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) (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: 145857 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 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 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)