Inspection·January 28, 2025

F 0554 Level of Harm - Minimal harm or potential for actual harm On 1/26/25 at 12:28 PM V2 Assistant Director of Nursing stated residents who self administer medications or keep medications at the bedside should have a physician's order to do so and they are currently in the process of getting these orders for R4. At 12:55 PM V2 stated there is a self medication administration assessment form that we use but one has not been completed yet for R4. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 2 of 21 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 01/28/2025 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 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. 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 deliver mail on Saturdays to five (R8, R9, R23, R35, and R37) of six residents reviewed for mail and package delivery on Saturdays from a sample list of 32. This failure also has the potential to affect all 38 residents residing in the facility. Residents Affected - Many Findings include: On 1/27/25 between 9:41 AM and 10:00 AM during a Resident Council Meeting, R8, R9, R23, R35, and R37 stated they don't get their mail on Saturdays. R8 and R9 reported that it's put on the Activity Director's (V25) desk and V25 hands it out on Mondays. R8's Minimum Data Set (MDS) dated [DATE] documents that R8 is cognitively intact. R9's MDS dated [DATE] documents R9 is cognitively intact. R23's MDS dated [DATE] documents that R23's cognitive abilities are moderately impaired. R35's MDS dated [DATE] documents that R35 is cognitively intact. R37's MDS dated [DATE] documents R37's cognitive abilities are moderately impaired. On 01/27/25 at 10:44 AM, V25 stated that residents get their cards that come in the mail on Saturdays, but the rest of the mail is put on V17's, Business Office Manager desk so V17 can determine where it goes. On 01/28/25 at 08:35 AM, V1 Administrator stated that mail is passed out on Saturdays by the Certified Nurse Assistants. On 01/28/25 at 8:36 AM, V17 stated that not all mail goes out on Saturdays, just cards. V17 reported that V17 goes through the other mail on Mondays and holds some mail like things from IDPH and saves for the Residents' Power of Attorneys or will contact them for permission to open it. V1 and V17 stated that not handing out all the mail on Saturdays has the the potential to affect all residents in the building. V1 stated, I guess we will have to figure something out for Saturdays. The facilities Long-Term Care Facility Application for Medicare and Medicaid dated 1/26/2025 documents 38 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 3 of 21 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 01/28/2025 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure the correct size brief was available for a resident to prevent skin breakdown for one of one resident (R33) reviewed for skin care from a total sample list of 32 residents. Residents Affected - Few Findings include: The facility provided Skin Condition Monitoring Policy dated 1/2018 documents that it is the policy of this facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. R33's care plan dated 4/23/24 documents that R33 is at an increased risk for skin abnormalities and requires weekly monitoring and safety measures to prevent dermatologic reactions. R33's wound assessment and plan dated 1/23/25 documents a new left abdominal fold wound with an order to cleanse with wound cleanser, apply honey coated absorbent dressing then cover with bordered gauze dressing daily and as needed. R33's nurse's notes dated 1/27/25 document wound culture results show infection in the wound with new orders received to provide Levofloxacin 250mg daily for three days. On 1/27/25 at 3:40PM V11 Licensed Practical Nurse provided wound care to R33. R33's wound is located under the left pannus, approximately one inch wide with an unknown depth, red and swollen. On 1/27/25 at 3:45 PM, R33 stated the wound began when the facility did not provide her correct size, extra large briefs (2XL), and instead had her wear smaller extra large (XL) briefs resulting in the brief rubbing her skin until there was an open wound. On 1/28/25 at 7:45AM, V12 Certified Nursing Assistant stated that the facility runs out of 2 XL briefs for R33 a lot and that when she has to wear the XL briefs, they rub her skin. On 1/27/24 at 4:15PM, V2 Assistant Administrator stated the last time 2XL briefs were ordered was 12/17/24, so they would have been out of briefs for several weeks. Certainly using smaller briefs that are needed could cause skin irritation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 4 of 21 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 01/28/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete a safe full mechanical lift transfer, thoroughly investigate a fall and document details of a fall and physician notification in the resident's medical record for one of two residents (R31) reviewed for falls in the sample list of 32. Findings include: On 1/26/25 at 8:36 AM R31 was lying in bed and stated within the last few months R31 was dropped out of the full mechanical lift sling during a transfer. R31 stated R31 was sent to the hospital due to R31 hitting his head during the fall but did not sustain any injuries. R31 stated there were two certified nursing assistants (CNAs) during the transfer, but the straps of the sling weren't secure and came off of the lift causing the fall. On 1/27/25 at 9:12 AM R31 was sitting in a wheelchair in R31's room with a full body cloth sling positioned underneath of R31. R31 stated this was not the type of sling that was used during R31's fall, which hasn't been used since the fall occurred. At 9:45 AM V7 and V10 CNAs transferred R31 from the wheelchair into bed with a full mechanical lift and a full body sling. R31's Face Sheet documents R31 has a diagnosis of hemiplegia and hemiparesis following cerebral infarction that affects R31's left non-dominant side. R31's Minimum Data Set (MDS) dated [DATE] documents R31 as cognitively intact and R31 is dependent on staff for transfers. R31's active Care Plan documents as of 3/8/24 R31 transfers with two staff and a full mechanical lift. This Care Plan documents R31 had a fall, root cause was related to positioning and improper full mechanical lift sling, and new intervention for CNA/Nursing staff to use full sling for every full mechanical lift transfer except when showering. The only documentation in R31's medical record regarding this fall is a nursing note dated 8/24/24 at 2:00 PM that documents R31 was sent to the emergency room following a fall and hitting R31's head. There is no documentation of any specific details regarding this fall, that a fall investigation was completed, or that R31's physician was notified. On 1/17/25 at 9:53 AM V7 stated V7 was assisting V8 CNA with R31's full mechanical lift transfer the day of R31's fall. V7 stated V8 was controlling the lift remote and once R31 was in the air above his wheelchair the lift sling shifted up R31's back and to the right causing R31 to fall out the side of the sling, between the upper and lower straps. V7 stated V7 tried to break R31's fall but R31 hit R31's left shoulder. V7 stated V7 thought the sling that was used at the time of R31's fall was too small for R31 and R31 now uses an extra large sling. On 1/27/25 at 10:08 AM V6 MDS/Care Plan Coordinator reviewed the fall investigations binder and confirmed there was no fall packet or fall investigation for R31's fall. V6 stated V6 would see if V6 could locate a fall packet for R31's fall. At 10:31 AM V6 stated V6 was unable to locate a fall packet or investigation for R31's 8/24/24 fall. On 1/27/25 at 1:10 PM V8 CNA stated the sling that was used during R31's fall was the type where the leg straps cross between the legs, but the leg straps were positioned on each side of R31's legs during that transfer. V8 stated the fall was months ago, V8 thought R31 had slid down in his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 5 of 21 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 01/28/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wheelchair and thought the strap of the lift broke during the transfer. V8 stated the leg straps should have been positioned between R31's legs during the transfer, but we did not do that since it caused R31 discomfort and this caused R31 to slip down and fall out of the sling. V31 reviewed the mechanical lift sling chart and verified the full back U style sling was used during R31's transfer fall. On 1/27/25 at 1:17 PM V9 Licensed Practical Nurse stated V9 was the nurse assigned to R31 the day R31 fell and the CNAs reported the leg straps of the sling were not crisscrossed during R31's transfer. V9 stated R31 was already on the floor when V9 got to R31's room, V9 assessed R31 and notified R31's physician. V9 stated V9 may have forgot to document that information. On 1/27/25 at 3:40 PM V2 Assistant Director of Nursing stated we determined that the sling used for R31's transfer fall was the type that crosses between the legs and the staff did not do that for R31's transfer. V2 stated V2 conducted an audit of all of the slings to ensure the proper slings were used and R31 no longer uses that style of sling. V2 confirmed there was no additional documentation to provide for R31's fall. The undated User Instruction Manual for the facility's full mechanical lift provided on 1/27/25, documents always check that the sling is suitable with the correct size and capacity for the particular patient, never use a sling that is frayed or damaged, always fit the sling and carry out lifting operations according to the users instructions provided, and check the slings daily for signs of damage or fraying. The undated Patient Lift instructions for use provided by the facility on 1/27/25 documents prior to transfer slightly raise the patient to verify the sling is attached properly to the mechanical lift and use a sling that is recommended by the resident's doctor, nurse or medical attendant for the resident's comfort and safety. These instructions document for a U shaped sling, position the top of the sling along the patient's upper arms and cross the leg straps between or underneath of the legs. The facility's Fall Prevention policy dated 11/10/18 documents following a resident fall the nurse will assess the resident and provide care, a fall huddle will be conducted with the on duty staff to determine circumstances of the event and appropriate interventions, and the nurse will document the circumstances of the fall and new interventions in the nurses notes of Assess Intervene Monitor for Wellness form. This policy documents falls will be discussed during the morning Quality Assurance meetings. The facility's Notification for Change in Resident Condition or Status policy dated 12/7/17 documents the nurse will notify the resident's physician when the resident is involved in an accident or incident and this will be recorded in the resident's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 6 of 21 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 01/28/2025 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 0690 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to provide hygienic incontinence care to one (R7) of one residents reviewed for incontinence care from a total sample list of 29 residents. Residents Affected - Few Findings include: The facility policy dated 12/2017 documents that the purpose of the policy is to eliminate odor, prevent irritation and infection and to enhance resident's self esteem. Directions include washing pubic area including the upper inner aspect of both thighs as well as the penis and scrotum by retracting the foreskin and washing carefully to remove secretions and washing the area under the scrotum. The area should be rinsed after washing and dried and the anal area should be washed with changing gloves and washing hands when going from contaminated to clean areas. R7's care plan dated 10/23/24 documents that R7 is dependent for toileting. On 1/28/25 at 9:36AM, V13 Certified Nursing Assistant (CNA) provided incontinence care for R7. During incontinence care, V13 CNA failed to cleanse R7's pubic area thoroughly, failed to retract R7's foreskin to cleanse the area, failed to rinse the area after washing the penis and the anal area and failed to change gloves after cleansing and before applying a clean brief. On 1/28/25 at 10:00AM, V13. stated that she should have cleaned R7's perineal area more thoroughly and changed her gloves between contaminated and clean fields. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 7 of 21 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 01/28/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on interview and record review the facility failed to monitor an enteral feeding including inputs and outputs and failed to monitor the weights of a resident receiving enteral feedings for one (R30) of one resident reviewed for enteral feedings from a total sample list of 32 residents. Findings include: The facility provided Enteral Feeding Closed System Ready to Hang Product documents that the enteral feeding amounts and other related information is to be documented on the flow record and or treatment/medication administration record. R30's Medication Administration Record dated January 2025 documents a tube feeding order for Jevity 1.5 calorie to be given at 65 milliliters per hour for 23 hours, to be held one hour before the administration of Levothyroxine and flushed with 100 cubic centimeters of water every four hours. R30's care plan dated 10/16/24 documents that tube placement and gastric contents/residual volume is to be checked and documented. Additionally, R30's care plan documents that R30 will maintain adequate nutrition and hydration status as evidenced by stable weights. R30's Medication Administration Record, Treatment Administration Record, nor food and fluid intake and output sheet document tube placement checks, residual checks, intakes nor outputs. R30's care plan dated 2/13/24 documents weights to be obtained daily. R30's physician order dated December 16, 2024 documents an order for weekly weights. R30's weight sheets from October 2025 through January 2025 do not document daily or weekly weights. On 1/27/25 at 9:00AM, V2 Assistant Director of Nursing stated that inputs and outputs should always be documented on residents with tube feeding and there should be evidence of auscultation of the stomach and placement checks. Not doing that makes it look like we are neglecting the patient and not providing them with the proper nutrition or monitoring. On 1/28/25 at 10:00AM, V2 Assistant Director of Nursing stated that R30's weights had not been obtained or monitored as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 8 of 21 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 01/28/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 implement orders, maintain supplies, provide hygienic care, accurately complete assessments and develop care plans for oxygen, nebulizer, continuous positive airway pressure (CPAP), and humidifier use for for four of six residents (R1, R4, R28, R33) reviewed for respiratory care in the sample of 32. Residents Affected - Some Findings include: 1.) The facility's Oxygen Therapy policy dated [NAME] 2019 documents there should be a written physician order for oxygen use, administer the flow rate as ordered, change tubing weekly, date the tubing and record on the treatment administration record (TAR). This policy documents to date humidification bottles when changed and record changes on the TAR. On 1/26/25 at 9:50 AM R1 was sitting on the side of the bed wearing oxygen at 2 liters per minute per nasal cannula. R1's oxygen humidification bottle was empty and dated 1/12/25. R1 stated it needs water and is changed about once per month. R1's January 2025 Physician Order Summary (POS) does not have active orders for oxygen use other than weekly tubing and humidification changes. R1's January 2025 TAR documents to change oxygen tubing and humidifier weekly on Sundays as of 11/15/24. This TAR is not signed on 1/19/25 to indicate this order was implemented as scheduled. R1's active care plan does not document oxygen use. On 1/26/25 at 11:10 AM V4 Licensed Practical Nurse (LPN) stated the night nurse is suppose to change oxygen tubing and humidification bottles weekly and label with dates. V4 stated V4 noticed this hasn't been getting done and V4 tries to change them when V4 has time. V4 stated the facility has been out of humidification bottles and currently doesn't have a supply. V4 stated R1 wears oxygen continuously at two liters per minute and should have an order for oxygen. V4 confirmed R1 does not have an active physician order for oxygen use. On 1/27/25 at 2:58 PM V6 Minimum Data Set (MDS)/Care Plan Coordinator reviewed R1's care plan and confirmed it does not address oxygen use. 2.) The facility's Cleaning Procedure for Room Humidifiers dated January 2003 documents to reduce the risk of infection with proper cleaning of the unit always clean the unit prior to refilling and to use a mixture of vinegar and water to clean the unit by running this mixture for 30 minutes. This policy documents to empty the cleaning solution, then refill the unit for use and always use distilled water. The facility's Nebulizer Therapy policy dated October 2007 documents to rinse all parts of the nebulizer with warm water after each use and wash all parts of the nebulizer in warm soapy water daily, rinse well, let air dry, and store in a plastic bag. This policy documents to change the mouthpiece and tubing weekly and record disinfecting procedures and equipment changes on the treatment sheet. On 1/26/25 at 9:00 AM R4 was sitting in a wheelchair in R4's room. There was an oxygen concentrator in R4's room with oxygen tubing that was dated 1/5/25. There was a nebulizer machine on a table (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 9 of 21 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 01/28/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some with an uncovered nebulizer mask/tubing dated 1/12/25 that appeared dirty. R4 stated R4 uses oxygen every night, R4 had a nebulizer treatment earlier this morning, and R4 was unsure how often the tubing was changed. At 12:20 PM there was a humidifier running in R4's room and there was a dried white substance on the top of the machine. V26, R4's Family, stated V26 uses tap water to fill R4's humidifier and turns the machine on. V26 and R4 both stated the machine needs to be cleaned and that no one routinely cleans it. On 1/27/25 at 9:35 AM R4's uncovered nebulizer mask and tubing was dated 1/26/25 and was on top of R4's nebulizer machine. R4's MDS dated [DATE] documents R4 as cognitively intact. R4's active care plan does not address nebulizer or humidifier use. R4's January 2025 POS does not document orders for humidifier use or routine care of the machine. R4's January 2025 TAR documents to change oxygen tubing/humidification bottle and nebulizer equipment weekly on Sundays. This TAR does not document these orders were implemented on 1/19/25 as scheduled and on 1/12/25 no supplies is recorded for the oxygen tubing/humidification bottle change. This TAR does not document any routine care for R4's humidifier. On 1/26/25 at 11:10 AM V4 LPN stated the night nurse is suppose to change the nebulizer masks/tubing weekly and V4 noticed this hasn't been getting done so V4 tries to change them when V4 has time. At 1:33 PM V4 stated V4 was unsure if there should be a physician's order for humidifier use and V4 does not provide any care for R4's humidifier. V4 stated V26 provides all the setup and care of the machine. V4 confirmed the machine should be cleaned routinely. On 1/27/25 at 11:49 AM V9 LPN stated V9 entered R4's room and initiated R4's nebulizer treatment. V9 stated V9 does not rinse or clean nebulizer masks/chambers after nebulizer treatments. On 1/27/25 at 2:58 PM V6 MDS/Care Plan Coordinator confirmed R4's care plan does not address humidifier or nebulizer use. V6 stated V6 wasn't aware that R4 uses a humidifier. On 1/27/25 at 3:40 PM V2 Assistant Director of Nursing (ADON) confirmed there should be physician orders for humidifier use and routine care/cleaning. V2 stated V2 was not aware that R4 was using a humidifier until yesterday. V4 stated the nurses should rinse nebulizer mask and chamber with water after each use, allow to air dry, and then store in a bag when not in use. 3.) The facility's CPAP and BiPAP (bilevel positive airway pressure) policy dated 3/18/13 documents CPAP use must be ordered by a physician to include type of unit, inspiratory positive airway pressure, device, frequency, oxygen if applicable, and humidification if applicable. This policy documents to clean the circuits and filters weekly and as needed. On 1/26/25 at 8:43 AM there was an uncovered CPAP mask lying on R28's bed. There was a crust of substance built up on the mask. R28 stated the nursing staff doesn't clean R28's mask, R28 just uses a wet wipe to wipe down the inside of the mask once a week. R28 stated R28 uses the CPAP every night and prefers not to use humidification with it. R28 stated an oxygen company comes to the facility about every three months and looks at R28's CPAP. R28's MDS dated [DATE] does not document CPAP use. R28's active care plan documents R28 as alert and oriented to person, place, and time and does not include CPAP use. R28's January 2025 Physician Orders Summary and TAR do not document orders for CPAP use or routine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 10 of 21 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 01/28/2025 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 0695 care/cleaning. Level of Harm - Minimal harm or potential for actual harm On 1/26/25 at 10:54 AM V4 LPN confirmed R28 does not have an active TAR. V4 stated R28 should have orders for CPAP use and care, which would be documented on the POS and TAR. Residents Affected - Some On 1/26/25 at 2:58 PM V6 MDS/Care Plan Coordinator confirmed R28's MDS and care plan does not address CPAP use. V6 stated V6 was not aware that R28 uses a CPAP. On 1/27/25 at 3:40 PM V2 ADON stated there should be orders for CPAP use, V2 orders CPAP masks which are replaced about every 90 days, and the nurses should routinely clean the mask. 4.) R33's undated care plan documents the following diagnoses: hypertension, hyperlipidemia, anxiety disorder, major depressive disorder, chronic obstructive pulmonary disease, insomnia, chronic pain syndrome, obesity, fibromyalgia, mitral valve prolapse, amnesia, restless legs syndrome, osteoarthritis, urinary incontinence, mild dysphasia, and obstructive sleep apnea. R33's care plan dated 3/8/24 documents that R33 has shortness of breath related to chronic obstructive pulmonary disease, restrictive lung disease and obstructive sleep apnea that requires oxygen and that the humidifier and tubing are to be changed weekly. On 1/26/24 at 12:00PM, R33's oxygen humidifier bottle was empty and dated 1/5/25. On 1/26/24 at 12:21PM, V4 Licensed Practical Nurse stated that the facility was currently out of oxygen humidifier bottles and that two weeks ago when she worked they were down to one bottle left. On 1/27/24 at 3:30PM, R33 stated that she had petroleum jelly in her bathroom because her (nares) were so dry from not having humidification with her oxygen for weeks. On 1/27/24 at 3:45PM, V2 Assistant Director of Nursing stated that there was a lapse of time between when the past director of nursing last ordered and when she had taken over the ordering of supplies for the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 11 of 21 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 01/28/2025 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide the services of a registered nurse for eight consecutive hours seven days a week every twenty-four hours and failed to employ a full time Director of Nursing. This failure has the potential to affect all 38 residents who reside in the facility. Findings include: The Long-Term Care Facility Application For Medicare and Medicaid dated 1/26/25 documents 38 residents reside at the facility. The facility's nursing work schedule for the month of January 2025 documents the facility did not have the services of a Registered Nurse (RN) for eight consecutive hours on January 2, 4, 7 and 27, 2025. The facility assessment dated [DATE] documents that facility accepts residents with a variety of clinically complex conditions. The facility assessment documents that a Director of Nursing and Registered Nurses are provided by the facility. On 1/28/25 at 11:01AM, V2 Assistant Director of Nursing confirmed that there has not been a Director of Nursing on staff since 1/10/25 and that there were no Registered Nurses on duty for a period of 24 hours on January 2, 4, 7 and 27 of 2025. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 12 of 21 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 01/28/2025 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 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. Based on interview and record review the facility failed to verify eligibility for employment through the healthcare workers registry prior to commencing employment for two Certified Nurse's Aides of five Certified Nurse's Aides reviewed for Healthcare Worker Background checks in a sample list of 32. This failure has the potential to affect all 38 residents residing at the facility. Findings Include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 1/26/25 documents the facility census as 38. The facility's employee roster documents V20, CNA (Certified Nurse's Aide) began employment at the facility on 11/15/24. The registry verification documents eligibility was verified as of 11/19/24. The facility's employee roster documents V21, CNA (Certified Nurse's Aide) began employment at the facility on 11/18/24. The registry verification documents eligibility was verified as of 12/2/24. On 1/28/25 at 3:30PM V1, Administrator verified all CNAs employed at the facility have the potential to care for all/any resident residing at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 13 of 21 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 01/28/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) On 1/26/25 at 8:43 AM R28 stated the facility has new nurses or agency nurses who don't administer R28's early morning medications. R28 stated R28 should have gotten Lantus, Lyrica (Pregabalin) and Omeprazole this morning but didn't receive these medications and an agency nurse (identified as V24 Registered Nurse) worked last night. R28 stated it was the first time that nurse had worked in the facility. R28 stated R28 has rheumatoid arthritis and fibromyalgia which requires pain medication. R28's January 2025 Physician's Order Summary (POS) documents orders for Omeprazole 20 milligrams (mg) by mouth daily at 6:00 AM prior to breakfast, Pregabalin (pain medication)150 mg by mouth three times daily and Lantus insulin 100 units per milliliter give 30 units subcutaneously twice daily. R28's January 2025 Medication Administration Record (MAR) documents these medications are scheduled at 6:00 AM and Omeprazole and Pregabalin are not signed out as given at 6:00 AM on 1/26/25. On 1/26/25 at 10:31 AM V4 Licensed Practical Nurse (LPN) confirmed an agency nurse, V24, worked night shift last night and had not worked in the facility prior. V4 stated R28 told V4 that R28's 6:00 AM medications were not given and R28 is cognitively intact. V4 confirmed R4's MAR does not document Omeprazole and Pregabalin were administered at 6:00 AM as ordered. V4 stated V4 administered R28's 6:00 AM Lantus as soon as V4 found out, which was at 9:00 AM. V4 stated there have been problems with night shift agency nurses not administering medications. 4.) On 1/26/25 at 9:54 AM R9 stated R9's only complaint is that the agency nurses don't have any idea of care needs, theses nurses don't always pass medications and R9 did not receive R9's scheduled early morning medications this morning. R9's Minimum Data Set, dated [DATE] documents R9 as cognitively intact. R9's January 2025 MAR documents to administer Hydrocodone/Acetaminophen 7.5-325 mg one tablet by mouth three times daily at 5:00 AM, 12:00 PM, and HS (bedtime). This MAR does not document that this medication was administered at 5:00 AM on 1/26/25. On 1/26/25 at 10:31 AM V4 LPN stated R9 told V4 that R9's 5:00 AM medications were not administered and R9 is cognitively intact. V4 confirmed R9's 5:00 AM Hydrocodone was not documented as given on 1/26/25. Based on interview and record review the facility failed to administer medications as ordered for four (R2, R9 R28 and R33) of four residents reviewed for medication administration from a total sample list of 32 residents. Findings include: The facility provided Medication Administration Policy dated 11/18/17 documents that medications must be prepared and administered within one hour of the designated time or as ordered. Document any medications not administered for any reason by circling initials and documenting on the back of the medication administration record, the date, the time, the medication and the dosage, and the reason for the omission and initials. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 14 of 21 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 01/28/2025 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 0755 1.) R2's undated care plan documents a diagnosis of Autoimmune Thyroiditis. Level of Harm - Minimal harm or potential for actual harm R2's Medication Administration Record dated 1/26/25 documents an order for Levothyroxine 75 micrograms, and that R2 did not receive her 5:00AM dose. Residents Affected - Some On 1/26/24 at 3:35PM, V4 Licensed Practical Nurse stated that she was calling the doctor now to let them know that the night nurse (V24) did not give R2 her 5:00AM Levothyroxine. V4 then stated, (V24) did not give most of the rest of the residents their early morning medications. 2.) R33's undated care plan documents the following diagnoses: hypertension, hyperlipidemia, anxiety disorder, major depressive disorder, chronic obstructive pulmonary disease, insomnia, chronic pain syndrome, obesity, fibromyalgia, mitral valve prolapse, amnesia, restless legs syndrome, osteoarthritis, urinary incontinence, mild dysphagia, and obstructive sleep apnea. R33's Minimum Data Set, dated [DATE] documents that R33 is cognitively intact and that R33 requires assistance with toileting. R33's Medication Administration Record dated 1/26/25 documents orders for the following medications to be administered at 5:00AM: Levothyroxine 200 milligrams, Pregabalin 75 milligrams, Hydrocodone / APAP 5-325, and Lorazepam 1 milligram. R33's nurse's notes dated 1/26/25 document that the on-call provider was notified at 1:40PM that the 5:00AM medications were not given timely. On 1/26/25 at 9:00AM, R33 stated that she did not receive her 5:00AM medications this morning. On 1/26/24 at 10:38AM, V5 RN stated, (R33) didn't get her 5:00AM meds (medications) today. I gave them when I got here. On 1/26/25 at 4:00PM, V2 Assistant Director of Nursing stated that she was made aware that the night nurse did not give the residents many of their early morning medications and that (V24 RN) would no longer be able to work at this facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 15 of 21 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 01/28/2025 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review the facility failed to implement a gradual dose reduction for one (R1) resident of five residents reviewed for psychotropic medications from a total sample list of 32 residents. Findings include: The facility psychotropic medication policy dated 6/17/22 documents that psychotropic medications shall not be used without proper monitoring. Additionally, residents who use antipsychotic medications will receive a gradual dose reduction at least twice in a year. R1's January 2025 Physician Order Summary documents orders for Sertraline (antidepressant) 75 milligrams (mg) by mouth daily since 11/27/23. The facility's Pharmacy Consultation Summary Report dated 9/27/24 documents R1 has ongoing antidepressant use and to attempt a gradual dose reduction (GDR). There is no documentation in R1's medical record that a GDR was attempted as recommended. On 1/27/25 at 1:42 PM V2 Assistant Director of Nursing reviewed the pharmacy report and confirmed R1 should have had a GDR attempted in September 2024. V2 stated usually pharmacy gives us a form to send to the physician to sign and V2 will have to look for additional information. At 2:02 PM V2 provided R1's Pharmacy Consultation Report dated 9/30/24 that documents R1 has received Sertraline 75 mg daily since R1 admitted to the facility in April 2022, a recommendation to consider a gradual dose reduction to 50 mg daily, and this recommendation was accepted by the provider. V2 stated this ordered GDR was never implemented and it will be initiated today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 16 of 21 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 01/28/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure foods were labeled and stored appropriately. This failure has the potential to affect all 38 residents in the facility. Residents Affected - Many Findings include: The facility's undated Storage of Food and Supplies policy documents prepared foods stored in the refrigerator will be covered and labeled with a date and expiration date and all foods will be covered, labeled and dated. The facility's undated Labeling and Dating Foods policy documents the following: Foods prepared to be held cold will be labeled with the date and time of preparation and potentially hazardous foods with sell by, use by, or expiration dates will be labeled with opened dates and discard/use by or expiration dates. Commercially processed and packaged foods will be labeled with opened dates and will be discarded by the third day or best by date. Opened shelf stable condiments should be refrigerated and labeled with opened and discard dates. On 1/26/25 between 7:57 AM and 8:17 AM an initial tour of the kitchen was conducted. The upright cooler contained individual plastic bags of chopped lettuce and shredded cheese, sliced cheese in plastic wrap, an opened plastic container of cottage cheese, a square plastic container of diced peaches, and a pitcher of orange juice that did not have dates labeled. There were hot dogs in a zip closing plastic bag that was dated 1/1/25, but did not have a discard or expiration date. The upright freezer contained individual sealed plastic bags of frozen chicken wings, egg patties, crumbled sausage, sausage patties, and sausage links that were not labeled with expiration dates or use by dates. There were opened unlabeled bags of breadsticks and chicken breasts that had ice crystallization, the bags were not sealed and the food exposed to air/contaminants. The chest freezer contained bags of carrots, peas, breadsticks, and corn that had no dates labeled. The outdoor cooler contained two metal trays of prepared broccoli and cheese casserole and a pan of prepared pork with gravy that were not labeled with dates. There were opened bags of lettuce, cheese cubes, and shredded cheese, and opened jars of mayonnaise and ranch dressing that were not labeled with opened or use by dates. V19 Dietary Manager confirmed all of the food and drinks should be labeled with opened and discard dates. V19 stated V19 will need to throw away the hot dogs and breadsticks. V19 stated bagged items are taken out of the original packaged boxes due to limited space and that is why some of the items do not have date labels. V19 stated the broccoli and cheese casserole and the pork were made yesterday, and they should have been labeled with dates. The facility's Long Term Care Application for Medicare and Medicaid dated 1/26/25 documents 38 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 17 of 21 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 01/28/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to implement COVID-19 transmission based precautions for one of three residents (R14) reviewed for infection control in the sample list of 32. The facility also failed to ensure COVID-19 (human coronavirus) symptomatic employees were restricted from work and tested timely for COVID-19. This failure has the potential to affect all 38 residents in the facility. Residents Affected - Many Findings include: The facility's COVID-19 Control Measures policy dated 5/19/23 documents the following: All healthcare personnel will be educated to notify the Administrator, Director of Nursing, or Infection Preventionist if they have tested positive for COVID-19, developed symptoms of COVID-19, or have had prolonged close contact with someone with COVID-19. Healthcare personnel who have been exposed should wear a well fitted facemask for 10 days, self monitor and report symptoms and not report to work when ill; if healthcare personnel are ill, ask if testing was done and obtain results. COVID-19 positive residents should be placed on transmission based precautions for 10 days and healthcare personnel should wear N95 respirator, eye protection, gowns and gloves when caring for COVID-19 positive residents. 1.) The facility's Resident and Employee COVID-19 logs dated 12/27/24-1/17/25 documents the following: The outbreak began on 12/27/24 when five residents and two employees (V18 and V14 Certified Nursing Assistants {CNAs}) tested positive. On 12/28/24 V15 Registered Nurse (RN) tested positive. A total of 17 residents and 11 employees have tested positive during the outbreak. On 1/27/25 at 3:30 PM V14 CNA stated V14 worked the day that V14 tested positive for COVID-19 and V14 had worked with symptoms of sneezing and runny nose. V14 stated V14 had symptoms at the start of V14's shift at 1:00 PM, tested positive around 4:30 PM, and was sent home. V14 stated V14 did not test for COVID-19 until later that afternoon once V14 found out there were residents who had tested positive. V14 stated V14 worked on the North Hall of the facility that day and was not wearing a mask at the time. V14 stated V18 CNA was also working on the North Hall that day, and tested positive and was sent home. On 1/27/25 at 4:15 PM V15 RN stated V15 had worked with symptoms of what V15 thought was a sinus infection for three days prior to testing positive. V15 stated V15 had a family member that had tested positive a few days prior to V15, which is what prompted V15 to test. V15 stated V15 did not report V15's symptoms or test sooner due to thinking V15's symptoms was just a sinus infection. The facility's Day Shift Assignment Sheet dated 12/26/24 documents V15 was scheduled for 6:00AM-6:00 PM. The facility's Evening Shift Assignment dated 12/27/24 documents V14 worked on the North Hall. V14's time card documents on 12/27/24 V14 worked from 12:59 PM until 4:46 PM. V15's time card documents on 12/26/24 V15 worked from 5:50 AM until 6:32 PM. On 1/27/25 between 11:01 AM and 11:26 AM V2 Assistant Director of Nursing/Infection Preventionist confirmed the facility is in a COVID-19 outbreak that began on 12/27/24 when residents and V14 and V18 CNAs tested positive. V2 stated on 12/27/24 residents first reported symptoms and were tested, then V14 and V18 tested positive and reported they had been sick. V2 stated V2 was unsure how long V14 and V18 had been experiencing symptoms prior to testing and they only tested since they found out residents had tested positive. V2 confirmed the outbreak has affected all halls of the facility. V2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 18 of 21 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 01/28/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm stated V15 RN worked on the North Hall of the facility on 12/27/24 and staff sometimes cross over to help on the other halls. V2 stated staff should report symptoms to V2 or their supervisor and the staff should stay home if symptomatic and test for COVID-19. V2 stated V2 did not know that V15 had a family member test positive or V2 would have tested V15 sooner. V2 stated masks were not initiated until after the outbreak was identified on 12/27/24. Residents Affected - Many The facility's Long Term Care Facility Application for Medicare and Medicaid dated 1/26/25 documents 38 residents reside in the facility. 2.) On 01/26/25 at 9:43 AM, a Transmission-Based Precaution's sign was posted on the door above a cart that was stocked with PPE (Personal Protective Equipment) outside of R14's room. On 01/26/25 at 12:08 PM, V5 Registered Nurse stated that she often reminds Certified Nurse Assistants the importance of applying PPE every time they enter R14's room but sometimes they must be reminded. On 01/26/25 at 1:20 PM, V16 [NAME] was pushing R14's wheelchair out of R14's room. V16 was not wearing PPE and R14 was not wearing a mask. At that time, V5 told V16 that R14 needed to have a mask on when going out to smoke. V16 was overheard saying, she has to wear a mask just to go out and smoke? V5 repeated that R14 was required to wear a mask when outside of room. On 01/27/25 at 1:28 PM, V16 was observed pushing R14 down the hall in a wheelchair. V16 was not wearing PPE and R14 was not wearing a mask. On 1/28/25 between 11:01 AM and 11:26 AM, V2 Assistant Director of Nursing stated COVID-19 positive residents are restricted to their rooms and only those who smoke are allowed to come out of their room. V2 stated isolated residents should wear a mask when out of their room, staff are to wear full personal protective equipment, and they should go out a separate door when going to smoke. V2 stated V2 was aware that V16 did not follow this procedure with R14. The facility's Infection control log dated January 2025 documents that R14 tested positive for COVID-19 on 1/17/25. This log documents R14 was on isolation until 1/28/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 19 of 21 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 01/28/2025 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 offer pneumococcal vaccination to four of five residents (R1, R4, R28, R31) reviewed for immunizations in the sample list of 32. Residents Affected - Some Findings include: The Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Timing for Adults dated 3/15/23 documents it is recommended that adults age [AGE] or older with no prior pneumococcal vaccination should be given PCV20 (pneumococcal conjugate vaccine), or be given PCV15 followed by PPSV23 (pneumococcal polysaccharide vaccine) a year later. Adults age [AGE] or older who have already received PCV13 (but not PCV15 or PCV20) at any age and PPSV23 at or after the age of 65 and in consultation with their provider may choose to administer PCV20 five years after their last pneumococcal vaccination. The facility's Influenza and Pneumococcal Immunizations policy dated November 2016 documents residents will be educated on the pneumococcal vaccine and will be given the opportunity to accept or refuse the vaccine. This policy documents the standard of practice time period for the pneumococcal vaccine is five years (not the current CDC guidance) and the facility will maintain documentation of resident's immunizations. 1.) R28's Face Sheet documents R28 admitted to the facility on [DATE] and R28 is over age [AGE]. R28's active immunization report does not document that R28 is up to date with the pneumococcal vaccinations and R28 last received Prevnar13 and Pneumovax23 in 2016. There is no documentation in R28's medical record that R28 was offered this vaccine prior to 1/26/25. 2.) R31's Face Sheet documents R31 admitted to the facility on [DATE] and R31 is over age [AGE]. R31's active immunization report does not document R31 has ever received a pneumococcal vaccination. There is no documentation in R31's medical record that R31 was offered this vaccine prior to 1/26/25. 3.) R4's Face Sheet documents R4 admitted to the facility on [DATE], R4 is over age [AGE], and R4's diagnoses include acute respiratory insufficiency and chronic obstructive pulmonary disease. R4's active immunization report does not document R4 has ever received a pneumococcal vaccination. There is no documentation in R4's medical record that R4 was offered this vaccine prior to 1/26/25. 4.) R1's Face Sheet documents R1 admitted to the facility on [DATE] and is over age [AGE]. R1's active immunization record does not document that R1 has ever received a pneumococcal vaccination. There is no documentation in R1's medical record that R1 was offered this vaccine prior to 1/26/25. On 1/27/25 at 12:20 PM V2 Assistant Director of Nursing/Infection Preventionist stated the facility had an immunization clinic in December 2024 for influenza, COVID-19 and Respiratory Syncytial Virus, but the pneumococcal vaccine was not included as part of that clinic. V2 stated V2 recently obtained resident consents for the pneumococcal vaccination. At 12:38 PM V2 provided R28's, R31's, R4's, and R1's pneumonia vaccine consent forms dated 1/26/25. V2 confirmed the accuracy of these residents' immunization records. V2 stated V2 has worked in the facility for six months and is not aware that during that time the pneumococcal vaccine was offered or available to be given. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 20 of 21 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 01/28/2025 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 0883 Level of Harm - Minimal harm or potential for actual harm On 1/27/25 at 1:49 PM V3 Regional Clinical Nurse stated there was no additional documentation to provide that the pneumococcal vaccine was offered prior to 1/26/25 for R1, R4, R28 and R31. V3 stated that is something we identified as a problem that we are working to fix. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146086 If continuation sheet Page 21 of 21