Taylorville Care Center
TAYLORVILLE CARE CENTER in TAYLORVILLE, IL — inspection on January 30, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(right) cheek. R2's Radiology Report dated 1/9/2026 documents, Acute nondisplaced fracture through
jeopardy to resident health or mood disturbance; Constipation, unspecified; Pressure ulcer of left heel, unstageable; Laceration safety without foreign body of left upper arm, initial encounter; Generalized anxiety disorder; Depression; and Pain.R1's MDS dated [DATE] document R1 was severely impaired for cognition for activities of daily
the ability to transfer to and from a bed to chair (or wheelchair).
Dependent: A helper completed all the activities for the resident.R1's Medical Records document R1 is currently on hospice.R1's Care Plan: Under Falls: Resident is at risk for falls due to: age related comorbidities.
Start date 3/30/2024.
Problem: I am cognitively impaired due to: Dementia, BIMS (Brief Interview for Mental Status) score previously was staff and remains staff due to nonsensical answers which is severely impaired.R1's Progress Notes dated 7/31/2025 at 11:02 AM, Resident was being transferred by CNA (certified nursing assistant) & this nurse from his bed to the wheelchair to get up for lunch.
Resident was in sling and properly fitted in, sling straps and hooks were intact with no noted fraying or breaks.
When CNA lowered sling down to place in wheelchair the sling straps to the left side straps part of the sling snapped, dumping resident backwards.
This nurse assisted resident to the floor breaking the fall by easing resident to floor as the right-side straps part of the sling and hooks were still intact on the lift.
Resident did not hit his head, has no c/o pain, alert, orientated to baseline.
Resident has 3 skin tears to the left arm and discoloration.
Resident has a red spot to the left cheek where he bumped this nurse's knee when going down.
Pillow placed under resident's head and sheet under arm to stop bleeding. EMS (Emergency Medical Service) called and they assisted resident to stretcher with a blanket sling.
Resident has been sent to (Hospital) for an evaluation. POA (Power of Attorney) & MD (Medical Doctor) has been notified. R1's Progress Notes dated 7/31/2025 at 11:14 AM, Writer called to resident room and found resident on the floor. ADON (Assisted Director of Nursing) and CNA were getting resident up for lunch and using (mechanical lift) and sling broke causing resident to go to the floor.
Resident skin tear on left arm resident also c/o (complained of) shoulder pain.
Writer called 911 and also contacted son and left message.
Ambulance here and transferred resident to (hospital) for evaluation. DON (Director of Nursing) and administrator aware of resident on floor.On 1/15/2025 at 10:07 AM, V2, Director of Nursing stated, When (R1) fell during his transfer I was not working as the Director of Nursing. I only know there was something with the sling. I don't remember anything else and was not part of the management team at that time.On 1/13/2026 at 2:32 PM, V9, Licensed Practical Nurse stated, I was not working when (R2) fell but I was working awhile back when they were transferring (R1) and his (mechanical lift) strap broke and he fell but he was okay.
The strap broke and he fell.Employee Witness Statement by V11, CNA dated 7/31/2025 documents, (V21, ADON) and myself were transferring (R1) to his w/c (wheelchair) with the (mechanical lift) when 2 of the straps on the (mechanical lift) sling snapped and he landed on the floor fell mostly on his shoulder. On 1/14/2026 at 10:39 AM, V14, Laundry Supervisor stated, We in laundry are supposed to inspect every sling and throw away any sling that is damaged. I know we were not documenting in the log like we were supposed to and I did get written up for it. I guess it broke again and somebody fell during a (mechanical lift because the sling broke). I work five days a week. On 1/29/2026 at 1:33 PM, V1, Administrator stated (R1) did fall during a transfer and the sling broke.
After (R1) fell from his sling we checked with laundry to make sure they were inspecting the slings, not using bleach on them and that they everyday they are supposed to check the slings, throw them out if they are damaged and document the sling condition.
After (R2) fell we re-educated laundry again. No other interventions were put in place expect in-serving staff.
The lift was a Invacare reliant 450.The (Mechanical Lift) Manufacture Instructions documents, Bleached, torn, cut, frayed, or broken slings[TRUNCATED]