Health inspection·September 26, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent resident to resident abuse for 1 (R5) of 3 residents reviewed for abuse in a sample of 3. 1)R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE] and had a medical diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Major Depressive Disorder, Alzheimer's Disease, and Dementia.R4's Minimum Date Set (MDS) dated [DATE] documents R4 is severely cognitively impaired. R4's Care Plan Date Initiated [DATE] documents R4 has behaviors related to makes accusatory statement, verbally aggressive toward others, misperceptions, jealous behaviors and R4 is at risk for alteration in psychosocial well-being related to Alzheimer's Disease, verbal behavioral symptoms toward others.2)R5's Undated Face Sheet documents R5 was admitted to the facility on [DATE] and has a medical diagnosis of Metabolic Encephalopathy, Anxiety Disorder, Dysphagia, Functional Quadriplegia, and Dementia.R5's MDS dated [DATE] documents R5 is severely cognitively impaired.R5's Care Plan Date Initiated [DATE] documents R5 has impaired cognitive function/dementia or impaired thought processes related to Dementia.R5's Care Plan Date Initiated [DATE] documents R5 has impaired cognitive function related to dementia. Interventions Date Initiated [DATE] documents reassure resident of safety.R5's Care Plan Date Initiated [DATE] documents R5 is at risk for alteration in psychosocial well-being related to conflicts with peers.The Facility's Initial Report Dated [DATE] at 12:00 PM documents Alleged Resident to resident physical altercation, residents immediately separated and assessed. Administrator immediately notified, investigation initiated, final report to follow. The Facility's Verification of Incident Investigation/Administrative Summary dated [DATE] at 12:00 pm documents: A comprehensive investigation was initiated and found that on [DATE] at approximately 1200 in the hallway, R4 observed R5 speaking with another female resident. Due to cognitive impairment and misperception, R4 believed R5 was her deceased husband ‘cheating' on her. R4 became agitated and attempted to strike R5 on the left cheek, grazing him with fingertips. Staff member immediately separated resident and supervised to prevent any reoccurrence. Both residents were assessed with no injuries noted. Skin assessment completed immediately on R5 revealed no redness, bruising, swelling, or other injuries noted. No c/o pain observed or voiced. Upon interview of R5 with administrator, he could not remember incident. Interview with R4 on 9-6-25, she states that R5 is her husband, and he is cheating on her. R4 was evaluated at ER for change of condition and returned to facility. Upon return to facility, R4 was re-interviewed. During interview R4 admitted she mistook R5 for her husband. She states, R5 is not my deceased husband and I'm sorry. I thought he was for a minute.R4's Physical Aggression Initiated Report dated [DATE] at 12:00 PM documents Nursing Description: Resident rolled next to a male resident. This resident thought the male resident was her husband and that he was cheating on her. Resident made contact with male resident's left cheek. Resident Description: How dare he cheat!R5's Physical Aggression Received Report dated [DATE] at 12:00 pm documents Nursing (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 09/26/2025 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)