Taylorville Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician's orders for one (R2) of 4 sampled residents reviewed for wound treatment.

Inspectors wroteFailures at this level required more than one deficient practice statement. A-Based on observation, interview and record review the facility failed to provide supervision and ensure residents at high risk for elopement were not able to leave the facility without the facility being aware the resident has left for one of five residents (R4) reviewed for elopement in the sample of 13. This failure resulted in R4 eloping from the facility on 7/25/2025. R4 was observed wandering in a ditch and found by a community member not affiliated with the nursing home. This community member contacted the assisted living facility who in turn notified the facility and asked if a resident was missing. The facility was unaware that (R4) had eloped. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from sexual abuse for one of three residents (R2) reviewed for abuse in the sample of three.

Inspectors wroteBased on observation, interview and record review, the Facility failed to employ a Director of Food and Nutrition. This has the potential to affect all 67 residents living in the Facility.

Inspectors wroteBased on observation, interview and record review, the Facility failed to follow its facility approved menu. This has the potential to affect all 67 residents living in the Facility.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to provide meals at scheduled times and offer snacks, including at bed time. This has the potential to affect all 67 residents living in the Facility.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure foods were stored and prepared in a manner that prevents foodborne illness. This has the potential to affect all 67 residents living in the Facility.

Inspectors wroteBased on interview, observation, and record review, the Facility failed to provide residents with palatable and safe temperature meals for 8 of 8 residents (R4, R20, R24, R27, R28, R43, R45, R46) reviewed for food and nutrition services in the sample of 33.

Inspectors wroteBased on observation, interview, and record review, the Facility failed to provide food in a form that meets individual needs for 4 of 4 residents (R9, R40, R44, R51) reviewed for food and nutrition services in the sample of 33.

Inspectors wroteBased on interview and record review the facility failed to promote dignity and to treat residents in a respectful manner during care for 3 of 10 residents (R1, R2, and R4) reviewed for dignity in a sample of 10. Findings Include: R2's face sheet, print date of 4/30/25, documented R2 has diagnoses including flaccid hemiplegia affecting left dominant side and dysphasia following cerebral infarction, hypertension, hyperlipidemia, epilepsy, and arthritis. R2's MDS (Minimum Data Set), dated 3/22/25, documented R2 is cognitively intact, is dependent on a wheelchair and assistance for mobility, and is dependent on facility staff for hygiene needs including showers. R2's care plan, undated, documented category: psychosocial well-being, I am considered at risk for abuse/neglect per assessment with approaches including address all complaints/concerns promptly with grievance policy and procedure. [...]

Inspectors wroteBased on interview and record review the facility failed to report an allegation of verbal and physical abuse to the State Agency for 1 (R2) of 3 residents reviewed for abuse in the sample of 10. Findings Include: R2's face sheet, print date of 4/30/25, documented R2 has diagnoses including flaccid hemiplegia affecting left dominant side and dysphasia following cerebral infarction, hypertension, hyperlipidemia, epilepsy, and arthritis. R2's MDS (Minimum Data Set), dated 3/22/25, documented R2 is cognitively intact, is dependent on a wheelchair and assistance for mobility, and is dependent on facility staff for hygiene needs including showers. R2's care plan, undated, documented category: psychosocial well-being, I am considered at risk for abuse/neglect per assessment with approaches including address all complaints/concerns promptly with grievance policy and procedure. [...]

Inspectors wroteBased on interview and record review the facility failed to operationalize their policy to conduct an investigation of allegations of physical and verbal abuse for 1 (R2) of 3 residents reviewed for abuse in the sample of 10. Findings Include: R2's face sheet, print date of 4/30/25, documented R2 has diagnoses including flaccid hemiplegia affecting left dominant side and dysphasia following cerebral infarction, hypertension, hyperlipidemia, epilepsy, and arthritis. R2's MDS (Minimum Data Set), dated 3/22/25, documented R2 is cognitively intact, is dependent on a wheelchair and assistance for mobility, and is dependent on facility staff for hygiene needs including showers. R2's care plan, undated, documented category: [...]

Inspectors wroteBased on interview and record review, the facility failed to report injury of unknown origin for one of four (R2) residents, reviewed for reporting, in a sample of 5.

Inspectors wroteBased on interview, observation and record review, the Facility failed to prevent, identify, obtain orders and monitor pressure ulcers for 2 of 3 residents (R14 and R71) reviewed for pressure ulcers, in the sample of 44. This failure resulted in R14 going from 4/15/2024 until 4/30/2024 without treatment for or monitoring of a stage 3 facility acquired pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired medication and glucose control solution from refrigerator and medication cart and date multi dose insulin pens after opening. This failure has the potential to affect all 69 residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store and label foods with open dates, secure hair during meal preparation and service, and utilize hand hygiene to prevent food contamination and/or borne illness. This failure has the potential to affect all 69 residents residing at the facility. Findings Include: 1. On 06/03/24 at 09:13 AM, the standup freezer was inspected and contained: - An open box of frozen pancakes with no open date and the inner bag with the pancakes in it was not sealed. - One box of maple sausage links with a date of 4/16 (arrival date) that was open, and the inner bag was not sealed in any way. There were two boxes of maple pork sausage links dated 5/14 (arrival date) in the freezer that were open and in the inner bag was not sealed or secured/tied up. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure wheelchair brakes were locked,a gait belt was utilized during transfers, and smoking was supervised for 4 of 7 residents (R38, R58, R61, R63), reviewed for accidents, in a sample of 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove soiled linens to prevent cross contamination, perform hand hygiene before donning and doffing of gloves, provide a clean barrier for supplies, and keep supplies clean to prevent the spread of infection for 6 of 17 residents (R14, R26, R60, R61, R62, R71) reviewed for infection control in the sample of 44.

Inspectors wroteBase on interview and record review, the facility failed to notify the Physician of high blood sugar results and a newly acquired pressure ulcer for 2 of 17 residents (R14, R51) reviewed for Physician notification in the sample of 44.

Inspectors wroteBased on interview and record review, the facility failed to prevent verbal abuse for 1 of 17 residents (R51) reviewed for abuse in the sample of 44.

Inspectors wroteBased on interview and record review, the Facility failed to ensure their Abuse Prevention Policy was followed/implemented for 2 of 24 residents (R50, R51) reviewed for abuse/neglect, in the sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to ensure standards of care were implemented for a resident with a diagnosis of diabetes by not monitoring blood sugars for 1 of 3 residents (R50), reviewed for quality of care, in the sample of 44.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide timely and complete incontinent care for 2 of 5 residents (R61,R71) reviewed for incontinence, in the sample of 44.

Inspectors wroteBased on interview and record review, the Facility failed to ensure physician's orders were accurately completed and implemented for 1 of 3 residents (R50) reviewed for significant medication error in the sample of 44.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision for residents who require supervised leave and have the potential for elopement for 2 of 2 residents (R5 and R8) reviewed for supervision to prevent accidents in the sample of 11. This failure resulted in R8 leaving the facility unsupervised, being found by a citizen walking on the road a block from facility at 10:48 PM. This failure has the potential to affect all 71 residents in the facility. This failure resulted in R5 leaving the facility being found on the ground by local police department at 9:08 PM, .6miles from the facility. The Immediate Jeopardy began on 4/28/2024 when R5 exited the facility without staff supervision and being found by the local police .6 miles from the facility on the ground. V1, Administrator, was notified of Immediate Jeopardy on 5/16/2024 at 10:02 AM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to use alternatives to bed rails, and assess and monitor for risks including injury and entrapment related to the use of bed rails for 3 of 3 residents (R7, R10 and R6) reviewed for bedrails in the sample of 11. This failure resulted in an Immediate Jeopardy when R7's right arm was caught in the bedrail during care resulting in R7's fractured arm and decline in R7's overall physical condition. In addition, R10 was observed several times with her arm through the right bedrail on her bed. R10's documented history of dementia with behavior disturbances, hallucinations, and psychiatric history put R10's entrapment of her right arm through the bedrail at an increased risk of injury. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Physician of a change of condition and delay in diagnostics for 1 of 3 residents (R6) reviewed for physician notification in the sample of 11. This failure resulted in delay of treatment and pain management for R6's right distal femoral fracture.

Inspectors wroteBased interview and record review, the facility failed to timely treat an injury of unknown origin for 1 of 1 resident (R6) reviewed for quality of care in the sample of 11. This failure resulted in R6's ongoing pain and delay of treatment for a fractured leg.

Inspectors wroteBased on interview, observation, and record review, the facility failed to assess, measure, document, obtain orders for, prevent the development and worsening of pressure ulcers, and provide pressure ulcer treatment following nursing standards for 1 of 3 residents (R6) reviewed for pressure ulcers. This failure resulted in R6 sustaining a new pressure ulcer and 2 previous pressure ulcers worsening.

Inspectors wroteBased on interview and record review, the facility failed to provide pain management for 1 of 3 residents (R6) in the sample of 11. This failure resulted in R6 being in pain from a sustained leg fracture without pain control for 2 days.

Inspectors wroteBased on record review, interviews and observations the facility failed to provide sufficient nursing staff to ensure resident safety/supervision and care needs are met for 5 or 5 (R1,R2,R3,R4 and R5) residents reviewed for sufficient staffing. This failure has the potential to affect all residents in the facility.

Inspectors wroteBased on record review, interviews, and observations the facility failed to provide the services of a Director of Nursing on a full-time basis. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on record review and interviews the facility failed to implement and maintain an affective Quality Assurance program. This has the potential to affect all 71 residents residing in the facility.

Inspectors wroteBased on record review, interviews, and observations the facility failed to answer call lights in a timely manner to meet residents need for 3 of 3 residents (R1, R2, R3) reviewed for call lights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide complete incontinence care for one of three residents (R3) reviewed for bladder incontinence in the sample of 11.

Inspectors wroteBased on record review and interview, the facility failed to provide a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week on the dates. This has the potential to affect all the 60 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the Facility failed to ensure mediations that require refrigeration were monitored for the correct/current temperature for storage as well as ensure medications were stored in properly labeled packaging. This Failure has the potential to affect all 60 residents residing in the Facility.

Inspectors wroteBased on interview and record review, the Facility failed to provide an Advanced Beneficiary Notice of Non-Coverage (ABN) to residents being discharged from Medicare part A with benefit days remaining for 2 of 3 residents (R45, R206) reviewed for Beneficiary Protection Notification in the sample of 40.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents privacy during transferring and wound care for 2 of 4 residents (R27 and R42) reviewed for privacy in a sample of 40.

Inspectors wroteBased on observation, interview and record review, the Facility failed to follow physician's orders for the treatment of pressure ulcers for 1 of 3 residents (R36) reviewed for pressure ulcers in the sample of 40.

Inspectors wroteBased on observation, interview, and record review the Facility failed to ensure residents have water available for hydration purposes for 2 of 3 residents (R25, R33) reviewed for hydration in the sample of 40.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform appropriate hand hygiene while passing out and setting up meal trays for residents and providing care to prevent the spread of infection for 3 of 8 residents (R7, R23 and R27) reviewed for infection control, in a sample of 40.