Jacksonville SKLD: Resident Slapped by Confused Peer - IL
The facility's own staff described what happened without much dispute. A certified nursing assistant who was working that day told Illinois Department of Public Health surveyors that the woman, identified in inspection records as Resident 4, approached Resident 5 while he was talking with another female resident near the nurses' station. The nursing assistant said Resident 4 came up and tapped Resident 5 on the cheek with her fingertips. The Social Services Director put it more plainly: Resident 4 is very confused, thought Resident 5 was her husband, and hit him on the cheek when she believed he was cheating on her.
A licensed practical nurse on staff told surveyors that Resident 4 had a delusion that Resident 5 was her deceased husband, and that he was cheating on her. The nurse said both residents are confused.
When surveyors attempted to speak with Resident 4 directly, at 12:18 in the afternoon, she did not respond to their questions. Four minutes later, a nurse was explaining the situation on her behalf. At 12:42, surveyors tried again with Resident 4. She was still unable to clearly answer questions about what had happened.
Resident 5, the man who was struck, is not described further in the inspection record. Whether he understood what happened to him, whether he was frightened or hurt, whether anyone sat with him afterward — none of that appears in the report.
What the report does include is the facility's abuse policy, quoted at length. The policy states that its purpose is to provide guidance and procedures to assure residents remain free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, or mistreatment. It affirms the right of residents to be free from abuse. It prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.
The policy does not mention what happens when the person doing the hitting is also a resident living with dementia, also confused, also unable to answer questions about what she did or why.
That tension, between a written policy designed to address staff conduct and a situation involving two cognitively impaired residents in a shared common space, is exactly what state inspectors flagged. The citation was classified at the level of minimal harm or potential for actual harm, and the number of residents affected was listed as few.
Those classifications, minimal and few, are the language of the inspection form. They do not describe what it is like to be an elderly man standing near a nurses' station, talking to another resident, and then getting hit in the face by a woman you may or may not recognize, who may or may not know what she is doing, while staff watch and take note of the time.
The nursing assistant's account placed both residents near the nurses' station, a common area, when the incident occurred. Resident 4 approached. Resident 5 was already there, mid-conversation. There is no account in the inspection record of staff intervening before contact was made, only accounts of what staff observed and reported after.
The facility's abuse policy, as quoted by inspectors, runs to several sentences and covers a wide range of prohibited conduct. It does not appear in the inspection record alongside any description of how the facility was applying that policy to manage interactions between residents with dementia in shared spaces, or what protocols were in place to anticipate and prevent situations like this one.
The Social Services Director confirmed the basic facts of the incident to surveyors at 2:52 in the afternoon, roughly two and a half hours after inspectors first began asking questions. Her account matched the nursing assistant's. Resident 4 is very confused. She thought Resident 5 was her husband. She hit him when she believed he was being unfaithful.
There is something almost unbearably human in that detail, a woman whose mind has collapsed inward to a grief and jealousy that may be decades old, whose deceased husband has somehow reappeared in the face of a stranger in a hallway, who acts on what she believes is happening with the full conviction of a person who has no way to know she is wrong. The dementia literature is full of cases like this. The inspection report is not interested in that context. It is interested in whether the facility's policies were followed and whether residents were protected.
On the question of protection, the record is thin. A resident was struck. Staff witnessed it. The incident was reported and investigated. The facility's written policy prohibits what happened, though the policy appears aimed at staff conduct rather than resident-on-resident incidents driven by cognitive impairment. Inspectors cited the facility. The harm was classified as minimal.
Resident 5, the man at the center of this, is identified in the inspection record by a number. His age is not given. His diagnosis is not given. Whether he has family who were notified is not given. Whether he was assessed for injury, whether he was upset, whether he asked what had happened or why, none of that is in the record inspectors produced.
What is in the record is a timestamp: 12:50 PM, the moment a nursing assistant described watching Resident 4 approach Resident 5 and make contact with his cheek. The nursing assistant used the word tapped. The licensed practical nurse used the word slapped. The Social Services Director used the word hit. Three staff members, three slightly different words for the same moment in a hallway near the nurses' station, on a day that is now part of a federal inspection file.
Resident 4 was still unable to answer questions about it more than half an hour after surveyors arrived. By then, she may not have remembered it at all.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Jacksonville Skld Nur & Rehab from 2025-09-26 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
JACKSONVILLE SKLD NUR & REHAB in JACKSONVILLE, IL was cited for violations during a health inspection on September 26, 2025.
The facility's own staff described what happened without much dispute.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.