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 Page 1 of 2 145273 145273 09/26/2025 Jacksonville Skld Nur & Rehab 1517 West Walnut Street Jacksonville, IL 62650

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Description: Resident was sitting in the lobby when another female resident rolled up next to him in her wheelchair and made contact with left cheek. Resident Description: She hit me.On [DATE] at 10:23 AM V1, Administrator, stated there was a recent incident where R4 thought that R5 was R4's deceased husband, and R4 thought R5 was cheating on her. V1 stated R4 made contact with R5 on R5's cheek. On [DATE] at 12:18 PM R4 didn't respond to questions asked by the Illinois Department of Public Health (IDPH) Surveyor. On [DATE] at 12:22 PM V8, Licensed Practice Nurse (LPN), stated R4 and R5 are confused. V8 stated R4 had a delusion that R5 was her husband and that he was cheating on her. V8 stated R4 slapped R5 on the cheek. On [DATE] at 12:42 PM R4 unable to clearly answer questions regarding incident from the IDPH Surveyor.On [DATE] at 12:50 PM V10, Certified Nursing Assistant (CNA), stated she was working on [DATE] when R4 hit R5 on R5's cheek. V10 stated R4 and R5 were up by the 2 nurse's stations and R5 was talking with another female resident. V10 stated R4 came up to R5 and tapped R5 on the cheek with her fingertips. V10 stated both R4 and R5 are confused and R4 thought R5 was her husband. On [DATE] at 2:52 PM V12, Social Services Director (SSD), stated R4 is very confused and thought R5 was her husband and hit R5 on the cheek when R4 thought R5 was cheating on her.The Facility's Abuse Policy Date Revised [DATE] documents Purpose: To provide guidance and procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. 145273 Page 2 of 2