Hearth Record

Jacksonville Memorial Hospital

A critical access hospital in Jacksonville, Illinois 62650

1600 W Walnut St, Jacksonville, Illinois 62650. (217) 245-9551.

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The short answer

Record last released by CMS on Oct 20, 2026.

The last 24 months 4 deficiencies in 1 month of the last 36. Last cited Mar 2024. Most serious: Condition-level. Every month

Each figure’s source sits beside it, in its section below.

What these words mean3
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
Condition-level deficiency
For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual.

What did inspectors find?

The last inspection on record was on Mar 14, 2024: a complaint inspection.

4 deficiencies cited in the last three years, 2 of them at condition level, the most serious.

2 deficiencies at condition level, the more serious of CMS’s two levels

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

When those deficiencies happened

4 deficiencies in 1 month of the last 36. Last cited Mar 2024. Most serious: Condition-level. The last 3 years, to Nov 5, 2026.

4 deficiencies by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

Each deficiency, as cited

Rule titles as CMS’s inspectors cite them, set in sentence case.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Mar 14, 2024: complaint inspection4 deficiencies

  • Compliance With Fed, St, And Local Laws

    The inspectors’ words, 106 words

    “COMPLIANCE WITH FED, ST, AND LOCAL LAWS CFR(s): The CAH and its staff are in compliance with applicable Federal, State and local laws and regulations. This Condition is not met as evidenced by: 32822 Based on document review and interview, it was determined that the CAH (Critical Access Hospital) failed to ensure adherence to Federal Laws and State Regulations. As a result, the Condition of Participation (485.608) Compliance With Federal, State, and Local Laws and Regulations was not met as evidenced by:. Findings include: 1. The Hospital failed to ensure notice was provided informing the patient of being placed in observation status. See deficiency at C-0812.”

    Rule C0810. Condition-level. From a complaint.

  • Number Of Beds And Length Of Stay

    The inspectors’ words, 98 words

    “NUMBER OF BEDS AND LENGTH OF STAY CFR(s): §485.620 Condition of Participation: Number of Beds and Length of Stay This Condition is not met as evidenced by: 32822 Based on document review and interview, it was determined that the CAH (Critical Access Hospital) failed to ensure adherence to the total number of inpatient beds. As a result, the Condition of Participation (485.620) Number of Beds and Length of Stay was not met as evidenced by:. Findings include: 1. The Hospital failed to follow Federal Regulations in maintaining an average daily census of 25 inpatients. See deficiency at C-0902.”

    Rule C0900. Condition-level. From a complaint.

  • Compliance Fed, St, And Local Laws And Regs

    The inspectors’ words, 516 words

    “COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 32822 Based on document review and interview, it was determined in 6 of 12 (Pt #1, Pt #3, Pt #4, Pt #6, Pt #9 and Pt #10) observation patients records reviewed, the CAH (Critical Access Hospital) failed to ensure notice was provided informing the patient of being placed in observation status. Findings include: 1. The Illinois Licensure Administrative Code Title 77: Public Health Chapter 1: Department of Public Health Subchapter b: Hospitals and Ambulatory Care Facilities Part 250 Hospital Licensing Requirements Section 250.240 Admission and Discharge” stated under (f) “patient Notice of Observation Status. Within 24 hours after a patient’s placement into observation status by a hospital, the hospital shall provide that patient with an oral and written notice that the patient is not admitted to the hospital and is under observation status. The written notice shall be signed by the patient or the patient’s legal representative...” 2. On 3/12/2024 at 10:00 AM, the policy titled “Observation Service Determination and Start Time” (effective 3/22/2023) was reviewed. The policy indicated under “Medicare/Medicaid: ... 9. The patient and/or person acting on behalf of the patient will be notified of the determination for observation services in writing via the Medicare Outpatient Observation Notice. The notification conversation will be documented in the patient’s record.” 3. On 3/12/2024 the following observation patient records were reviewed and lacked notification of observation admission. -Pt #1 was admitted to Observation status with a diagnosis of “frequent falls and right distal fibula fracture” on 12/28/2023 at 4:40 PM. Pt #1 was discharged from observation status on 1/3/2024 at 5:02 PM. -Pt #3 was admitted to Observation status with a diagnosis of “HHS (Hyperosmolar Hyperglycemic State)” on 1/192024 at 5:29 PM. Pt #3 was discharged from observation status on 1/21/2024 at 7:16 AM. -Pt #4 was admitted to Observation status with a diagnosis of “COPD (Chronic Obstructive Pulmonary Disease) Exacerbation, and debility” on 1/1/2024 at 10:52 PM. Pt #4 was discharged from observation on 1/5/2024 at 12:54 PM. -Pt #6 was admitted to Observation status with a diagnosis of “diverticulitis and sepsis” on 2/26/2024 at 5:57 PM. Pt #6 was discharged from observation status on 2/27/2024 at 7:35 PM. -Pt #9 was admitted to Observation status with a diagnosis of “falls,generalized weakness and sacral fracture” on 12/28/2023 at 3:55 PM. Pt #9 was discharged from observation status on 1/1/2024 at 10:35 PM. -Pt #10 was admitted to Observation status with a diagnosis of “Colitis and Diarrhea” on 2/6/2024 at 11:04 PM. Pt #10 was discharged from observation status on 2/10/2024 at 10:02 AM. All six records lacked documentation of a MOON (Medicare Outpatient Observation Notice). 4. On 3/13/2024 at approximately 4:30 PM an interview was conducted with the Discharge Planner (E #4). E #4 reviewed Pt #1, Pt #3, Pt #4, Pt #6, Pt #9 and Pt #10’s record and confirmed a MOON was not completed on these observation patients.”

    Rule C0812. Standard-level. From a complaint.

  • Number Of Beds

    The inspectors’ words, 458 words

    “NUMBER OF BEDS CFR(s): Except as permitted for CAHs having distinct part units under §485.647, the CAH maintains no more than 25 inpatient beds. Inpatient beds may be used for either inpatient or swing-bed services. This Standard is not met as evidenced by: 32822 Based on document review and interview, it was determined the CAH (Critical Access Hospital), failed to follow Federal Regulations in maintaining an average daily census of 25 inpatients. Findings include. 1. The policy titled, “Observation Service Determination and Start Time” (effective 03/22/22) was reviewed. The policy stated, “... Medicare/Medicaid: 1. Outpatient Observation Services should be ordered by the practitioner when he/she anticipates the patient’s length of stay is less than two midnights, requires medically necessary monitored care and/or short-term hospital treatment.... 6. Observation Services end when the patient is medically ready for discharge and no longer requires monitoring or treatment, regardless of whether a discharge order has been written by a practitioner, or the patient is admitted as an inpatient...” 2. The Census log (Inpatient and Observation Admissions) dated 02/01/24 through 02/29/24 was reviewed. On February 22nd, the log indicated the facility had 28 inpatients and 13 observation patients. The log also indicated the average daily inpatient census was 20 and the average daily observation census was 11 (greater than 50% of the average inpatient census). 3. The Discharge Observation log dated 12/01/23 through 03/06/24 was reviewed. From February 1, 2024 through March 6, 2024, the log indicated: - 62 patients were admitted for observation in February with a length of stay that totaled 3,108 hours (Average length of observation stay per patient is 50 hours). - 11 patients were admitted for observation in March with a length of stay that totaled 485 hours (average length of observation stay per patient is 44 hours). - 5 observation patients length of stay was greater than 96 hours (100 hours, 109 hours, 112 hours, 121 hours and 168 hours). 4. The census on 3/12/24 during the survey indicated there were 22 inpatient and 8 observation patients. Of the 8 observation patients, 4 patients had a length of stay greater than 50 hours (52 hours, 64 hours, 66 hours and 95 hours). 5. On 3/12/2024 at approximately 4:15 PM an interview was conducted with the Discharge Planner (E #4). E #4 reviewed both logs and confirmed the findings. E #4 stated, “if the observation patients require more than 2 midnights (48 hours) the patient should be admitted as an inpatient. In most cases, the patients that are here greater than 48 hours after medicare stops paying or exceed 96 hours is because we do not have a safe discharge plan, or we are waiting for insurance authorization for Nursing Home placement or skilled Nursing Rehabilitation admission.” .”

    Rule C0902. Standard-level. From a complaint.

The one inspection in the last three years
Inspections on record
DateVisitWhat the record says
Mar 14, 2024Complaint inspection4 deficiencies cited

How do patients fare?

  • CMS gives no overall : “There are too few measures or measure groups reported to calculate a star rating or measure group score.”
  • Of the measures behind its , CMS counts against the national value: readmission, 0 better and 0 worse of 2.
  • CMS gives no : “Results are not available for this reporting period.”
  • After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
  • Emergency department patients spent a median of 178 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 4% left before being seen.
Source:

CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.

CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.

Ratings and measures, as published
MeasureRating
Overall ratingCMS’s overall hospital quality star rating, 1 to 5Not rated
Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5Not rated

Is it certified, and in good standing?

  • Medicare-certified critical access hospital since Apr 26, 2022.
  • Ownership: voluntary non-profit - private.
  • It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
  • Cited at in the last three years: it didn’t meet a whole condition of Medicare’s rules for hospitals.
  • Voluntary non-profit - Private.
Source:

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Has it been penalized?

  • CMS doesn’t publish fines or other penalties for hospitals.
  • CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
  • 4 deficiencies cited in the last three years came from inspections that included a complaint investigation.
Source:

CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

What do patients say about their care?

  • CMS doesn’t publish staffing levels for hospitals.
Source:

CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.

Who owns it?

  • Memorial Health System owns 100% directly since Apr 1, 2014.
  • 19 owners or officers are people: Thomas Veith (corporate director); Lindsay Mcqueen (corporate director); Maryjane Bradbury (corporate director); Polly Pulley (corporate director); Stephen C Symons (corporate director); Bradley W Wilson (corporate director); Kim Andras (corporate director); Paul R Eddington (corporate director); Paul R Eddington (managing employee (on the payroll)); Michael T Huffman (corporate officer); Kelly Staake (corporate director); Gary Westermeyer (corporate director); James E Hinchen (corporate director); Elias Daniel Trace (corporate director); Reginald H Benton (corporate director); Stephanie Seaman (managing employee (on the payroll)); Barbara A Farley (corporate director); Timothy Greene (corporate director); Peter D Russotto (corporate director).
  • CMS’s Provider of Services file records no change of ownership.
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

Organisations CMS lists
OrganisationRoleShareSince
Memorial Health SystemOwns 5% or more directly100%Apr 1, 2014

How does it compare nearby?

  • No other hospital CMS lists is in Morgan County.
Source:

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

What the record doesn’t say

  • CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
  • Only complaints that led to a citation appear; complaints that didn’t aren’t published.
  • Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
  • QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
  • CMS doesn’t publish staffing levels for hospitals.

Sources

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the hospital

The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

1 of 4

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Who published it, when, and how often it changes sit beside each fact, with a link to the agency’s own file.

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