Inspection·February 10, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: The facility's policy, Abuse Prevention Policy, dated 9/29/2022, documented, A. Must ensure that all alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours . 1. R2's Minimum Data Set (MDS) dated [DATE], documented that her cognition was severely impaired. R2's Physician's order sheet, dated 2/2025, documented diagnosis of dementia and atrial fibulation. It also documented orders for Adult Low Dose Aspirin (aspirin) 81 mg tablet, delayed release 1 tab oral, once a day and Eliquis (apixaban) 2.5 mg (milligram) tablet twice a day. R2's Care Plan, dated 6/11/2024, documented, Approach: Protect resident from injury/trauma. It continues, Approach: Observe for signs of active bleeding (nosebleeds, bleeding gums, petechiae, purpura, ecchymotic areas, hematoma, blood in urine, blood in stools, hemoptysis, elevated temp, pain in joints, abdominal pain, epistaxis). R2's Care Plan, dated 2/26/2024, documented, Approach: Report any suspected of abuse/neglect to administrator immediately. R2's Progress note, dated 02/02/2025 at 02:09 PM, V2, ADON, documented,[Recorded as Late Entry on 02/04/2025 02:11 PM] While giving meds to resident this afternoon, writer noticed light bluish V shaped bruise to resident's upper right forehead. Writer investigating possible cause, interviewing all staff. Resident independent and with confusion, resident not sure what happened when asked about bruise. R2's Progress note, dated 02/03/2025 at 01:01 PM, V3, LPN, documented, Not acting her normal self. Had to be feed. Would not even open her mouth for meds. (medications) Stares off. Episodes of crying. No verbal response. Noted bruise to forehead. (V10, R2's Physician) notified and will send to ER (Emergency Room). POA notified. (Local Ambulance) called. Call report to hospital. R2's Skin integrity events, dated 2/2/25, documented, PHYSICAL OBSERVATION: Location of Bruise and Size of Bruise right upper forehead 3cm (centimeter) x 3cm at biggest parts V shaped. It continues, (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: 145502 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 145502 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Taylorville Care Center 600 South Houston Taylorville, IL 62568 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)