Inspection·August 26, 2025

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that each resident's nutritional and hydration status was maintained for two (R1, R3) of three residents reviewed for weight loss. Findings include:The facility's Passing Meal Trays undated 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 the following: 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. Nourishing snacks will be offered if the span is more than 14 hours between the ending of the evening meal and the serving of at least one or in combination from the basic food groups. Example: milk, grain product, meat/cheese or other protein rich item, fruit or 100% fruit juice.R1 was admitted to the facility on [DATE] for rehabilitation following left total hip replacement. R1 was discharged from the facility on 8/12/25. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of fifteen indicating that R1 has normal cognitive function.R3's MDS dated [DATE] documents a BIMS score of fifteen indicating that R1 has normal cognitive function.R3's Care Plan dated 8/05/25 documents that 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 intake.On 8/25/25 at 11:14 AM, R1 stated the facility didn't bring her breakfast or lunch on the day after her admission on [DATE]. R1 also stated that she was not offered any snacks while residing at the facility and she lost ten pounds.On 8/25/25 at 11:49 AM, R3 stated the facility failed to bring her breakfast on several days within the past 2 weeks and that she had to call to have it delivered.R1's Electronic Medical Record (EMR) documents an admission weight of 181 pounds. On 8/25/25 at 3:15 PM, V16 Registered Nurse (RN) working with V17 Physician Assistant (PA) confirmed that R1 was seen by V17 for a surgical follow-up on 8/12/25. V16 stated that R1 was weighed at this visit and was 78 kilograms (171.9 pounds). V16 stated that R1 was wearing baggy pants and R1 told V16 that the facility was feeding her.On 8/26/25 at 8:12 AM, R3 was sitting up in her bed with the head of the bed elevated and she was wearing a clothing protector. R3 stated that breakfast hadn't arrived yet and that R3's last meal was delivered around 5:30 PM the previous evening. On 8/26/25 at 8:30 AM, R3's breakfast observed being delivered to R3's room. On 8/26/25 at 9:30 AM, V17 PA stated that he saw R1 for a surgical follow-up visit on 8/12/25. V17 stated that he had known R1 as a patient for 14 years and had never seen her so distraught. V17 said that R1 was very upset and crying. V17 stated R1 told him that the facility was not feeding her. V17 stated that R1 did appear to be thinner and that if she would have continued to remain at the facility, he feared for R1's health and her recovery.On 8/26/25 at Residents Affected - Few (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 3 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 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)