Inspection·November 14, 2025

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, and record review, the facility failed to ensure residents consistently received food that was palatable, properly prepared, and consistent with posted menus for three (R1, R2, and R3) of three residents reviewed for dietary services. This has the potential to affect all 47 residents residing in the building.Findings include:The facility's Resident Nutrition Status policy dated 11/1/2015 documents each resident shall receive the correct diet, with food preferences accommodated as feasible, and shall receive prompt meal service and appropriate assistance. The Facility's Resident Council Minutes dated 9 11/25 documents Residents say that Toast, grilled cheese, and cookies are too hard and burnt to eat. The Facility's Resident Council Minutes dated 10/9/25 documents a resident stated she was fed bloody chicken.The Facility's Resident Council Minutes dated 11/6/25 documented that a staff member reported witnessing bloody chicken being served again during lunch on 11/3/25. Residents stated they are not receiving what is posted on the menu and that food is often served cold. Multiple residents reported they are still not receiving the items they request on the menus. Residents and staff members stated they observed bloody chicken being served during meals. Residents further reported that French fries are frequently soggy and mushy.On 11/14/25 at 9:32 AM, V5 (Activity Director) stated he is not present in the dining room during meals, but residents consistently complain in resident council meetings that food is burnt, raw, or cold. V5 stated he submits grievances to V1 (Administrator) for follow?up but has not received documentation of follow?up.On 11/14/25 at 10:50 AM, V6 (Certified Nursing Assistant) stated the food is often burnt and overcooked and residents complain. V6 stated food portions are too small, noting a five?year?old could eat more than what they serve, and reported residents frequently ask for more food but staff do not have enough to provide additional portions, resulting in residents being given snacks instead.On 11/14/25 at 10:59 AM, V7 (Activity Assistant) stated the food is often burnt and reported seeing a resident served bloody chicken. V7 further stated food preparation is inconsistent, with oatmeal appearing very dry, and noted she has observed burnt cookies and rolls served to residents, with portions often small. On 11/14/25 at 10:00 AM, R1 stated residents are often served very small portions at mealtimes and menu items are frequently repeated. R1 reported receiving cold, burnt, and undercooked food, sometimes too hard to eat, and gave examples of pork, biscuits, and au gratin potatoes that were served burnt. R1, who requires a mechanical soft diet due to having no teeth, stated she is supposed to receive gravy with meals to aid chewing but often does not because the facility runs out. R1 stated she has raised these concerns in resident council. On 11/14/25 at 11:45 AM, R2 stated that menu items are frequently changed because the facility reports not having the food needed to prepare the posted meals. R2 reported food is often burnt, dry, or overcooked, and further stated that portions are sometimes very small, leading to resident complaints.On 11/14/25 at 11:30 AM, R3 stated the kitchen often runs out of food at mealtimes, resulting in residents not receiving what is posted on the menu. R3 reported observing undercooked chicken served to residents in the dining room on more than one occasion. R3 Residents Affected - Many (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: 146080 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 146080 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Care Center 400 West Grant Street Macomb, IL 61455 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)