Health 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 Page 1 of 3 146086 146086 08/26/2025 The Haven of Tuscola 1203 Egyptian Trail Tuscola, IL 61953

F 0692 Level of Harm - Actual harm Residents Affected - Few 11:36 AM, V2 Director of Nursing stated that obviously if 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 R1 had been entered into the facility's electronic system upon admission and that meals were being delivered to R1. R1's admission weight dated 8/6/25 documents that R1 weighed 181 pounds. R1's weight on 8/12/25 was 171.9 pounds which is equivalent to 5 % weight loss in 6 days. 146086 Page 2 of 3 146086 08/26/2025 The Haven of Tuscola 1203 Egyptian Trail Tuscola, IL 61953

F 0809 Level of Harm - Actual harm Residents Affected - Few 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 (R1, 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. 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 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, R1 stated the facility failed to bring her breakfast or lunch on the day after her admission to the facility on 8/05/25. R1 stated she lost ten pounds while residing in the facility. On 8/25/25 at 11:49 AM, 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.R1's Electronic Medical Record (EMR) documents an admission weight of 181 pounds. On 8/26/25 at 8:12 AM, R3 was sitting up in her bed with the head of the bed elevated and R3 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 was 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 11:36 AM, V2 Director of Nursing stated that obviously if 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 R1 had been entered into the facility's electronic system upon admission and that meals were being delivered to R1. 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's weight at this visit was 78 kilograms (171.9 pounds). V16 stated that R1 was wearing baggy pants and R1 told V16 that the facility was not feeding her. 146086 Page 3 of 3