Haven of Tuscola: Missed Meals, 10-Pound Weight Loss - IL
The patient, identified as R1 in federal inspection records, was admitted on August 5, 2025, for rehabilitation following left total hip replacement surgery. She weighed 181 pounds on admission but had dropped to 171.9 pounds by her discharge date of August 12.
R1 told inspectors the facility failed to bring her breakfast or lunch on the day after her admission. She said she lost 10 pounds while residing at the facility.
Her physician of 14 years, identified as V17 PA, saw her for a surgical follow-up visit on her discharge date. He told inspectors he had never seen R1 so distraught in their long patient relationship.
"R1 was very upset and crying," the physician told inspectors. "R1 told him that the facility was not feeding her."
The physician noted R1 appeared thinner and stated that if she had continued to remain at the facility, he feared for her health and recovery. A registered nurse working with the physician confirmed R1 was wearing baggy pants during the visit and told staff "the facility was not feeding her."
R1 was not the only resident affected. Another patient, R3, told inspectors the facility failed to bring her breakfast on several days within the past two weeks and that she had to call to have meals delivered.
On August 26, inspectors observed R3 sitting in her bed at 8:12 AM wearing a clothing protector. R3 told inspectors breakfast had not arrived yet and her last meal was delivered around 5:30 PM the previous evening. Her breakfast was finally delivered 18 minutes later at 8:30 AM.
The gap between R3's evening meal and delayed breakfast exceeded 14 hours, violating the facility's own policy that states there will be no more than 14 hours between a substantial evening meal and breakfast the following day.
R3's care plan dated August 5 specifically noted she had potential for pressure ulcer development related to circulation problems. The plan included interventions for staff to monitor nutritional status, serve diet as ordered, and monitor and record intake.
The facility's policies clearly outlined meal delivery responsibilities. The Passing Meal Trays policy states nursing staff are responsible for delivering all trays to residents whether they eat in the dining room or their room. Nursing staff are required to advise food services of residents not eating in their usual location.
When inspectors questioned facility staff about the meal delivery failures, the responses revealed systemic problems with the dietary system.
The Director of Nursing, V2, acknowledged the obvious connection between missed meals and weight loss, stating "obviously if R1 missed meals it caused her to lose weight."
More concerning was the response from V14, the Dietary Manager. When asked about documentation showing R1 had been entered into the facility's electronic meal system upon admission, V14 stated she could not provide any such documentation.
The dietary manager explained the facility uses an electronic system to enter resident dietary information that generates daily meal tickets. However, she was unable to demonstrate that R1 had been properly entered into this system, suggesting meals were never scheduled for delivery to begin with.
The inspection findings indicate the facility failed to ensure meals and snacks were served according to residents' needs and preferences. Federal regulations require facilities to provide suitable and nourishing alternative meals and snacks for residents who want to eat at non-traditional times or outside scheduled meal times.
Both affected residents had normal cognitive function, with Brief Interview for Mental Status scores of 15, meaning they were fully aware of the meal delivery failures and their impact.
R1's case was particularly troubling given her rehabilitation status following major hip surgery. Proper nutrition is critical for surgical recovery and healing, making the meal delivery failures potentially dangerous to her medical progress.
The facility's inability to provide basic documentation showing a resident was entered into the meal delivery system raises questions about how many other residents may have experienced similar problems without reporting them or being observed by inspectors during their brief visit.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of Tuscola from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
THE HAVEN OF TUSCOLA in TUSCOLA, IL was cited for violations during a health inspection on August 26, 2025.
The patient, identified as R1 in federal inspection records, was admitted on August 5, 2025, for rehabilitation following left total hip replacement surgery.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.