Inspection·November 14, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure three residents (R1, R3, R4) were free from abuse by another resident (R2). This failure affects five (R1, R2, R3, R4, R5) residents reviewed for abuse in the sample of four. Findings Include: 1.) R2's Minimum Data Set (MDS) dated [DATE] documents R2 was severely cognitively impaired and was independently mobile with a wheelchair. R2's Care plan reviewed 8/15/24 documents R2 has behavioral problem: Physical behaviors related to Parkinson's Disease. The facility's Incident Report dated 10/21/24 documents (R1) alleged (R2) struck (R1) with (R2's) foot on the front porch. Residents immediately separated pending investigation. All parties notified. R2's AIMS for Wellness note dated 10/25/24 documents, transferred to hospital for increased aggressive behaviors. On 11/13/24 at 1:00PM V3, [NAME] stated Dietary staff go outside with residents and observe the smokers after lunch. On 10/21/24 I was outside with residents and so was (V4) another dietary employee. (R1, R2, and R4) were on the East side of the patio and (V4) and I were on the [NAME] side of the patio. The first thing I noticed was (R2) had rolled the wheelchair off the concrete and I was afraid (R2) would get in the gravel and tip the chair over, so I went toward (R2) . As I approached (R2) before I could get there I heard (R2) yell get out of the way. I saw (R2) raise her foot up and deliberately kick (R1) in the lower leg. By that time (V4) was there and we separated (R1 and R2). (R1) was kicked hard enough to holler out 'ouch'. Then we notified the nurse and they checked out (R1 and R2). R1's MDS dated [DATE] documents R1 is cognitively intact. On 11/13/24 at 10:00AM R1 was observed in R1's room in electric wheelchair. R1's lower legs were covered with several purple to yellow areas. R1 stated I take blood thinners and have poor circulation and my legs really bruise easily. I remember when (R2) kicked me on the patio. She kicked me there (R2) pointed to her lower Right leg. It hurt, but luckily it did not break the skin. I'm not sure it caused a bruise because I have some bruises on my arms and legs most all the time. Of course I did not like being kicked, but I knew (R2) wasn't in her right mind. I do feel safe most of the time here. 2.) The facility's incident report dated 10/12/24 documents (R3) alleged (R2) hit (R3's) arm. R3's Interdisciplinary Team Note dated 10/12/24 (no time documented) by V1, Administrator documented (R5) stated (R2) had been cussing. (R2) was up by the window maneuvering (wheelchair) (R2) hit (R3's) (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: 146086 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 146086 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/14/2024 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)