The Haven Of Tuscola

F 0692 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

11:36 AM, V2 Director of Nursing stated that obviously if Resident R1 missed meals it could have led to her weight loss.On 8/26/25 at 1:06 PM, V14 Dietary Manager stated that they use an electronic system to enter resident information regarding their dietary needs and then create daily meal tickets. V14 stated that she could not provide me with any documentation showing that Resident R1 had been entered into the facility's electronic system upon admission and that meals were being delivered to Resident R1. Resident R1's admission weight dated 8/6/25 documents that Resident R1 weighed 181 pounds. Resident R1's weight on 8/12/25 was 171.9 pounds which is equivalent to 5 % weight loss in 6 days.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Haven of Tuscola

1203 Egyptian Trail Tuscola, IL 61953

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 - Actual harm Residents Affected - Few

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to provide a bedtime snack and breakfast for two (Resident R1, Resident R3) of three residents reviewed for food services on a sample list of six. Findings include:The facility's undated Passing Meal Trays policy provided by the facility documents that nursing will be responsible for delivering all trays to residents whether the resident is eating in the dining room or in the resident room.

Nursing will advise Food Service of residents not eating in their usual location. The facility's Meal Schedule undated policy provided by the facility documents that three meals will be served daily at similar times as served in the community. This policy documents that there will be no more than fourteen (14) hours between a substantial evening meal and breakfast the following day. And an evening snack will be served. Resident R1 was admitted to the facility on [DATE REDACTED] for rehabilitation following left total hip replacement. Resident R1 was discharged from the facility on 8/12/25. Resident R1's Minimum Data Set (MDS) dated [DATE REDACTED] documents a Brief

Interview for Mental Status (BIMS) score of fifteen indicating that Resident R1 has normal cognitive function.Resident R3's MDS dated [DATE REDACTED] documents a BIMS score of fifteen indicating that Resident R1 has normal cognitive function.Resident R3's Care Plan dated 8/05/25 documents The resident has potential for pressure ulcer development related to alteration in circulation. This Care Plan lists an intervention for staff to monitor nutritional status and serve diet as ordered, monitor intake and record.On 8/25/25 at 11:14 AM, Resident R1 stated the facility failed to bring her breakfast or lunch on the day after her admission to the facility on 8/05/25. Resident R1 stated she lost ten pounds while residing in the facility. On 8/25/25 at 11:49 AM, Resident R3 stated the facility failed to bring her breakfast on several days within the past two weeks and that she had to call to have it delivered.Resident R1's Electronic Medical

Record (EMR) documents an admission weight of 181 pounds. On 8/26/25 at 8:12 AM, Resident R3 was sitting up in her bed with the head of the bed elevated and Resident R3 was wearing a clothing protector. Resident R3 stated that breakfast hadn't arrived yet and that Resident R3's last meal was delivered around 5:30 PM the previous evening. On 8/26/25 at 8:30 AM, Resident R3's breakfast was observed being delivered to Resident R3's room. On 8/26/25 at 9:30 AM, V17 PA stated that he saw Resident R1 for a surgical follow-up visit on 8/12/25. V17 stated that he had known Resident R1 as

a patient for 14 years and had never seen her so distraught. V17 said that Resident R1 was very upset and crying.

V17 stated Resident R1 told him that the facility was not feeding her. V17 stated that Resident R1 did appear to be thinner and that if she would have continued to remain at the facility, he feared for Resident R1's health and her recovery. On 8/26/25 at 11:36 AM, V2 Director of Nursing stated that obviously if Resident R1 missed meals it caused her to lose weight.On 8/26/25 at 1:06 PM, V14 Dietary Manager stated that they use an electronic system to enter resident information regarding their dietary needs and then it creates daily meal tickets. V14 stated that she could not provide me with any documentation showing that Resident R1 had been entered into the facility's electronic system upon admission and that meals were being delivered to Resident R1. On 8/25/25 at 3:15 PM, V16 Registered Nurse (RN) working with V17 Physician Assistant (PA) confirmed that Resident R1 was seen by V17 for a surgical follow-up on 8/12/25. V16 stated that Resident R1's weight at this visit was 78 kilograms (171.9 pounds). V16 stated that Resident R1 was wearing baggy pants and Resident R1 told V16 that the facility was not feeding her.

Event ID:

Facility ID:

If continuation sheet