Health inspection·December 28, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide and ensure the use of the correct size incontinence brief for three of three residents (R3, R4, R5) reviewed for insufficient supplies on a sample list of five residents. This failure placed the residents at risk for skin breakdown.Findings:R3's Minimum Data Set (MDS) dated [DATE] documents that R3's cognition is intact. This MDS also documents that R3 is frequently incontinent of bowel and bladder. R4's MDS dated [DATE] documents that R4's cognition is intact. This MDS also documents that R4 is always incontinent of bowel and bladder.R5's MDS dated [DATE] documents that R5's cognition is intact. This MDS also documents that R5 is always incontinent of urine and frequently incontinent of bowel.On 12/27/25 at 9:19 AM, V9 Certified Nurse Assistant (CNA) stated the facility had a recent shortage of size 3X incontinence briefs due to a shipment error that sent supplies to another state. V9 (CNA) stated that during the shortage, CNAs were instructed to use size 2X pull-up type briefs, which are harder to manage and less absorbent for residents with large urine output. V9 CNA stated that several residents have expressed concerns about the facility frequently running out of supplies.On 12/27/25 at 1:21 PM, V14 CNA stated supplies occasionally run low, mostly at the end of the week, including disposable washcloths and bariatric incontinence briefs. V14 stated the CNAs improvise by using smaller briefs, which residents dislike.On 12/27/25 at 1:45 PM, V12 CNA stated CNAs are using XL incontinence briefs instead of 3X for a few residents with increased body size and excessive urine output, making it difficult to keep them dry. V12 CNA reported that this issue has been ongoing for two weeks and has been brought to the attention of the person responsible for ordering (Director of Nursing (DON)) and the (Assistant Director of Nursing (ADON)) multiple times. V12 CNA stated at one point, staff were told they would have to make do with what was available.On 12/27/25 at 2:51 PM, R4 stated the facility occasionally runs out of large incontinence briefs (3X), requiring R4 to wear smaller ones (2X) that rub her skin and cause discomfort. R4 stated this occurred for two days a couple of weeks ago until a shipment arrived and noted this issue has persisted since R4's admission to the facility.On 12/28/25 at 9:20 AM, R3 stated the facility has had a recent shortage of large (3X) incontinence briefs lasting a couple of days, during which R3 had to wear smaller briefs (2X pull-ups type). R3 stated the 2X incontinence briefs are uncomfortable, less absorbent, and require more frequent changes due to R3's large urine output.On 12/28/25 at 9:30 AM, R5 stated the facility has a frequent shortage of 3X incontinence briefs since R5's admission in September. R5 stated the facility has run out of 3X briefs five times and R5 was told to use size 2X pull-up type incontinence briefs until the 3X shipment arrived. R5 stated the 2X pull-up type incontinence briefs are difficult for R5 to manage and cause skin irritation. R5 expressed concern about sores returning.On 12/28/2025 at 10:14 AM, V2 DON acknowledged awareness of the shortage of 3X incontinence briefs and stated that some residents who use that size were unhappy about having to Page 1 of 3 146086 146086 12/28/2025 The Haven of Tuscola 1203 Egyptian Trail Tuscola, IL 61953

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few wear smaller briefs. V2 DON agreed that smaller briefs can be uncomfortable and may cause skin irritation.On 12/28/25 at 10:26 AM, V3 ADON stated the facility has experienced supplier issues resulting in a shortage of 3X incontinence briefs. During the shortage, only 2X pull-ups were available, which did not meet the needs of residents requiring 3XL briefs. V3 agreed residents who feel more comfortable in larger briefs should have them provided but stated the facility cannot always meet preferences.The facility's undated Incontinence Care Educational Training Guidelines document that CNAs must ensure briefs fit appropriately. These guidelines document that the purpose of proper incontinence care is to monitor skin condition, maintain cleanliness and comfort, and prevent infection, skin irritation, and skin breakdown. 146086 Page 2 of 3 146086 12/28/2025 The Haven of Tuscola 1203 Egyptian Trail Tuscola, IL 61953

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. 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. This failure has the potential to affect all 47 residents who reside in the facility.Findings:The facility's Midnight Census Report dated 12/27/25 documents that there are 47 residents that reside at the facility.V2 Director of Nursing (DON) provided the nursing schedules for October through December 2025. Review of these schedules showed multiple days without an RN scheduled for eight consecutive hours. Those days are as follows: October 2025: 4, 5, 6, 7, 11, 12, 15, 16, 17, 20, 21, 22, 23, 28, and 31, November 2025: 3, 4, 7, 8, 9, 10, 11, 12, 13, 17, 18, 19, 20, 22, 24, 25, 26, 27, 28, 29, and 30, December 2025: 1, 2, 3, 4, 6, 7, 8, 11, 12, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25, 26, 29, 30, and 31.On 12/28/25 at 10:14 AM, V2 DON stated the facility was not meeting the requirement to have a registered nurse on duty for eight consecutive hours each day, seven days a week every twenty-four hours. 146086 Page 3 of 3