Inspection·March 12, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 3/6/25 at 2:05 PM, V6, CNA stated that the pull tab alarm needs to be attached to the resident in order for it to be effective and work. R2's Minimum Data Set, dated [DATE] documented that his cognition was severely impaired. R2's Fall risk Assessment, dated 2/12/2025, documented that he was a high risk for falls and that he was chair bound and /or assist with elimination. R2's Physician's orders dated 3/2025, documented diagnosis of Wedge Compression Fracture of T5-T6 and T11-T12, Lymphoid Leukemia and Neurocognitive Disorder with Lewy Bodies. It also documents an order on 2/18/2025 for Device: Alarm: To Bed and Chair as resident will allow. Check for placement and functioning every shift. R2's Care Plan, dated 2/8/2025, documented, Transfer: One person physical assistance required. R2's Care Plan, dated 2/11/2025, prior to a fall on 2/19/2025, documented, fall interventions of 2/11 Fall Mats, 2/11 Low bed, 2/18 Personal alarm at all times as resident will allow. It continues, Provide/Reinforce use of non-skid footwear. R2's Progress note, dated 2/19/2025 at 7:13 AM, documented, Resident found on floor in room face down near dresser. Laceration to chin and above left eye, hematomas started on forehead at this time. Right sided jaw pain and right shoulder pain. Wife notified, on call nurse aware, MD aware. Sent out for eval and treatment. Resident is alert x 4 at this time with paramedics. Unwitnessed fall and hit head. All paperwork sent with resident. R2's General Note, dated 2/19/2025 at 12:56 PM, documented, Resident returned from hospital. Closed comminuted fracture of right sided mandibular alveolar bone; Atypical syncope; chin laceration. Remove sutures in 5 days Ciprofloxacin 500 mg, 1 tab BID 14 days Potassium chloride 20 meq oral tab extended release po q day follow up with (Unknown Physician) within 1-2 days for worsening/continued problem. Call to schedule appointment. R2's Fall investigation with root cause analysis, dated 2/19/2025, documented, Type of incident: fall with injury. It continued, Pertinent Diagnosis: Neurocognitive Disorder with Lewy Bodies. Resident Status/Description of injuries (If Any): Laceration, mandibular FX. It continues, 78 y/o male who is non independent with ambulation. Resident got up to use the bathroom despite the indwelling catheter, became dizzy and fell. Laceration noted to chin and above left eye, right sided jaw pain, right shoulder pain. EMS was called to the facility and transported resident to (local hospital) for evaluation and treatment. (R2) returned from (local hospital) to the facility with sutures to close the laceration to chin. CT was negative for intracranial abnormality but did reveal an acute fracture of the right sided mandibular condyle. Resident returned to facility on 2/19/2025 and remains at baseline. Care Plan updated. Resident assessed for pain. Fall intervention updated and in place. It continues, Conclusion: IDT discussion on fall. Root cause: Bladder spasms. Upon investigation, resident recently returned to facility from hospitalization. During hospital stay, previous medications used to treat bladder spasms and hypotension had been discontinued. Intervention: Medication review. Problem Statement: Resident stood up to go to the restroom, got dizzy and fell forward. Why 1: bladder spasms, urge to void. Why 2: bladder spasms r/t indwelling foley cath. R2's Hospital record, dated 2/19/2025, documented, History of Present illness: Patient is a 78- year old male who presents emergency department after fall. According to the patient who resides in a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 2 of 3 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 03/12/2025 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm nursing home currently and he reports that he blacked out and fell but this was witnessed. It continues, CT facial bones: It continues, .There is an acute comminuted and displaced fracture of the right mandibular condyle and there is right temporal mandibular dislocation. The right mandibular condyle is displaced medially and anteriorly with the jaw in a closed position. Residents Affected - Few On 3/10/2025 at 2:55 PM, V2, Assistant Administrator, stated that they do not have a fall prevention policy. The facility's Policy, Accidents and Incidents, dated 9/7/2023, documented, 5. the Interdisciplinary Team (IDT) will conduct a thorough investigation of the accident/incident. Findings of the investigation, including root cause of the accident/incident and appropriate interventions will be indicated in the incident report and implemented. Prior to the survey date of 3/12/2025, the facility had taken the following actions to correct the noncompliance. 1. All staff inserviced on Fall interventions that need to be in place at all times and where to find this information. 2. House wide fall interventions audit and care plans reviewed. 3. Alarms were added to CNA task. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145273 If continuation sheet Page 3 of 3