Inspection·September 25, 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 observation, interview, and record review, the facility failed to ensure proper inflation of the air mattress in 3 (R2, R4, and R5) of 3 residents in the sample of 8 reviewed for safety. This failure resulted in R2 being found on the floor from an unwitnessed fall and suffering a laceration on the right side of the head and several skin tears. Findings include: 1. R2's undated face sheet documented that R2 was admitted to the facility on [DATE] with diagnoses of Parkinson's, dementia, neurocognitive disorder with Lewy Bodies, cachexia, and hypotension. R2's Minimum Data Sheet (MDS), dated [DATE], documented that R2 has severe cognitive impairment. R2 requires use of a wheelchair and is always incontinent of bowel and bladder. R2's Care Plan, dated [DATE], documented that R2's problems include self-care deficit, impaired cognitive function due to dementia with Lewy bodies, is at a risk for falls and injuries related to balance problems, dementia, tremor, scoliosis, and medications. The interventions for the fall risk include encourage use of call light, keep call light within reach, keep environment clutter free, keep personal belongings within reach, and provide adequate lighting. On [DATE] low bed was added. On [DATE], the care plan was updated adding bolsters to the air mattress and bed reset by maintenance and reviewed for proper functioning. R2's progress notes, dated [DATE] at 9:30 PM, documents that R2 was noted to be on the floor bedside her bed on her right side tangled up in her blankets. R2 was curled up laying on right side. There was a laceration to right side of head approximately 1 cm, a skin tear to right elbow approximately 1 centimeter, a skin tear to right hand approximately 1 centimeter, a skin tear to right knee approximately 1 centimeter. All wounds cleansed and dressed. Resident denies pain and cannot state what happened. Range of motion intact. Fall was unwitnessed. Neurology checks initiated. R2's physician orders, dated [DATE], at 10:06 PM documents monitor, steri-strips to right knee and reinforce as needed. To clean right elbow with normal saline, dry, apply xeroform & dry dressing. To also monitor steri-strips to the back of right hand two times per day and reinforce as needed. To right side of head monitor steri-strips, cleanse two times per day and reinforce as necessary. R2's incident report, dated [DATE], documents on [DATE] that the root cause was air mattress deflation. Bed was reset and properly functioning. Request entered for maintenance to check properly. Bolsters added to bed. (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 3 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 09/25/2024 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)