Cycle 1
Health 2024-12-06 · Fire 2024-12-06
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Belleville, IL
Memorial Care Center
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
4315 Memorial Drive, Belleville, IL
(618) 619-5000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
62
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
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
Staffing
Hours and turnover
RN hours / resident day
0.91
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
2.11
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
5.73
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
3.02
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
5.32
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
4.86
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,121
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.66
Composite VBP score used to determine payment impact.
Payment multiplier
1.0148
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.93
Baseline 18.66% · Performance 17.29% · Measure score 8.93 · Achievement 8.93 · Improvement 7.89
Healthcare-associated infections
6.60
Baseline 6.09% · Performance 5.86% · Measure score 6.60 · Achievement 6.60 · Improvement 1.57
Total nurse turnover
3.22
Performance 50.54% · Measure score 3.22 · Achievement 3.22 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.11
Baseline 5.2 hours · Performance 4.53 hours · Measure score 5.11 · Achievement 5.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 536 · Observed rate 11.38% · Lower 95% interval 8.92% |
| Discharge to community | 71.33% |
50.57%
20.8 pts better
|
Better than the National Rate · Eligible stays 539 · Observed rate 63.45% · Lower 95% interval 66.4% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.09% |
95.27%
0.2 pts worse
|
Numerator 310 · Denominator 326 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 326 |
| Discharge self-care score | 54.12% |
53.69%
0.4 pts better
|
Numerator 138 · Denominator 255 |
| Discharge mobility score | 51.76% |
50.94%
0.8 pts better
|
Numerator 132 · Denominator 255 |
| Pressure ulcers or injuries, new or worsened | 0.92% |
2.29%
1.4 pts better
|
Numerator 3 · Denominator 326 · Adjusted rate 1.17% |
| Healthcare-associated infections requiring hospitalization | 5.86% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 290 · Observed rate 4.83% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 13.14% |
8.2%
4.9 pts better
|
Numerator 18 · Denominator 137 |
| Staff flu vaccination coverage | 92.81% |
42%
50.8 pts better
|
Numerator 129 · Denominator 139 |
| Discharge function score | 46.67% |
56.45%
9.8 pts worse
|
Numerator 119 · Denominator 255 |
| Transfer of health information to provider | 99.58% |
95.95%
3.6 pts better
|
Numerator 238 · Denominator 239 |
| Transfer of health information to patient | 98.84% |
96.28%
2.6 pts better
|
Numerator 85 · Denominator 86 |
| Resident COVID-19 vaccinations up to date | 22.89% |
25.2%
2.3 pts worse
|
Numerator 38 · Denominator 166 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.1% |
68.8%
6.7 pts worse
|
81.7%
19.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.5% · Q2 59.4% · Q3 68.9% · Q4 63.3% · 4Q avg 62.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
14.0%
4.9 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 7.9% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
2.3%
2.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.3% · Q3 0.3% · Q4 0.3% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.3% |
63.0%
6.7 pts worse
|
79.7%
23.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
26.2%
2.4 pts better
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.8% · Observed 20.4% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-19 · Fire 2024-01-19
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-02-06 · Fire 2023-02-06
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-26
E · Potential for more than minimal harm
2024-01-19
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-02-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-14
F · Potential for more than minimal harm
2023-02-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-01-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-02-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-06
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-02-09
Penalties and ownership
What sits behind the stars
Ownership
Bethesda Health Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Protestant Memorial Medical Center, Inc.
5% Or Greater Direct Ownership Interest · Organization
Bethesda Health Group Inc
Operational/Managerial Control · Organization
Boyer, Geri
Corporate Director · Individual
Bryer, Keri
Operational/Managerial Control · Individual
Byrne, Roger
Corporate Director · Individual
Byrne, Roger
Corporate Officer · Individual
Cook, Keith
Corporate Director · Individual
Dossett, Jeffrey
Operational/Managerial Control · Individual
Dossett, Jeffrey
Corporate Director · Individual
Dossett, Jeffrey
Corporate Officer · Individual
Dyer, Rob
Corporate Director · Individual
Dyer, Rob
Corporate Officer · Individual
Eckert, Chris
Corporate Director · Individual
Eckert, Chris
Corporate Officer · Individual
Ganim, Randolph
Corporate Director · Individual
Halloran, Teresa
Operational/Managerial Control · Individual
Halloran, Teresa
Corporate Director · Individual
Halloran, Teresa
Corporate Officer · Individual
Hoering, Edward
Corporate Director · Individual
Jackson, Rachel
Corporate Director · Individual
Journagan, Kevin
Operational/Managerial Control · Individual
Journagan, Kevin
Corporate Director · Individual
Koesterer, Susan
Corporate Director · Individual
Koesterer, Susan
Corporate Officer · Individual
Moosa, Hans
Corporate Director · Individual
Oliver, Staci
Corporate Director · Individual
Olroyd, Rebecca
Corporate Director · Individual
Pardo, Beatriz
Corporate Director · Individual
Parks, Jeffrey
Operational/Managerial Control · Individual
Protestant Memorial Medical Center, Inc.
Operational/Managerial Control · Organization
Schroeder, Kurtis
Corporate Director · Individual
Stephens, Ronald
Corporate Director · Individual
Thaxton, Valerie
Corporate Director · Individual
Thaxton, Valerie
Corporate Officer · Individual
Nearby options
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#1
Bria Of Belleville
Belleville, IL
1-star overall rating with 2-star inspections with abuse icon flag with $340,688 in total fines with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Evervella Of Swansea
Swansea, IL
1-star overall rating with 2-star inspections with $173,550 in total fines with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Nexus Pavilion at Belleville
Belleville, IL
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $876,893 in total fines with 21 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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