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 (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 07/17/2025 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)