Inspection·August 15, 2025

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based 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.Findings include:The Facility's Weekly Menu documents the following will be served for lunch on 8/14/25: cornflake chicken thigh, hashbrown casserole, whole baby carrots, roll, dessert, and beverages.On 8/14/25 at 12:50 PM, V10, Medical Records, was serving lunch from the steam table in the kitchen. The items being served included fried chicken, baked potato, baked beans and a cookie.On 8/14/25 at 1:08 PM, V10 stated carrots were on the menu for both lunch and supper, so she decided they would just have the carrots tonight. She did not check with the Registered Dietitian (RD) to make sure menu changes were acceptable.On 8/15/25 at 8:50 AM, V25, RD, stated it is important to follow Facility menus, and the carrots should not have been omitted from the meal.On 8/15/25 at 9:16 AM, V1, Administrator, stated she expects dietary staff to follow dietary policies.The Facility's Menus and Food Preparation Policy revised December 2016 documents, Meals shall be prepared according to the facility approved menu. Changes to a menu or recipe based on geographic preferences or resident preferences shall be approved by the registered, licensed dietitian to the residents.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/12/25 documents there are 67 residents living in the Facility. Event ID: Facility ID: 145502 If continuation sheet Page 2 of 6 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 08/15/2025 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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based 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.Findings include: On 8/12/25 at 10:20 AM, R20 stated the food lacks flavor and is never at the right temperature.On 8/12/25 at 10:24 AM, R28 stated the Facility's food is just not good. It is always cold, and the toast is hard.On 8/12/25 at 10:40 AM, R43 stated the food quality could be better. On 8/12/25 at 10:50 AM, R27 stated the food is cold and tastes bad.On 8/13/25 at 9:00 AM, during the Resident Council group meeting, R4, R24, R45, and R46 all stated the kitchen and food quality have really gone downhill.On 8/12/25 at 1:12 PM, food temperatures were obtained with a metal calibrated thermometer after the last resident tray was served. The ham salad measured 55 Fahrenheit (F). The pureed ham salad measured 68 F. The pureed deviled eggs measured 71 F.On 8/15/25 at 8:50 AM, V25, Registered Dietitian (RD), stated the temperatures of the ham salad and deviled eggs were not good.On 8/15/25 at 9:16 AM, V1, Administrator, stated she expects dietary staff to follow food service policies.The Facility's Menus and Food Preparation Policy revised December 2016 documents, Food shall be prepared by methods that conserve nutritive value, flavor and appearance and in a form designed to meet individual needs. Food and drinks served shall be palatable, attractive and at a safe and appetizing temperature. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145502 If continuation sheet Page 3 of 6 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 08/15/2025 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)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based 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.Findings include: On 8/14/25 at 1:08 PM, R40 was sitting in the dining room feeding himself lunch. There was a baked potato with the skin on his plate. He picked up the skin of the potato with his fingers and attempted to take a bite. V10, Medical Records, stated she just finished serving lunch, and the residents on mechanical soft diets received baked potatoes with skin.R40's Diet Order starting 12/13/24 documents regular, mechanical soft diet.R44's Diet Order starting 11/18/24 documents regular, mechanical soft diet.R51's Diet Order starting 7/16/25 documents no added salt, mechanical soft diet.R9's Diet Order starting 11/13/24 documents regular, mechanical soft diet. On 8/15/25 at 8:50 AM, V25, Registered Dietitian (RD), stated mechanical soft diets should not have potato skins. He stated they could have mashed potatoes, diced potatoes, or potatoes with the skin removed, but residents on mechanical soft diets should not have the skins. On 8/15/25 at 9:16 AM, V1, Administrator, stated she expects dietary staff to follow their dietary policies.The Facility's Consistency Modified Diets Policy revised December 2024 documents, The following diets are modified in texture to promote ease of chewing and swallowing. The mechanical soft diet is used for patients/residents with limited chewing ability, and vegetable options include canned vegetables, well-cooked, soft vegetables, and finely chopped fresh vegetables, as tolerated.The Facility's Menus and Food Preparation Policy revised December 2016 documents, Food shall be prepared by methods that conserve nutritive value, flavor and appearance and in a form designed to meet individual needs. Event ID: Facility ID: 145502 If continuation sheet Page 4 of 6 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 08/15/2025 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)

F 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based 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.Findings include: On 8/13/25 at 9:00 AM, during the Resident Council group meeting, R4, R24, R45, and R46 all stated the Facility has not been providing snacks.On 8/13/25 at 11:58 AM, V6, Dietary Aid, stated he does not know anything about snacks and has never passed them out before.On 8/13/25 at 12:04 PM, V13, Certified Nursing Assistant (CNA), stated dietary should be bringing a snack cart to the nurse's station, but it has not been done for the past month or so.On 8/13/25 at 12:07 PM, V12, CNA, stated snacks are not being passed in the Facility. She stated they used to take a cart with snacks and drinks to offer to each resident, but they do not do that anymore.The Facility's Meal Times documents breakfast is served at 7:00 AM, lunch is served at 12:00 PM, and dinner is served at 5:00 PM daily.On 8/12/25 at 1:12 PM, the last resident tray was served. V7, Cook, stated they are usually done serving earlier, but the deviled eggs took longer to make.On 8/13/25 at 1:20 PM, V1, Administrator, stated all residents should receive a lunch meal by 12:30 PM.On 8/14/25 at 1:08 PM, the last resident lunch tray was served.On 8/15/25 at 8:50 AM, V25, Registered Dietitian (RD), stated evening snacks should be offered to residents, especially residents with diabetes, to ensure they do not go too long without eating.On 8/15/25 at 9:16 AM, V1, Administrator, stated she expects dietary staff to follow the Facility's dietary policies.The Facility's Meal Service & Snack Times Policy revised December 2016 documents, Meal service shall be provided to residents on a regularly scheduled basis according to facility established times. An H.S. (bedtime) snack shall be provided by Dietary and offered to the residents by nursing. Additional snacks shall be provided between meals as ordered by the physician or per resident's request. The Dietary Department shall be responsible for food preparation for all meals and snacks. Snacks shall be provided at: 10 a.m., 2:30 p.m., and 7:00p.m. Dietary shall deliver nourishments to the nursing units. Nursing shall be responsible for distribution of snacks.The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/12/25 documents there are 67 residents living in the Facility. Event ID: Facility ID: 145502 If continuation sheet Page 5 of 6 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 08/15/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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.Findings include:On 8/12/25 at 9:00 AM, V6, Dietary Aid, was unloading clean dishes that had just run through the dish machine and putting them away on shelves. V6 dropped a plastic cup on the floor, picked it up, and put it back in the crate containing clean dishes. V6 continued to unload dishes until all glassware was placed on shelves. V6 stated he did not know what happened to the cup that fell on the floor. V6 stated dietary staff do not have to check sanitizer levels or temperatures on the dish machine. On 8/12/25 at 9:05 AM, in the dry storage room, there was a dented can of beef ravioli on a shelf with several other cans. V7, Cook, stated there is no separate place where dented cans are stored. On 8/12/25 at 9:08 AM, next to the three-compartment sink, there was a clear container with a white powdery substance inside. The container was not covered, labeled or dated, leaving the contents open to air. V6 stated the white powder is thickener.On 8/12/25 at 9:10 AM, in the standing freezer, there was a box of uncooked chicken tender fritters stored directly above boxes of cauliflower and roasted turkey breast. There was a box of bacon stored on the shelf directly above boxes of waffles and pancakes. V6 stated there is no specific location for storing uncooked meat, she just tries to separate it by breakfast, lunch and dinner.On 8/12/25 at 9:12 AM, in the walk-in refrigerator, there was a box of pasteurized shell eggs stored on a shelf directly above a box of 2% milk. There was a container labeled applesauce and 5/8. There was a pitcher half full of orange liquid with no label or date. On 8/12/25 at 1:12 PM, food temperatures were obtained from the steam table after the last resident tray was served using a metal calibrated thermometer. The ham salad measured 55 Fahrenheit (F). The pureed ham salad measured 68 F. The pureed deviled eggs measured 71 F.On 8/15/25 at 8:50 AM, V25, Registered Dietitian (RD), stated he is unsure if dietary staff have been checking the temperatures of food before serving, but the temperatures of the ham salad and eggs were not good due to potential for foodborne illness. He stated uncooked animal proteins should be stored on the lower level to reduce risk of contamination.On 8/15/25 at 9:16 AM, V1, Administrator, stated she expects dietary staff to follow dietary policies.The Facility's Undated Food Safety Requirements Policy documents, It is the policy of this facility to provide safe and sanitary storage, handling, and consumption of all food.The Facility's Food and Supply Storage Policy revised January 2012 documents, Food and supply storage areas shall be maintained in a clean, safe, and sanitary manner. Plastic containers with tight-fitting lids will be used for storing flour, sugar, bulk cereal, dried vegetables, etc. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. All foods will be covered, labeled, and dated.The Facility's Cleaning and Sanitation - General Policy revised January 2012 documents, Any utensil or dishware that falls on the floor before use will be washed, rinsed, and sanitized before it is used. Food will be maintained at proper internal temperatures. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 8/12/25 documents there are 67 residents living in the Facility. Event ID: Facility ID: 145502 If continuation sheet Page 6 of 6