Health inspection·June 9, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure four (R1, R2, R3, ,R4) residents have a homelike, clean environment out of four residents reviewed for Physical Environment in a sample list of six residents. Findings include: Resident Council Minutes dated 3/18/24 document a nursing concern of Aides (CNA) putting clothes on floor, beds not being made, call lights not answered in timely manner, sheets not changed, bed pans need to be put out of sight and in a bag and housekeeping needs improvement with picking up trash, mopping floors and cleaning bathrooms. Resident Council Minutes dated 4/15/24 document concerns of residents ask for beds being made and report weekend trash issues. 1. R1's undated Medical Diagnosis List documents R1's medical diagnoses as Acute Kidney Injury, Chronic Depression, Trans Ischemic Attack (TIA), Vitamin B12 Deficiency, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus Type II. R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R2's undated Medical Diagnosis List documents R2's medical diagnoses as Osteoarthritis of both Knees, Urinary Incontinence, Cerebral Meningioma, Restrictive Lung Disease, Restless Leg Syndrome, Fibromyalgia, Degenerative Disc Disease, Hypertension, Depression, Chronic Pain, Chronic Obstructive Pulmonary Disease (COPD), Obesity and Anxiety. R2's Cognitive assessment dated [DATE] documents R2 as cognitively intact. On 6/8/24 at 12:17 PM R1 and R2's shared bathroom showed paper debris on the floor, the bathroom garbage can was full to the top with soiled incontinence briefs and the toilet riser had smeared stool on it and was stained brown around the back half of the riser. R1, R2's bathroom had a very strong foul odor of bowel movement and body odor. On 6/8/24 at 12:15 PM R1 and R2 are sitting in separate recliner chairs in their shared room. R1 stated R1 uses the toilet riser and calls for staff to clean the inside of it after he is finished in the bathroom. R1 stated the staff don't clean the toilet riser for 'hours and hours' and then R2 uses the same toilet. R2 stated R2 does not need the toilet riser but I have to sit on that (bowel movement smeared) thing because I have to go and no one will clean it when we call for help. R2 stated the housekeeper does come into their room 'most every day.' R2 stated This room needs a good Page 1 of 7 146086 146086 06/09/2024 The Haven of Tuscola 1203 Egyptian Trail Tuscola, IL 61953

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cleaning. There is always garbage on the floor. The bathroom is a mess. Someone needs to scrub hard on that toilet. On 6/9/24 at 1:00 PM V1 Administrator stated R1 and R2's toilet riser has been replaced. V1 stated R1 and R2 do like to keep a lot of items in their room but should have a clean room to live in everyday. V1 stated all residents should be able to live in a clean room everyday. 2. R3's undated Medical Diagnosis List documents R3's medical diagnoses as Inability to ambulate due to Knee, Multiple Sclerosis, Chronic Obstructive Pulmonary Disease (COPD), Class 3 Severe Obesity, Cardiovascular Accident (CVA) and Diabetes Mellitus Type II. R3's Cognitive assessment dated [DATE] documents R3 as cognitively intact. On 6/8/24 at 9:05 AM R3's closet does not have a door. R3's bathroom wall above the baseboard has large areas approximately six inches tall of paint missing for several feet. There is a black cable wire hanging from a ceiling tile that is not connected to anything approximately five feet long next to the entry door. R3's floor has multiple pieces of debris and stains on tile floor. On 6/8/24 at 8:42 AM R3 stated the housekeepers don't do a very good job. They come around but don't really clean anything. I kept a clean house. I like it that way but this is not at all what I would consider clean. 3. R4's undated Medical Diagnosis List documents R4's medical diagnoses as Cerebral Infarction due to Occlusion of Right Internal Coronary Artery, Physical Debility, Cerebral Vascular Accident (CVA) and Hypertension. R4's Cognitive assessment dated [DATE] documents R4 as moderately cognitively impaired. On 6/8/24 at 9:15 AM R4 stated The staff are very nice here. I don't have any complaints other than my room could be cleaned more often. The housekeeper comes in about twice a week. It really needs cleaned more often than that. I share a room with another lady. That means we have to share a bathroom too. That at least should be cleaned every day. On 6/8/24 at 11:50 AM V11 Maintenance Director stated R3's closet door was broken. V11 stated (R3's) closet door was a hazard so we just took it down. We (facility) are supposed to be getting curtain rod style doors to keep the closets covered. The missing paint in (R3's) room has been there awhile. I am the only maintenance person. They (facility) have had me doing landscaping so I haven't had time to get things taken care of in the resident rooms. I have a clipboard for staff to write down room problems but no one uses it. V11 showed the facility maintenance report log with last entry of 10/13/2020. 146086 Page 2 of 7 146086 06/09/2024 The Haven of Tuscola 1203 Egyptian Trail Tuscola, IL 61953

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of staff to resident mental abuse to the State Agency for one (R5) of three residents reviewed for abuse in a sample list of six residents. Findings include: R5's Physician Order Sheet (POS) dated June 2024 documents R5's medical diagnoses as Hypertension, Chronic Kidney Disease, Cardiovascular Disease, Anemia, Hyperlipidemia, Nocturnal Muscle Spasm and Cerebral Vascular Accident (CVA). R5's Cognitive assessment dated [DATE] documents R5 as cognitively intact. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as requiring maximum assist for transfers, bed mobility, personal hygiene and toileting. R5's Grievance Report dated 6/6/24 documents V10 Certified Nurse Aide (CNA) allegedly was mentally abusive to R5. The facility was unable to provide documentation of R5's allegation of abuse being reported to the State Agency. On 6/8/24 at 3:55 PM V1 Administrator stated R5's allegation of abuse was not reported to the State Agency. V1 Administrator stated the facility Abuse Policy instructs V1 Administrator/Abuse Coordinator to report an allegation of abuse and the facility abuse policy was not followed. The facility policy titled 'Abuse Prevention Program' revised 11/28/2016 documents a written report will be sent to the State Agency within 24 hours and should contain the following information: Resident name, age, medical diagnosis, mental status of the resident who was allegedly abused or neglected, type of abuse, date/time/location and circumstances of abuse, any obvious injury or complaints of injury and steps the facility has taken to protect the resident. 146086 Page 3 of 7 146086 06/09/2024 The Haven of Tuscola 1203 Egyptian Trail Tuscola, IL 61953

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to thoroughly/timely investigate an allegation of staff to resident mental abuse and failed to remove the accused staff member from resident care during the investigation for one of three residents (R5) reviewed for abuse on the sample of six residents. Residents Affected - Few Findings include: R5's Physician Order Sheet (POS) dated June 2024 documents R5's medical diagnoses as Hypertension, Chronic Kidney Disease, Cardiovascular Disease, Anemia, Hyperlipidemia, Nocturnal Muscle Spasm and Cerebral Vascular Accident (CVA). R5's Cognitive assessment dated [DATE] documents R5 as cognitively intact. R5's Grievance Report dated 6/6/24 documents V10 Certified Nurse Aide (CNA) allegedly was mentally abusive to R5. The facility was unable to provide documentation of R1's allegation of abuse being investigated timely. On 6/8/24 at 11:45 AM V1 Administrator stated V1 interviewed R5 on the morning of 6/6/24 after V14 Social Service Director (SSD) reported R5's allegation to V1. V1 Administrator stated no staff were interviewed, no other residents were interviewed besides R5 and V10 Certified Nurse Aide (CNA) was not interviewed nor suspended. V1 Administrator stated V10 has not worked since the evening of 6/5/24. On 6/8/24 at 12:50 PM V14 Social Service Director (SSD) stated R5 came to V14 on the morning of 6/6/24 to report an allegation from the evening of 6/5/24. V14 stated R5 reported that (R5) wanted to go to bed and (V10) told her she was busy and wait until 10:00 PM. So you (R5) will sit there till 10:00 PM. When (V10) came back and put (R5) to bed (V10) was telling (R5) to control her legs. (R5) said she could not and (V10) told (R5) that she needed to control them, so do it. Then (V10) wanted (R5) to roll over and (R5) can not roll over much on Left side. (R5) told (V10) I can't and (V10) said well then I could shove you off of the bed. When (V10) left (R5) (V10) did not leave (R5) her call light. Then (V11) Certified Nurse Aide (CNA) came in and asked Why are you at the end of the bed and have no call light? (R5) told (V11) that the other CNA (V10) left me there. On 6/8/24 at 4:05 PM V10 Certified Nurse Aide (CNA) stated I worked the night of 6/5/24 from 5:00 PM until 1:00 AM the morning of 6/6/24. My next scheduled day to work is today (6/8/24). I came in to work at 1:00 PM and went straight to the halls to work. No one ever called me and suspended me. About 2:30 PM today (V1) Administrator talked to me and had me write a written statement of what happened that night. (V1) never told me what any allegation was, just write a statement of what I did. I am surprised I wasn't suspended. That is what normally happens whether the person is guilty or not. The facility policy titled 'Abuse Prevention Program' revised 11/28/2016 documents employees of the facility who have been accused of mistreatment, exploitation, neglect, abuse or misappropriation of resident property will be immediately removed from resident contact until the results of the investigation have been reviewed by the Administrator or designee. Employees accused of alleged mistreatment, exploitation, neglect, abuse or misappropriation of resident property shall not complete their 146086 Page 4 of 7 146086 06/09/2024 The Haven of Tuscola 1203 Egyptian Trail Tuscola, IL 61953

F 0610 shift as a direct care provider to residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146086 Page 5 of 7 146086 06/09/2024 The Haven of Tuscola 1203 Egyptian Trail Tuscola, IL 61953

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide individual functioning call lights to two (R1, R2) residents out of six residents reviewed for call lights in a sample list of six residents. Residents Affected - Few Findings include: R1's undated Medical Diagnosis List documents R1's medical diagnoses as Acute Kidney Injury, Chronic Depression, Trans Ischemic Attack (TIA), Vitamin B12 Deficiency, Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus Type II. R1's Cognitive assessment dated [DATE] documents R1 as cognitively intact. R2's undated Medical Diagnosis List documents R2's medical diagnoses as Osteoarthritis of both Knees, Urinary Incontinence, Cerebral Meningioma, Restrictive Lung Disease, Restless Leg Syndrome, Fibromyalgia, Degenerative Disc Disease, Hypertension, Depression, Chronic Pain, Chronic Obstructive Pulmonary Disease (COPD), Obesity and Anxiety. R2's Cognitive assessment dated [DATE] documents R2 as cognitively intact. On 6/8/24 at 12:15 PM R1 and R2 are sitting in separate recliner chairs in their shared room. R1 and R2 both stated their call lights do not work. R2 stated They (facility) gave us a bell to ring when we need something, but no one can hear it. I don't know what we would do if something really bad happened. They only gave us one bell. Our call lights have been out for three weeks. They (facility) told us that an electrician is supposed to be coming but they have never been here. On 6/8/24 at 12:18 PM R2 rang the call bell with no response from staff. Both R1 and R2's Oxygen concentrators were running, a stand up fan was running and also the window air conditioning unit was running making a low air sound. R1 and R2's door was closed to their room. The bell sound was not able to be heard right outside R1 and R2's room, nor across the hall, nor at the nurses station. No staff responded to R2's bell. On 6/8/24 at 12:40 PM V4 Agency Licensed Practical Nurse (LPN) stated R1 and R2's call lights have not been functioning. V4 stated I was standing at my medicine cart across the hall from (R1, R2) room and did not hear the bell being rung. On 6/8/24 at 12:45 PM V5 Certified Nurse Aide (CNA) stated (R1, R2's) call lights have been out for weeks. Their light doesn't come on outside their door. There is a board at the nurses station that will sound when a call light is on but it doesn't tell which room's call light is going off. On 6/8/24 at 12:46 PM a hand written note taped to the call light board at the nurses station documents Room (R1 and R2's room number) call light is not working outside of their room or on this board. It is sounding from the board only. On 6/8/24 at 2:05 PM V11 Maintenance Director stated R1 and R2's call lights have been non-functioning for three weeks. V11 stated the corporate electrician has been called and supposed to come and fix R1 and R2's call lights on 6/10/24. V11 stated (R2) was given one ringer bell to be able to contact staff for both (R1, R2). 146086 Page 6 of 7 146086 06/09/2024 The Haven of Tuscola 1203 Egyptian Trail Tuscola, IL 61953

F 0919 On 6/9/24 at 2:00 PM V1 Administrator confirmed R1 and R2's call lights have been non-functional. V1 stated the corporate electrician is scheduled to come fix R1 and R2's call lights on 6/10/24. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146086 Page 7 of 7