Cycle 1
Health 2024-10-17 · Fire 2024-10-17
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fairfield, IL
Fairfield Memorial Hospital
5-star overall rating with 5-star inspections with 4 recent health deficiencies
North West 11th Street, Fairfield, IL
(618) 842-2611
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
22
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-03-26
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.32
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
2.41
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.73
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.32
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.49
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
2.09
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
2.59
CMS adjusted RN staffing hours
Adjusted total hours
5.28
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
27%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
628
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.28
Composite VBP score used to determine payment impact.
Payment multiplier
1.0202
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.62
Baseline 18.41% · Performance 19.29% · Measure score 4.62 · Achievement 4.62 · Improvement 0
Healthcare-associated infections
5.26
Baseline 5.53% · Performance 6.26% · Measure score 5.26 · Achievement 5.26 · Improvement 0
Total nurse turnover
10
Performance 13.04% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.2% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 6.36% · Lower 95% interval 6.57% |
| Discharge to community | 64.99% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 108 · Observed rate 68.52% · Lower 95% interval 57.09% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.83% |
95.27%
2.6 pts better
|
Numerator 45 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 74.42% |
53.69%
20.7 pts better
|
Numerator 32 · Denominator 43 |
| Discharge mobility score | 74.42% |
50.94%
23.5 pts better
|
Numerator 32 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 2.17% |
2.29%
0.1 pts better
|
Numerator 1 · Denominator 46 · Adjusted rate 2.97% |
| Healthcare-associated infections requiring hospitalization | 6.26% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 1.85% · Lower 95% interval 3.21% |
| Staff COVID-19 vaccination coverage | 2.33% |
8.2%
5.9 pts worse
|
Numerator 1 · Denominator 43 |
| Staff flu vaccination coverage | 78.18% |
42%
36.2 pts better
|
Numerator 43 · Denominator 55 |
| Discharge function score | 76.74% |
56.45%
20.3 pts better
|
Numerator 33 · Denominator 43 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.3%
2.4 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.9% |
50.3%
47.4 pts better
|
11.4%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.9% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.5%
0.3 pts better
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.7% |
18.5%
4.2 pts worse
|
19.6%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.8% |
22.8%
2 pts better
|
16.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.2% |
17.2%
8 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
15.0%
8.3 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.6% |
1.1%
3.5 pts worse
|
1.0%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 11.6% |
1.7%
9.9 pts worse
|
1.7%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.9% |
21.3%
15.4 pts better
|
19.8%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.2%
5.2 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
68.8%
31.2 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.4% |
14.0%
10.4 pts worse
|
12.0%
12.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 21.1% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
63.0%
32.8 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.8% |
26.2%
18.4 pts better
|
23.9%
16.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 5.3% · Expected 16.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-08 · Fire 2023-09-08
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-10-20 · Fire 2022-10-20
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
G · Actual harm
2024-10-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-14
D · Potential for more than minimal harm
2024-10-17
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-13
D · Potential for more than minimal harm
2024-10-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-11-18
D · Potential for more than minimal harm
2024-10-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-11-19
Penalties and ownership
What sits behind the stars
Ownership
Fairfield Memorial Hospital Association
5% Or Greater Direct Ownership Interest · Organization
Copeland, Michael
Corporate Director · Individual
Copeland, Michael
Corporate Officer · Individual
Deaconess Health System Inc
Operational/Managerial Control · Organization
Fairfield Memorial Hospital Association
Operational/Managerial Control · Organization
Flemer, David
Corporate Director · Individual
Florence, Marc
Corporate Director · Individual
Knight, Mary
Operational/Managerial Control · Individual
Masterson, Donna
Corporate Director · Individual
Molt, Patrick
Corporate Director · Individual
Molt, Patrick
Corporate Officer · Individual
Pollard, James
Corporate Director · Individual
Pond, Anita
Corporate Director · Individual
Scott, Josh
Corporate Director · Individual
Seng, Matthew
Corporate Director · Individual
Sterling, Jessica
Operational/Managerial Control · Individual
Taylor, Dana
Operational/Managerial Control · Individual
Taylor, Dana
Corporate Officer · Individual
Trowbridge, Brianna
Corporate Director · Individual
Wilson, Doug
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Fairfield Senior Living & Rehabilitation LLC
Fairfield, IL
1-star overall rating with 2-star inspections with $110,110 in total fines with 6 recent health deficiencies with 28 fire-safety deficiencies in the latest cycle
#2
Cisne Rehabilitation and Health Care Center
Cisne, IL
2-star overall rating with 3-star inspections with $19,669 in total fines with 6 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Axiom Gardens of Flora
Flora, IL
1-star overall rating with 1-star inspections with abuse icon flag with $119,254 in total fines with 24 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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