Health inspection·July 17, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident's low air loss mattress was working properly for 1 (R2) of 3 residents reviewed for safe, function, sanitary, comfortable environment in the sample of 3. R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] with a medical diagnosis of Thromboangitis Obliterans Buerger's Disease, Hyperlipidemia, Arthropathy, and Morbid Obesity. R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact, is dependent on staff for rolling left and right, and is always incontinent of bladder and bowel.R2's Care Plan with a focus area revision date of 12/9/2023 documents R2 is at risk for pain and R2 needs assistance with activities of daily living including bed mobility with two-person physical assistance required and pressure redistribution device.R2's Care Plan with a focus area revision date of 2/21/2024 documents R2 has the potential for impaired skin integrity related to decreased mobility, morbid obesity with interventions including a pressure redistribution support surface.R2's Physician Order dated 9/18/2024 at 11:30 AM documents low air loss mattress.On 7/17/2025 at 8:55 AM, R2 stated her low air loss mattress has not been working correctly and losing air for almost a week. R2 stated she informed staff of the mattress deflating on 7/10/2025, with V7, Maintenance Director, aware of the issue on 7/11/2025. R2 stated on 7/11/2025, her mattress was completely flat, and she was lying on the metal bed frame causing her severe pain in her back. R2 stated on 7/16/2025 V7, Maintenance Director, replaced the mattress pump to try to fix the air loss issues, however the mattress is still malfunctioning and deflating at times. R2 stated while the facility staff helped clean her up and change her on 7/16/2025, she could feel the bed frame on her hips as she rolled side to side which was painful. On 7/17/2025 at 9:09 AM R2's low air loss mattress pump beeped 3 times, flashed a red low-pressure light and then the alarm stopped. On 7/17/2025 at 9:10 AM R2's low air loss mattress pump beeped 3 times again, flashed a red low-pressure light and the alarm stopped.On 7/17/2025 at 9:11 AM R2's low air loss mattress pump started to beep continuously and with the red low-pressure light flashing. R2 stated she could feel the mattress starting to lose air at this time around her lower back and buttock area. On 7/17/2025 at 9:15 AM V3, Certified Nursing Assistant (CNA) and V4, CNA arrived in R2's room to address R2's mattress pump. V3, CNA, stated she does not know what is wrong with the mattress or pump, but knows it has not been functioning properly for a couple days and knows V7, Maintenance Director, has been made aware. V4, CNA, stated she has told V7, Maintenance Director several times that R2's bed is losing air and is not working as it should. V4, CNA, stated V7, Maintenance Director, replaced the pump on the mattress yesterday, 7/16/2025, and it is still alarming and not working correctly. On 7/17/2025 at 9:17 AM R2 stated she is starting to feel the bed frame underneath her buttock.On 7/17/2025 at 9:25 AM V5, Licensed Practical Nurse (LPN) stated she was made aware of R2's mattress losing air and not working properly on 7/16/2025 and was informed that V7, Maintenance Director, was aware of the mattress deflating. V5, LPN, stated she knows when Page 1 of 2 145273 145273 07/17/2025 Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's mattress deflates and starts to get flat; it causes R2 pain. On 7/17/2025 at 10:17 AM R2 stated once she laid the head of the bed down, the mattress started to inflate back up with air. R2 stated she cannot always lie flat due to pain in her back. On 7/17/2025 at 10:20 AM V3, CNA, stated V7, Maintenance Director, informed her that R2's mattress and pump are not working correctly, and a new mattress and pump have been ordered.On 7/17/2025 at 10:32 AM V2, Director of Nursing (DON), stated she was made aware of R2's mattress losing air on 7/16/2025 and is unsure what is wrong with it. V2, DON, stated V7, Maintenance Director, had replaced the pump for R2's mattress on 7/16/2025 and it is now working on and off. On 7/17/2025 at 10:37 AM V7, Maintenance Director, stated he was informed 2 days prior that R2's mattress was not functioning properly and losing air. V7, Maintenance Director, stated he replaced the mattress pump yesterday and the pump will work for a while, then will alarm and start to lose air. V7, Maintenance Director, stated R2 needs a new mattress and pump, which has been ordered, and a rental mattress is coming for R2.On 7/17/2025 at 10:56 AM V8, Social Services, stated she was made aware R2's mattress was losing air on 7/13/2025 and was informed by staff that a work order was in place for the mattress to be looked at.On 7/17/2025 at 11:06 AM V4, CNA, stated she was informed of R2's mattress beeping and losing air on 7/10/2025 and placed a work order that day. V4, CNA, stated the facility staff had to constantly adjust R2's mattress pump all weekend for the mattress to hold air. V3, CNA, stated she was also aware of R2's mattress losing air on 7/10/2025, and knew a work order was already in place for the mattress.On 7/17/2025 at 11:11 AM V1, Administrator, stated R2's mattress is working and functioning properly. On 7/17/2025 at 11:31 AM V7 Maintenance Director, brought a work order dated 7/16/2025 stating R2's mattress pump was beeping, and mattress was deflating. The Resident Rights for People in Long-Term Care Facilities document last revised 11/2018 documents Your facility must be safe, clean, comfortable, and homelike. 145273 Page 2 of 2