a gait belt and was positioned behind R59, tried to hold onto her but could not prevent her fall. She had
transferred R59 before and had not had any problems with transferring her. V1 (Administrator) had provided
in-service training on the correct way to transfer residents.
On 11/21/24 at 12:47 PM, V28 (Certified Occupational Therapy Assistant) stated when using a gait belt with
a resident you position yourself in front of the resident to help guide them and prevent resident from falling
over.
On 11/22/24 at 1:31 PM, V1 (Administrator) stated R59 was new to the facility and had not been assessed
by physical therapy for an assistive device for mobility. V1 stated she was unaware of the positioning of the
CNA with the gait belt that contributed to R59's falling over during transfer. V1 stated V1 had provided
in-service training on transfers to the CNA.
2. R39's Face Sheet documents R39 was admitted to the facility on [DATE] with diagnoses including
hemiplegia and hemiparesis following cerebral infarction, polyneuropathy, heart failure, and fatigue.
(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 6
Event ID:
146142
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
146142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meridian Village Care Center
27 Auerbach Place
Glen Carbon, IL 62034
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 0689
R39's Minimum Data Set (MDS) dated [DATE] documented R39 was cognitively intact, required substantial
assistance with rolling from side to side, and was dependent with transfer.
Level of Harm - Minimal harm
or potential for actual harm
R39's Morse Fall Scale dated 6/4/24 documents R39 was at risk for falls.
Residents Affected - Few
The Facility's Fall Log documents R39 had falls on 6/20/24 and 6/28/24.
R39's Adverse Event Documentation dated 6/20/24 documents R39 fell out of bed, hit his head and nose,
and sustained a bruise and hematoma to his forehead. R39 was admitted to the hospital with skull and
facial fractures, trace subarachnoid hemorrhage, and small parafalcine subdural hematoma.
R39's Adverse Event Documentation dated 6/28/24 documents staff were getting ready to mechanically lift
R39 from his wheelchair to bed, and when they removed his footrest, he slid to the floor with his back
against the wheelchair.
On 11/21/24 at 10:05 AM, V26 (Registered Nurse) stated she did not witness R39's 6/28/24 fall but was
notified by V30 and V31 (CNAs) that he had fallen when they were preparing to transfer him via mechanical
lift. She stated R39 was supporting himself with the footrest because of the way he was positioned, and
when they moved the foot pedals out, he slid down from the chair.
On 11/21/24 at 2:00 PM, V30 (CNA) stated she was assisting with (R39's) transfer from wheelchair to bed
and did not realize he was supporting himself with the foot pedals on his wheelchair. R39's sling was
underneath him but was not yet hooked up to the lift. They moved the foot pedals out, and he slid from the
chair to a seated position on the floor. She stated they probably could have prevented this if they had
repositioned him or hooked the sling to the lift before removing the foot pedals.
On 11/21/24 at 2:17 PM, V31 (CNA) stated she was removing R39's foot pedals from his wheelchair before
hooking his sling to the mechanical lift when he started to slide. She was standing behind him and helped
lower him to the ground to a seated position. She stated he was slouched to one side in his chair and the
foot pedals were keeping him in place, and the moment she took the pedals away he started to slide down.
She stated better positioning in his chair may have prevented this from happening.
On 11/22/24 at 9:20 AM, V1 (Administrator) stated she expects staff to ensure residents are positioned
properly prior to transfer.
The facility policy Management of Fall Risk with a review date 1/30/24 documents the definition of a fall is
an incident in which the resident unintentionally comes to rest on the ground, floor, or other lower level.
Based on previous evaluations and current data, the staff will identify interventions related to the resident's
specific risks and causes to try prevent the resident from falling from falling and to try to minimize
complications from falling.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146142
If continuation sheet
Page 2 of 6
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
146142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meridian Village Care Center
27 Auerbach Place
Glen Carbon, IL 62034
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 0808
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or
licensed dietitian, to the extent allowed by State law.
Based on observation, interview, and record review, the Facility failed to ensure food was prepared
according to physician prescribed diet orders for 3 of 3 residents (R6, R38, R47) reviewed for therapeutic
diets in the sample of 43.
Findings include:
1. R6's Physician Order dated 9/21/24 documents, Diet: IDDSI (International Dysphagia Diet
Standardization Initiative) Level 5 Minced & Moist.
On 11/19/24 at 12:20 PM, R6 was eating lunch in the dining room. R6's ground chicken did not have a
sauce or liquid on top to moisten it.
2. R38's Physician Order dated 1/24/24 documents, Diet IDDSI Level 5 Minced & Moist.
On 11/19/24 at 12:14 PM V15 (Licensed Practical Nurse) was assisting R38 with her lunch in the dining
room. R38's ground chicken did not have a sauce or liquid on top to moisten it.
3. R47's Physician Order dated 5/5/24 documents, Diet IDDSI Level 5 Minced & Moist.
On 11/19/24 at 12:20 PM R47 was eating lunch in the dining room. R47's ground chicken did not have a
sauce or liquid on top to moisten it.
On 11/19/24 at 12:25 PM V7 (Dietary Aid) stated the cooks have not been preparing sauces or gravies for
the mechanically altered diets lately.
On 11/19/24 at 3:00 PM, V4 (Dietary Manager) stated all mechanical soft diets should come with some sort
of liquid or gravy.
On 11/20/24 at 3:30 PM, V17 (Speech Language Pathologist) stated minced and moist meats should be
covered with a sauce or gravy or some kind of liquid to ensure the food stays moist.
On 11/22/24 at 9:20 AM, V1 (Administrator) stated she expects staff to follow food service policies and
physician prescribed diets.
The Facility's Therapeutic and Mechanically Altered Diets - Long Term Care Policy reviewed 2/16/24
documents, The CDM (Certified Dietary Manager) and Dining Services supervisor will establish and use
and identification system to ensure that each resident receives their diet as ordered. Staff should be trained
on the system to ensure that correct procedures are followed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146142
If continuation sheet
Page 3 of 6
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
146142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meridian Village Care Center
27 Auerbach Place
Glen Carbon, IL 62034
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the Facility failed to ensure food was stored and prepared in a
manner that prevents foodborne illness. This has the potential to affect all 62 residents living in the Facility.
Findings include:
On 11/19/24 at 8:27 AM in the standing freezer there were open bags of hash browns, chicken strips, onion
rings, egg rolls, French fries, and chicken drumsticks. These bags were not labeled, dated, or resealed
upon opening, leaving the contents open to air. There was an opened package of pepperoni that was not
dated or resealed upon opening, leaving the contents open to air. There was a bag of fish and a bag of raw
chicken breasts that were labeled and dated upon opening, but were not resealed, leaving the contents
open to air. The bag of raw chicken breasts was stored directly above a box of shrimp which had also been
opened but was not dated.
On 11/19/24 at 8:30 AM in the standing refrigerator to the right of the standing freezer, there were two
gallons of skim milk labeled Best by [DATE]. There was a box of brown, unpasteurized shell eggs stored
directly above cartons of liquid pasteurized eggs. There was a container with a red liquid substance that
was not labeled or dated. V5 (Dietary Supervisor) stated it was tomato soup, and she thinks it was made
yesterday. There was a half full container of commercially made tuna salad that was not dated upon
opening. There was a container with an unknown substance that V5 stated was creamed corn that was not
labeled or dated. There was a package labeled corned beef dated 11/6. V5 stated food should not be kept
for that long.
On 11/19/24 at 8:32 AM, V8 (Dishwasher) stated she does not test the sanitizer in the dish machine and
has only seen test strips when the maintenance company comes in to check the machines periodically.
On 11/19/24 at 8:35 AM in the walk-in refrigerator there was commercially prepared container of tuna salad
that had been previously opened. The lid was not sealed, and the container was not dated upon opening.
There were containers of onions, tomatoes, and black olives that were not labeled or dated.
On 11/19/24 at 8:38 AM in the walk-in freezer there was a plastic bag of corn dogs and a plastic bag of
breaded meat that had been removed from the original packaging and were not labeled or dated.
On 11/19/24 at 8:41 AM in the dry storage room there was a package of coconut flakes that was not dated
upon opening. There was plastic bag of raisins inside a large box that had been opened, but was not
resealed upon opening, leaving the raisins open to air.
On 11/19/24 at 8:44 AM, V6 (Executive Chef) stated the Facility does make eggs over easy and does not
believe the shell eggs they use are pasteurized.
On 11/19/24 at 8:43 AM, holding temperatures were obtained from the steam table on Willow Way during
breakfast service with a metal calibrated thermometer. The oatmeal measured 125º Fahrenheit (F).
V7 (Dietary Aid) was stated he was not sure of the goal temperature but tries to keep the food
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146142
If continuation sheet
Page 4 of 6
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
146142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meridian Village Care Center
27 Auerbach Place
Glen Carbon, IL 62034
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 0812
warm.
Level of Harm - Minimal harm
or potential for actual harm
On 11/19/24 at 9:40 AM, V4 (Dietary Manager) stated they do keep test strips for the dish machine, but V8
just started working that shift as the dishwasher.
Residents Affected - Many
On 11/22/24 at 9:20 AM, V1 (Administrator) stated she expects staff to follow food service policies.
The Facility's Food Storage Policy revised 10/1/20 documents, It is the policy of the Dining Services
Department to develop a mechanism to ensure the safe and accurate storage of food and nonfood
products. Items that arrive in their original packaging with a manufacturer's expiration date will utilize that
date for discard. Should an item be opened and stored in a different container, it will be labeled with an
open date and a discard date. Food Safety practices based on Serv Safe Standards will be followed at all
times.
The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 11/19/24
documents there are 62 residents living in the Facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146142
If continuation sheet
Page 5 of 6
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
146142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Meridian Village Care Center
27 Auerbach Place
Glen Carbon, IL 62034
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 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to provide antibiotic stewardship for 1 of 2 residents
(R116) reviewed for antibiotic stewardship in the sample of 43.
Residents Affected - Few
Findings Include:
The facility's Infection Control Log dated 7/2/24 documents R116 prophylactic use admitted with a UTI
(Urinary Tract Infection). The Infection Control Log also documented that R116 received Methenamine
Hippurate 1 gram.
R116's Nurses Note dated 7/9/24 documents V33 (Attending Physician) gave okay to check a UA
(Urinalysis) and C&S (Culture and Sensitivity) to R/O (Rule Out) UTI. PT (Patient) cont. (continues) to c/o
(complain of) UTI symptoms. She (R116) is on prophylaxis ABX (antibiotic) daily now and UA on 7/3 was
neg (negative). Son cont. to request UA.
R116's Medication Administration Record for the month of July documents Methenamine Hippurate 1 gram
one tablet per day starting 7/1/24 through 7/26/24 UTI Prophylactic.
R116 Physician Order Sheet dated 7/1/24 documents Methenamine Hippurate 1 gram tablet oral Indication:
UTI Prophylactic. Discontinued on 7/26/24.
R116's Infection Care Plan dated 7/9/24 to present documents (R116) is presenting with infection (R116)
will be assessed for signs and symptoms of infection. Intervention: chronic use of antibiotic related to
methenamine prior to admitting to the facility current active.
On 11/22/24 at 1:25 PM V1 (Administrator) stated, she (R116) was admitted on that chronic antibiotic. We
did not discontinue it because she was admitted on it.
The facility policy Antibiotic Program dated 1/30/24 documents the antibiotic program promotes the
appropriate use of antibiotics and a system of monitoring to improve resident outcomes and reduce
antibiotic resistance
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146142
If continuation sheet
Page 6 of 6
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Back to topCitations
6 citations 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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
FAQ · About this visit
Common questions about this visit
What happened during the November 22, 2024 survey of MERIDIAN VILLAGE CARE CENTER?
This was a inspection survey of MERIDIAN VILLAGE CARE CENTER on November 22, 2024. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MERIDIAN VILLAGE CARE CENTER on November 22, 2024?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
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.