Inspection·August 13, 2024

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide safety and supervision for 1 of 3 (R3) residents reviewed for falls. This failure resulted in R3 falling, obtaining a laceration to the head, sutures and experiencing pain. Findings include: R3's Care Plan documents 6/28/23, documents that (R3) has a Self-Care Deficit As Evidenced by: Needs assistance with Activities of Daily Living (ADLs). It also documents Bed Mobility and Dressing require - One person physical assist required. R3's Care Plan continues (R3) is at risk for falls and injuries related to (r/t) cognition deficit and history of fall with fx. I have impaired mobility and lack safety awareness due to (d/t) my diagnosis (dx) of dementia. R3's Minimum Data Set, dated [DATE], documents that R3 is dependent on staff for Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support. R3's Progress Note, dated 8/1/2024 at 5:15 AM, documents Nursing Note Late Entry: Note Text: Upon entering residents' room the resident was sitting on floor by roommate's bedside with Nurse's Aide (V8) sitting beside the resident. Resident noted to have a Laceration to their center of their forehead. I cleaned the resident's injury and applied a band aide to injury. Notified Hospice Care Team who recommended resident be sent out to ED (emergency department) for further evaluation along with Physician (V9) recommending the same as above stated. Notified residents emergency contact (V10) and on call Nurse (V3), ADON who verbalized an understanding of situation. R3's Progress Notes, dated 8/1/2024 at 5:15 AM, documents Change of Condition / Transfer Late Entry: Note Text: (R3) was transferred on a gurney via ambulance to acute care hospital Sent To: (Local) Hospital Date: 8/1/2024 5:15 Sent From: (Facility) Unit: Unit [NAME] Reason(s) for Transfer: Trauma (fall-related or other) -- head injury MD notified of transfer. See Transfer Form for other details. R3's Progress Note, dated 8/1/2024 at 8:34 AM, documents Nursing Note Text: Resident returned from (local) Hospital per facility transport in wheelchair. R3's Progress Note, dated 8/1/2024 at 12:54 PM, documents Nursing Note Text: Resident wincing with movement to arm/hand. Resident received scheduled Tylenol, still wincing/frowning/guarding arm/hand when attempting movement. Call to Hospice, Spoke with (V11 Case Manager.) NEW ORDER: Tramadol 50 mg q 6 hours for pain. Call to (V10), informed of new order. (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 2 Event ID: 145273 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 145273 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650 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)