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The Haven of Tuscola

1203 Egyptian Trail, Tuscola, IL 61953 · Douglas County · (217) 253-4791

71 certified beds, about 49 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2005

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 146086 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on January 28, 2025, inspectors cited 14 health deficiencies (the Illinois average is 12.6, the national average 9.2).

Of 88 health citations since January 2023, 7 were rated as actual harm or immediate jeopardy to residents.

CMS lists 3 fines totaling $68,999 in the last three years; the largest was $24,863, and the latest is dated February 4, 2026.

Nurses and nurse aides worked 2.94 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.28 of those hours.

46.7% of nursing staff left within the year CMS measured (Illinois average 44.5%).

CMS links it to Haven Healthcare, an affiliated group of 8 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 88 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
7G
0H
0I
Potential for more than minimal harm
44D
21E
15F
Potential for minimal harm
0A
0B
1C
July 31, 2026Complaint inspection · 2 citations
  1. G
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · deficient, provider has August 1, 2026
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain medication supply was available for administration for two residents (R1 and R2), failed to clarify a physician order for a pain medication dose for one resident (R2), and failed to initiate a care plan for pain triggered on a Care Area Assessment (CAA) for one resident (R2). These failures affected two (R1 and R2) of three residents reviewed for pain on the sample list of three residents. This failure resulted in R1, going without needed Morphine narcotic pain medications, during end-of-life (Hospice) comfort focused care, for greater than 24 hours. This failure resulted in R2 going without Lidocaine (topical numbing agent, for nerve ending) patch for pain, continually for five days which prevented R2's ability to sleep comfortably. 1. [...]
  2. G
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Actual harm, isolated · found on a complaint visit · deficient, provider has August 1, 2026
    Inspectors wroteBased on observation, interview and record review the facility failed to obtain physician ordered medications in a timely manner, which resulted in significant medication errors due to repeated, missed administration of medication. These failures affected two (R1 and R2) of three residents reviewed for medication on the sample list of three residents. This failure resulted in R1, going without needed Morphine narcotic pain medications, during end-of-life (Hospice) comfort focused care, for greater than 24 hours. This failure resulted in R2 going without Lidocaine (topical numbing agent, for nerve ending) patch, for pain, continually for five days which prevented R2's ability to sleep comfortably and going without Mirabegron Urinary Antispasmodic medication for seven days, which increased frequency of urgency to urinate. 1. [...]
May 20, 2026Complaint inspection · 1 citation
  1. E
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) June 9, 2026
    Inspectors wroteFailures at this level required more than one Deficient Practice Statement. A. Based on interview, observation and record review, the facility failed to keep resident rooms at comfortable temperatures for seven of nine (R19, R22, R25, R27, R28, R31, R57) residents reviewed for safe, clean, comfortable homelike environment, in a sample of 40. B. Based upon observation, interview, and record review, the facility failed to provide a clean and sanitary environment for one of nine residents (R16) reviewed for safe, clean, comfortable homelike environment, in a sample of 40.
February 4, 2026Complaint inspection · 1 citation
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 9, 2026
    Inspectors wroteBased 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. [...]
December 28, 2025Complaint inspection · 2 citations
  1. F
    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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) January 9, 2026
    Inspectors wroteBased 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.
  2. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 9, 2026
    Inspectors wroteBased 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.
August 26, 2025Complaint inspection · 2 citations
  1. G
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 17, 2025
    Inspectors wroteBased 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.
  2. G
    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.
    F809 · Nutrition and Dietary · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 17, 2025
    Inspectors wroteBased 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.
March 4, 2025Complaint inspection · 2 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 21, 2025
    Inspectors wroteBased on interview and record review, the facility failed to effectively supervise R1 to prevent a traumatic fall and thoroughly investigate a fall. This failure resulted in R1 striking R1's head on a closet door during a fall to the floor and sustaining a brain bleed requiring emergency medical evaluation and treatment at two hospitals. R1 is one of three residents reviewed for accidents in the sample list of three.
  2. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 21, 2025
    Inspectors wroteBased on interview and record review, the facility failed to report a resident fall to the resident's representative and provider for one (R1) of three residents reviewed for accidents in the sample list of three.
January 28, 2025Standard inspection · 14 citations
  1. F
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    F576 · Resident Rights · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
  2. F
    Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
    F729 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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. [...]
  3. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
  4. F
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
  5. E
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
  6. E
    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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
  7. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
  8. E
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
  9. D
    Allow residents to self-administer drugs if determined clinically appropriate.
    F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to assess for the ability to self administer medications for one of one resident (R4) reviewed for self administration of medications in the sample list of 32.
  10. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
  11. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 21, 2025
    Inspectors wroteBased 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.
  12. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
  13. D
    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.
    F693 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
  14. D
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 20, 2025
    Inspectors wroteBased 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.
November 14, 2024Complaint inspection · 1 citation
  1. E
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 27, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three residents (R1, R3, R4) were free from abuse by another resident (R2). This failure affects five (R1, R2, R3, R4, R5) residents reviewed for abuse in the sample of four. Findings Include: 1.) R2's Minimum Data Set (MDS) dated [DATE] documents R2 was severely cognitively impaired and was independently mobile with a wheelchair. R2's Care plan reviewed 8/15/24 documents R2 has behavioral problem: Physical behaviors related to Parkinson's Disease. The facility's Incident Report dated 10/21/24 documents (R1) alleged (R2) struck (R1) with (R2's) foot on the front porch. Residents immediately separated pending investigation. All parties notified. R2's AIMS for Wellness note dated 10/25/24 documents, transferred to hospital for increased aggressive behaviors. [...]
October 30, 2024Complaint inspection · 3 citations
  1. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 10, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide a dependent resident with dressing assistance of compression stocking for one of four residents (R1) reviewed for wounds/activities of daily living assistance on the sample list of four.
  2. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 10, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination between wounds, during wound treatment for one of four residents (R3) reviewed for wounds on the sample list of four.
  3. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 10, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed post infection control/contact isolation precaution sign to alert staff and visitors to wear personal protective equipment, and failed to wear personal protective gowns during high risk personal care care These failures affected one of four (R3) residents reviewed for wound/infection control on the sample list of four.
August 16, 2024Complaint inspection · 5 citations
  1. E
    Ensure that the resident and his/her doctor meet face-to-face at all required visits.
    F712 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 29, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure five (R1, R2, R5, R6, R7) residents received timely Physician visits out of five residents reviewed for Physician visits in a sample list of seven residents.
  2. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 29, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to maintain a residents' dignity by not providing timely incontinence care for one (R1) of three residents reviewed for incontinence care in a sample of seven residents.
  3. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 29, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure a residents' preferences for personal care (toileting) were honored. This failure affects one (R5) of three residents reviewed for dignity in a sample list of seven residents.
  4. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 29, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to provide timely incontinence care for a resident dependent on staff assistance with toileting and a history of skin breakdown. This failure affects one (R1) of three residents reviewed for incontinence care in a sample of seven residents.
  5. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) August 29, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one (R1) resident out of three residents reviewed for incontinence care in a sample list of seven residents.
June 9, 2024Complaint inspection · 4 citations
  1. E
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) June 21, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure four (R1, R2, R3, ,R4) residents have a homelike, clean environment out of four residents reviewed for Physical Environment in a sample list of six residents.
  2. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 21, 2024
    Inspectors wroteBased on interview and record review the facility failed to report an allegation of staff to resident mental abuse to the State Agency for one (R5) of three residents reviewed for abuse in a sample list of six residents.
  3. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 21, 2024
    Inspectors wroteBased on interview and record review the facility failed to thoroughly/timely investigate an allegation of staff to resident mental abuse and failed to remove the accused staff member from resident care during the investigation for one of three residents (R5) reviewed for abuse on the sample of six residents.
  4. D
    Make sure that a working call system is available in each resident's bathroom and bathing area.
    F919 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 21, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to provide individual functioning call lights to two (R1, R2) residents out of six residents reviewed for call lights in a sample list of six residents.
May 1, 2024Complaint inspection · 5 citations
  1. F
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    F801 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) May 22, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to employ a clinically qualified director of food and nutrition services. This failure has the potential to affect all 38 residents residing in the facility.
  2. F
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    F802 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) May 22, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to employ dietary staff who had completed safe food handling training. This failure has the potential to affect all 38 residents residing in facility.
  3. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) May 25, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure expired food products were disposed of and not served to residents, monitor food temperatures, monitor freezer and refrigerator temperatures, prevent cross contamination during food service, properly label and store foods, maintain a sanitary kitchen environment, store chemicals and soiled cleaning equipment away from food storage areas, and monitor temperatures/sanitizer levels for the dishwasher to ensure dishes were sanitized prior to resident use. These failures have the potential to affect all 38 residents residing in the facility.
  4. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 25, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to serve foods that were palatable to five (R1, R2, R3, R5, R9) residents out of five residents reviewed for Dietary Services in a sample list of nine residents.
  5. D
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    F805 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 22, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to prepare the safe texture of pureed food for three residents (R6, R7, R8) out of three residents reviewed for pureed diet orders in the sample list of nine.
February 22, 2024Standard inspection · 25 citations
  1. F
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    F801 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to employer a clinically qualified Director of Food and Nutrition. This failure has the potential to affect all 47 residents residing in the facility.
  2. F
    Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
    F802 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to have sufficient dietary staff to provide meals in a timely manner. This failure has the potential to affect all 47 residents who reside at the facility.
  3. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label opened refrigerator items, check steam table food temperatures for safety (TCS) foods (R5, R8, R10, R12, R26, R31 and R36) properly label time and temperature control for safety (TCS) foods, test the dishwasher for sanitation purposes and use pasteurized eggs when serving soft, cooked eggs (R4, R9, R31). These failures have the potential to affect 10 (R5, R8, R10, R12, R26, R31, R4, R9, R31 and R36) of 10 residents reviewed for altered diets on the sample list of 36 and all 47 residents residing in the facility.
  4. F
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    F868 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on interview and record review the facility failed to have an Infection Preventionist attend quarterly quality meetings. This failure has the potential to affect all 47 residents in the facility.
  5. F
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on interview and record review the facility failed to trend the facility's monthly infections. This failure has the potential to affect all 47 residents residing in the facility.
  6. E
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    F640 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on interview and record review the facility failed to timely submit Minimum Data Sets (MDSs) for six (R43, R39, R27, R16, R33, R32) of 36 residents reviewed for MDS in the sample list of 36.
  7. E
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to implement physician ordered nutritional supplements, document supplement intakes, and update a care plan with weight loss and nutritional interventions for four (R198, R13, R39, R4) of four residents reviewed for nutrition in the sample list of 36.
  8. E
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on interview and record review the facility failed to complete psychotropic assessments, ensure psychotropic assessments were accurate, care plan for behaviors and interventions, and document behaviors to justify increasing psychotropic medications for four (R8, R24, R45, R41) of five residents reviewed for unnecessary medications in the sample list of 36.
  9. E
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to document an open date of insulin upon opening a new pen/vial for five of five residents (R32, R18, R17, R22, R28) reviewed for medication storage in the sample list of 36.
  10. E
    Provide or get specialized rehabilitative services as required for a resident.
    F825 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 18, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure therapy services were provided for five of six residents (R17, R41, R44, R148, R149) reviewed for therapy services on the sample list of 36.
  11. E
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on interview and record review the facility failed to determine vaccinations status and offer influenza and pneumococcal vaccinations upon admission for four (R45, R41, R44, and R35) of five residents reviewed for immunizations on the sample list of 36.
  12. D
    Ensure that residents are fully informed and understand their health status, care and treatments.
    F552 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on interview and record review the facility failed to obtain psychotropic medication consents for one (R8) of five residents reviewed for unnecessary medications in the sample list of 36.
  13. D
    Allow residents to self-administer drugs if determined clinically appropriate.
    F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to observe a resident consume medications during medication administration for one of one resident (R4) reviewed for self-administration of medication in the sample list of 36.
  14. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide an individualized fitting wheelchair and commode for one (R45) of 16 residents reviewed for accommodation of needs on the sample list of 36.
  15. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on interview and record review, the facility failed to investigate an injury of unknown origin for one resident (R21) of one resident reviewed for abuse in the sample list of 36.
  16. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on interview and record review the facility failed to develop comprehensive care plans for two (R6, R45) of 16 residents reviewed for care plans on the sample list of 36.
  17. D
    Provide care by qualified persons according to each resident's written plan of care.
    F659 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to administer a medication according to physician's orders and manufacturers recommendations for one of one resident (R4) reviewed for following physician's orders in the sample list of 36.
  18. D
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    F676 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide methods for communication for a resident who has limited English proficiency and failed to provide a call light (to alert staff of resident needs) to be within the resident's reach for one resident (R39) of four residents in the sample list of 36.
  19. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on interview and record review, the facility failed to obtain daily weights and failed to follow up with the medical doctor for weight gain for 2 residents (R21, R22) of two residents reviewed for daily weights in the sample list of 36.
  20. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to document wound measurements upon admission, document weekly skin checks, document weekly wound measurements, document that a treatment was provided as ordered by the physician and develop a pressure ulcer plan of care for one (R45) of one resident reviewed for pressure ulcers on the sample list of 36.
  21. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to complete a smoking assessment and develop a plan of care for smoking for one of one (R6) resident reviewed for smoking on the sample list of 36.
  22. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide toileting for two (R6, R45) of 16 residents reviewed for toileting on the sample list of 36.
  23. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to change oxygen and nebulizer tubing for one (R10) of two residents reviewed for respiratory care in the sample list of 36.
  24. D
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    F805 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on observation, interview and record review the facility failed to provide the correct consistency for a pureed diet for two (R13 and R15) of two residents reviewed for pureed diets in the sample list of 36.
  25. D
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    F887 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 15, 2024
    Inspectors wroteBased on interview and record review the facility failed to offer COVID boosters for two (R45, R44) of five residents reviewed for vaccinations on the sample list of 36.
January 25, 2024Complaint inspection · 1 citation
  1. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on interview and record review, the facility failed to protect the residents right to be free from physical abuse by another resident for one of three residents (R1) reviewed for physical abuse on the sample list of three.
October 31, 2023Complaint inspection · 6 citations
  1. G
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 24, 2023
    Inspectors wroteBased on interview and record review the facility failed to timely obtain a urinalysis and follow up with the physician to treat a urinary tract infection for one (R1) of three residents reviewed for change in condition in the sample list of ten. This failure resulted in R1 being hospitalized with Acute Encephalopathy secondary to Urinary Tract Infection and Sepsis.
  2. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 24, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control measures to prevent the spread of COVID-19 (Human Coronavirus) during an outbreak by failing to post isolation signage to identify COVID-19 positive rooms, ensure staff wore appropriate Personal Protective Equipment (PPE) in COVID-19 positive rooms, ensure staff change PPE upon leaving COVID-19 positive rooms, and keep COVID-19 positive room doors closed. These failures affect nine (R1, R2, R3, R5, R6, R7, R8, R9, R10) of ten residents reviewed for infections in the sample list of ten residents.
  3. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 24, 2023
    Inspectors wroteBased on interview and record review the facility failed to report a resident's (R2) weight gain and laboratory results to the physician. R2 is one of three residents reviewed for change in condition in a sample list of ten.
  4. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 24, 2023
    Inspectors wroteBased on interview and record review the facility failed to develop a care plan with problems, goals, and interventions to address Congestive Heart Failure for two (R2, R3) of three residents reviewed for changes in condition in the sample list of ten.
  5. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 24, 2023
    Inspectors wroteBased on interview and record review the facility failed to accurately transcribe physician orders for three (R1, R2, R3) of three residents reviewed for physician's orders in the sample list of ten.
  6. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 24, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a COVID-19 medication was available to be administered as ordered for two (R1, R2) of three residents reviewed for physician's orders in the sample list of ten.
January 11, 2023Standard inspection · 14 citations
  1. F
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    F868 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on interview and record review, the facility failed to ensure the required quarterly Quality Assessment and Assurance (QAA) committee meetings were completed. This failure has the potential to affect all 44 residents in the facility.
  2. F
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on observation record review the facility failed to follow their COVID-19 Control Measure policy by failing to ensure nursing staff were wearing masks and eye protection while working in the facility. This failure had the potential to affect all 44 residents residing in the facility.
  3. E
    Assure that each resident’s assessment is updated at least once every 3 months.
    F638 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on interview and record review the facility failed to complete quarterly Minimum Data Set assessments every three months for seven (R8, R13, R14, R21, R22, R23, and R28) of 26 residents reviewed for quarterly assessments on the sample list of 26.
  4. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteR86's Physician Order Sheet dated January 2023 documents R86 was admitted to the facility on [DATE]. R86's Baseline Care Plan is dated 12/16/22. R86 does not have a Comprehensive Care Plan. On 1/9/23 at 2:30 PM, V3 Care Plan Coordinator confirmed R86's Comprehensive Care Plans should have been completed. R24's Physician Order Sheet dated January 2023 documents R24 was admitted to the facility on [DATE]. R24's Baseline Care Plan is dated 9/26/22. R24 does not have a Comprehensive Care Plan. On 1/9/23 at 2:30 PM V3 Care Plan Coordinator confirmed R24's Comprehensive Care Plans should have been completed. Based on interview and record review the facility failed to develop a Comprehensive Care Plan for four residents (R139, R136, R24, R86) the facility also failed to develop a Care Plan for Pressure Ulcers, Anticoagulant, and Pain for two residents (R17, R25). [...]
  5. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on interview and record review the facility failed to revise and update resident's Comprehensive Care Plans. This failure affected four of thirteen residents (R9, R11, R14, R25) reviewed for Care Plans on the sample list of 26.
  6. E
    Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
    F700 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on observation, interview, and record review the facility failed to assess the risk of entrapment for four of four residents (R9, R25, R15, R136) reviewed for side rails on the sample list of 26.
  7. E
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on interview and record review the facility failed to complete initial and quarterly Psychotropic Medication assessments. This failure effected five of five residents (R11, R86, R9, R22, R25) reviewed for unnecessary medications on the sample list of 13.
  8. D
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    F636 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on interview and record review the facility failed to complete timely admission and Annual Minimum Data Set (MDS) Assessments (Resident Assessment Instrument/RAI) for two of 13 residents (R136, R9) reviewed for MDS assessments in the sample list of 26.
  9. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during Pressure Ulcer dressing changes and failed to complete dressing changes as ordered for two of three residents (R139, R17) reviewed for Pressure Ulcers in the sample list of 26.
  10. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to secure an Oxygen tank for one of one resident (R6) reviewed for Oxygen in the sample list of 26.
  11. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during incontinence care for one of one resident (R136) reviewed for incontinence care in the sample list of 26.
  12. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on interview and record review the facility failed to address pharmacy recommendations for one (R25) of 13 residents reviewed for medication monitoring reviews on the sample list of 26.
  13. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on interview and record review the facility failed to review a resident's medication orders to prevent duplicate therapy and the potential for excess dosage for one of 13 residents (R136) reviewed for medications in the sample list of 26.
  14. C
    Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
    F851 · Administration · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) February 3, 2023
    Inspectors wroteBased on interview and record review the facility failed to accurately submit payroll data. This failure has the potential to affect all 44 residents residing in the facility.

Fire safety inspections

28 fire safety citations on file: 16 on January 28, 2025, 5 on February 22, 2024, 7 on January 11, 2023.

Every fire safety citation28 citations
  1. F
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · January 28, 2025 · Corrected (the home has a date of correction)
  2. F
    Develop Emergency Preparedness policies and procedures.
    E 13 · January 28, 2025 · Corrected (the home has a date of correction)
  3. F
    Develop a communication plan.
    E 29 · January 28, 2025 · Corrected (the home has a date of correction)
  4. F
    Establish emergency prep training and testing.
    E 36 · January 28, 2025 · Corrected (the home has a date of correction)
  5. F
    Establish staff and initial training requirements.
    E 37 · January 28, 2025 · Corrected (the home has a date of correction)
  6. F
    Conduct testing and exercise requirements.
    E 39 · January 28, 2025 · Corrected (the home has a date of correction)
  7. F
    Install a fire alarm system that can be heard throughout the facility.
    K 341 · January 28, 2025 · Corrected (the home has a date of correction)
  8. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · January 28, 2025 · Corrected (the home has a date of correction)
  9. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · January 28, 2025 · Corrected (the home has a date of correction)
  10. F
    Have simulated fire drills held at unexpected times.
    K 712 · January 28, 2025 · Corrected (the home has a date of correction)
  11. F
    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
    K 741 · January 28, 2025 · Corrected (the home has a date of correction)
  12. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · January 28, 2025 · Corrected (the home has a date of correction)
  13. E
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · January 28, 2025 · Corrected (the home has a date of correction)
  14. E
    Provide properly protected cooking facilities.
    K 324 · January 28, 2025 · Corrected (the home has a date of correction)
  15. E
    Ensure proper usage of power strips and extension cords.
    K 920 · January 28, 2025 · Corrected (the home has a date of correction)
  16. E
    Have proper medical gas storage and administration areas.
    K 923 · January 28, 2025 · Corrected (the home has a date of correction)
  17. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · February 22, 2024 · Corrected (the home has a date of correction)
  18. F
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · February 22, 2024 · Corrected (the home has a date of correction)
  19. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · February 22, 2024 · Corrected (the home has a date of correction)
  20. E
    Provide properly protected cooking facilities.
    K 324 · February 22, 2024 · Corrected (the home has a date of correction)
  21. E
    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
    K 372 · February 22, 2024 · Corrected (the home has a date of correction)
  22. F
    Conduct risk assessment and an All-Hazards approach.
    E 6 · January 11, 2023 · Corrected (the home has a date of correction)
  23. F
    Provide a means of sharing information on occupancy/needs.
    E 34 · January 11, 2023 · Corrected (the home has a date of correction)
  24. F
    Provide family notifications of emergency plan.
    E 35 · January 11, 2023 · Corrected (the home has a date of correction)
  25. F
    Conduct testing and exercise requirements.
    E 39 · January 11, 2023 · Corrected (the home has a date of correction)
  26. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · January 11, 2023 · Corrected (the home has a date of correction)
  27. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · January 11, 2023 · Corrected (the home has a date of correction)
  28. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · January 11, 2023 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
February 4, 2026Fine $22,315
August 26, 2025Fine $21,821
October 31, 2023Fine $24,863

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeIllinoisUnited States
All nursing staff (RN, LPN and aides)2.943.453.86
Registered nurses0.280.720.69
All nursing staff on weekends2.523.073.42
Nurse aides1.81
Licensed practical nurses0.85
Nursing staff turnover (share who left in a year)46.7%44.5%45.8%
Registered nurse turnover55.6%41.8%42.9%
Administrators who left0

CMS expects 4.97 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.11 on weekdays and 2.52 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.90 in April to June 2025 to 2.94 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20262.940.283.112.52 1.5%3 of 9049
Oct to Dec 20253.290.323.462.85 5.4%5 of 9247
Jul to Sep 20253.570.513.812.97 10.8%0 of 9243
Apr to Jun 20253.900.534.183.19 14.6%0 of 9140
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Illinois, Jan to Mar 20263.260.653.402.925.4%0.6% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Illinois

JobMedianMiddle halfEmployed
Illinois, all employers
CNAs (nursing assistants)$22.10$18.95 to $23.2668,640
LPNs and LVNs$36.06$30.57 to $38.2517,440
Registered nurses$46.15$38.47 to $50.94138,910
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeIllinoisUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
15.613.413.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
1.30.90.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.61.51.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
4.33.13.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.02.21.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
18.314.314.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
4.04.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
21.321.715.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
31.826.123.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
9.113.812.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
3.62.01.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.92.21.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for The Haven of Tuscola's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (48.2% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

48.2% this home

No different from the national rate

US median of homes 51.5% · Illinois: 106 better, 85 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 36 eligible stays.

Potentially preventable readmissions

11.0% this home

No different from the national rate

US median of homes 10.7% · Illinois: 2 better, 14 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 39 eligible stays.

Infections that led to a hospital stay

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

US median of homes 7.1% · Illinois: 3 better, 10 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 24 eligible stays.

Self-care and mobility at discharge

14.3% this home

Median of homes: Illinois50.0% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 21 residents counted.

Falls with major injury

0.0% this home

Median of homes: Illinois0.3% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 28 residents counted.

New or worsened pressure ulcers

4.1% this home

Median of homes: Illinois1.5% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 28 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Illinois100.0% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 13 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: HAVEN OF TUSCOLA LLC. CMS links this home to Haven Healthcare, a group of 8 nursing homes averaging 1.1 stars overall.

NameRoleTypeShareSince
Ecapital Healthcare Corp5% or greater security interestOrganization12/01/2024
Glat, DavidManaging control - governing bodyIndividual12/01/2024
Ecapital Healthcare CorpOperational/managerial controlOrganization03/01/2025
Glat, DavidOperational/managerial controlIndividual12/01/2024
Robinson, SyndeyOperational/managerial controlIndividual12/01/2024
Zaman, AsadOperational/managerial controlIndividual12/01/2024
Glat, DavidIndividual is an owner, partner or trustee of any ADP of the SNFIndividual10/21/2025
Katz, HaroldTrustee of the SNFIndividual12/01/2024
Rothner, WilliamTrustee of the SNFIndividual12/01/2024
Haven Healthcare LLCAdp of the SNFOrganization12/01/2024
Glat, DavidAdp of the SNFIndividual12/01/2024
Israel, LeviAdp of the SNFIndividual12/01/2021
Robinson, SyndeyAdp of the SNFIndividual12/01/2024
Zaman, AsadAdp of the SNFIndividual12/01/2024

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 28 problems in this area, most recently on July 31, 2026: "Provide safe, appropriate pain management for a resident who requires such services."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 11 problems in this area, most recently on May 20, 2026: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely."
  3. Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 11 problems in this area, most recently on August 26, 2025: "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."
  4. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 9 problems in this area, most recently on July 31, 2026: "Ensure that residents are free from significant medication errors."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.52 hours per resident per day, below the Illinois average of 3.07.

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Common questions

What is The Haven of Tuscola's Medicare star rating?
CMS rates The Haven of Tuscola 1 out of 5 stars overall, with 1 for health inspections, 1 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did The Haven of Tuscola get at its last inspection?
14 health deficiencies at the standard inspection on January 28, 2025. The Illinois average is 12.6.
Has The Haven of Tuscola been fined?
Yes. CMS lists 3 fines totaling $68,999 in the last three years.
Does The Haven of Tuscola accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns The Haven of Tuscola?
CMS lists 14 owners and managers, and links the home to Haven Healthcare. Legal business name: HAVEN OF TUSCOLA LLC.

Sources

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