Health inspection·March 7, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure incontinence care was provided per current standards of practice for 2 of 3 (R2 and R3) residents reviewed for incontinence care in the sample of 7. Residents Affected - Few Findings Include: 1. R2's admission Record with a print date of 3/7/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease and weakness. R2's MDS (Minimum Data Set) dated 2/15/24 documents R2 has a BIMS (Brief Interview for Mental Status) score of 06, which indicates a moderate cognitive impairment. This same MDS documents R2 is dependent on staff for toileting. R2's current Care Plan documents a Focus Area of Due to R2's general weakness, unsteadiness and impaired cognitive function, she is in need of staff assistance to complete her functional abilities. The interventions for this focus area include, R2's usual performance to complete her toileting hygiene is: dependent. On 3/6/24 at 8:56 PM, R2 was laying in bed, covered with blankets. V8 (RA/Resident Assistant) and V5 (CNA/Certified Nursing Assistant) pulled the blankets back and R2's gown was wet with urine. V5 and V8 replaced R2's wet gown with a dry one and changed the bed pads located under R2. V5 and V8 covered R2 back up without providing incontinence care to R2. R2's skin was not washed or wiped down throughout this observation. 2. R3's admission Record with a print date of 3/7/24 documents R3 was admitted to the facility on [DATE] with diagnoses that include schizophrenia, chronic obstructive pulmonary disease, and chronic kidney disease. R3's MDS dated [DATE] documents R3 has a BIMS score of 13, which indicates R3 is cognitively intact. This same MDS documents R3 is dependent on staff for toileting. R3's current Care Plan documents a Focus Area of Due to (R3's) general weakness, unsteadiness, poor endurance and behavioral complications, he is in need of staff assistance to meet his functional abilities needs. The interventions for this focus area include, (R3's) usual performance to complete his toileting hygiene is: dependent. On 3/6/24 at 8:47 PM, R3 was laying in bed on his left side wearing sweat pants and a shirt. R3's (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 03/07/2024 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)