Inspection·February 4, 2026

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to utilize footrests when transporting a dependent resident in a wheelchair resulting in entrapment of lower extremities in front wheels and the staff member transporting the resident failed to report the incident resulting in a two day delay of care for one (R1) of three residents reviewed for accidents in a sample of three residents. This failure caused R1 to suffer a fractured left tibia. Findings Include:R1's Care Plan, updated on 12/17/25, lists the following diagnoses: Congestive Heart Failure, Chronic Kidney Disease Stage III, Paroxysmal Atrial Fibrillation, Lymphedema and Chronic Venous Insufficiency of the lower extremities, unsteady gait, muscle wasting, and difficulty walking.R1's Minimum Data Set (MDS) dated [DATE] documents R1 was cognitively intact and totally dependent on staff to propel her 150 feet in the corridor using a manual wheelchair.R1's Progress Note dated 12/27/25 at 5:21 a.m. documents: Message sent to (V8), Nurse Practitioner (NP), regarding left knee swelling and bruising. (R1) states it has been present for three days. Pedal pulse palpable, skin warm, able to push down and pull back with foot. States there is pain, not severe.R1's Progress Note dated 12/28/25 at 3:41 p.m. documents: At approximately 3:00 p.m., CNA came and notified nurse that (R1's) leg appeared more swollen and (R1) was having difficulty rolling. Nurse went to (R1's) room to assess her leg and noted it was worse than earlier that morning. (R1) stated she was agreeable to being sent to the hospital. Nurse completed paperwork, notified (V8), NP, called the ambulance at approximately 3:13 p.m., and notified the Power of Attorney. The ambulance arrived at 3:30 p.m., and the nurse called report to the hospital at 3:40 p.m.R1's Progress Note dated 12/29/25 at 1:30 p.m. documents: Nurse writer called to obtain an update after rounds. Hospital nurse stated the resident would need surgery; however, they were waiting for the surgeon to discuss the surgery and risks with the resident and her daughter prior to scheduling. Nurse stated the CT scan showed a mildly displaced oblique fracture of the proximal left tibia.On 2/4/26 at 9:00 a.m., R1 was observed lying in her bed wearing an orthopedic boot on her left lower extremity. R1 stated, I think it was the day before Christmas I decided to have them get me up in my chair. (V6) and (V10), Certified Nurse Aides (CNAs), came in with the sling-type mechanical lift and moved me to my chair. Since I was up, (V6) pushed me down to the scale to weigh me. She didn't put on the foot pedals. There is a little bump when you wheel onto the scale, and I slipped down in the chair a little. When she pushed me off the scale, my left foot got caught on the front wheel under the chair. I said, ‘Ouch, I'm tangled,' and (V6) got me loose. It hurt, but I have swelling and bad circulation in my feet and legs, so sometimes I don't feel pain as much. After a while, the pain and swelling got so bad I couldn't stand for my leg to be moved. They sent me to the hospital, and my leg was broken. They talked about surgery, but with my heart problems, my weight, and not being able to stand anyway, we decided to use the boot and let it heal.On 2/5/26 at 10:18 a.m., V6 stated, I took (R1) in her wheelchair down to the scale to weigh her. I think it was the day after (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 02/04/2026 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)