Health inspection·May 11, 2023

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the required 80 square feet per resident bed for 20 of 20 residents (R4, R6, R18, R19, R20, R23, R26, R27, R28, R30, R31, R32, R37, R38, R39, R41, R42, R44, R45, and R46) reviewed for room size in the sample of 36. Findings include: On 05/11/23 at 8:55 AM, V1 (Administrator) stated rooms 19-31 are covered under the room waiver. V1 said these rooms have been measured and do not provide the required 80 square feet of floor space per resident bed. V1 said the waivered rooms are dually certified for Medicare and Medicaid. Rooms 19 -31 are double occupancy rooms. The following rooms containted two beds with one dresser and one chair with measurements as follows: room [ROOM NUMBER]: 143.17 square (sq) feet (ft)= (71.59 sq ft per resident bed) room [ROOM NUMBER]: 156.8 sq ft = (78.4 sq ft per resident bed) room [ROOM NUMBER]: 148.4 sq ft = (74.2 sq ft per resident bed) room [ROOM NUMBER]: 148.4 sq ft = (74.2 sq ft per resident bed) room [ROOM NUMBER]: 151.2 sq ft = (75.6 sq ft per resident bed) room [ROOM NUMBER]: 151.2 sq ft = (75.6 sq ft per resident bed) room [ROOM NUMBER]: 151.2 sq ft = (75.6 sq ft per resident bed) room [ROOM NUMBER]: 152.3 sq ft = (76.14 sq ft per resident bed) room [ROOM NUMBER]: 152.3 sq ft = (76.14 sq ft per resident bed) room [ROOM NUMBER]: 152.3 sq ft = (76.14 sq ft per resident bed) room [ROOM NUMBER]: 144.2 sq ft = (72.1 sq ft per resident bed) Page 1 of 2 145857 145857 05/11/2023 The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458

F 0912 room [ROOM NUMBER]: 150.87 sq ft = (75.44 sq ft per resident bed) Level of Harm - Potential for minimal harm room [ROOM NUMBER]: 152.28 sq ft = (76.14 sq ft per resident bed) Residents Affected - Some The facility's Midnight Census Report dated 5/7/23 and Resident Matrix dated 5/8/23 both document R4, R6, R18, R19, R20, R23, R26, R27, R28, R30, R31, R32, R37, R38, R39, R41, R42, R44, R45, and R46 currently reside in rooms 19-31. Inquiries regarding the size of these rooms during the survey from 05/8/23 to 05/11/23, found no concerns or negative interviews from residents or families of residents who reside in the waivered rooms. On 5/8/23 R30, R31 and R41 all voiced no concerns with the size of their rooms during interviews. Observations and measurements of these rooms, during the survey, determine adequate space exists to meet the medical and personal needs of residents living in these waivered rooms. Review of Resident Council Minutes from the past 6 months indicated no concerns related to the size of the rooms included in the waiver. On 05/11/23 at 1:15 PM, V16 (Maintenance Director) confirmed the waivered room sizes remain the same for rooms 19 - 31 and provide less than 80 square feet of floor space per resident bed. 145857 Page 2 of 2