Inspection visit
Inspection
19 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 19 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
interview, observation and record review the facility failed to provide timely assistance for 3 (R30, R33, and
R21) of 4 residents reviewed for ADL (Activities of Daily Living) care in a sample of 35.
Residents Affected - Few
Findings include:
1. R30's face sheet documents diagnoses including: dementia, dysphagia, Alzheimer's disease, protein
calorie malnutrition, schizoaffective disorder, major depressive disorder, seizures, chronic obstructive
pulmonary disease, and chronic kidney disease. R30 care plan documents a focus area dated 02/13/24 of
due to (R30's) general weakness, unsteadiness, endurance and severe cognitive deficits, she is in need of
staff assistance to complete her functional abilities with an intervention dated 02/13/24 of (R30's) usual
performance to complete her eating is dependent. R30's Minimum Data Sheet (MDS) dated [DATE] (signed
07/22/24) documents a BIMS (Brief Interview of Mental Status) score of 03 indicating severe impairment.
Section GG of the same MDS documents that R30 requires partial/moderate assistance (Helper does less
than half the effort. Helper lifts holds or supports trunk or limbs but provides less than half the effort.) R30's
MDS dated [DATE] documents in section GG that R30 is dependent for eating (Helper does all of the effort.
Resident does none of the effort to complete the activity.)
On 07/21/24 at 11:51 AM, R30 received her food uncovered and set in front of her. R30 did not eat any of
her food or make an effort to eat any of her food. At 12:33 PM V18 (CNA) came over and assisted R30. R30
ate less then 5% of her food.
On 07/22/24 at 11:43 AM, R30's food was set in front of her. At 12:03 PM, R30 had still not received any
assistance with her lunch. At 12:26 PM, another resident was observed attempting to assist R30 by putting
her carrots on her fork. V17 (CNA) told the resident that R30 can feed herself, she does not need
assistance. At this time R30 still had not had any bites of food. At 12:36 PM, V18 (CNA) came over and
attempted to assist R30 with her meal. R30 took some bites when assisted and ended up eating
approximately 5% of her food.
2. R33's face sheet documents diagnoses including: neurocognitive disorder with Lewy bodies, muscle
wasting and atrophy, anorexia, Parkinson's disease without dyskinesia, dementia, anxiety disorder, major
depressive disorder, Alzheimer's disease, cerebral infarction, hemiplegia and hemiparesis following
cerebral infarction affecting right dominant side, chronic kidney disease stage 3A, and convulsions. R33's
care plan documents a focus area dated 02/08/24 of Due to (R33's) severe cognitive deficits, general
weakness and unsteadiness, he is in need of staff assistance to complete his functional abilities with an
intervention dated 03/19/24 of (R33's) usual performance to complete his eating is dependent. R33's MDS
dated [DATE] documents no BIMS was conducted due to resident is rarely/never
(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 16
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
07/24/2024
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)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
understood. Section GG of the same MDS documents R33 is dependent for eating (Helper does all of the
effort. Resident does none of the effort to complete the activity.)
On 07/21/24 at 11:53 AM, R33 received his food, it was set on a table by his chair. At 12:04, R33 received
assistance with his meal by V18 (CNA).
Residents Affected - Few
On 07/22/24 at 11:45 AM, R33's food was set on the table next to his chair. At 12:02 PM, V18 (CNA)
started assisting R33 with his lunch.
3. R21's face sheet documents diagnoses including: Alzheimer's disease, disorder of urea cycle
metabolism, gastro-esophageal reflux disease without esophagitis, anxiety disorder, anorexia, major
depressive disorder, nutritional deficiency, type 2 diabetes mellitus, and dementia. R21's care plan with a
focus area dated 02/14/24 of Due to (R21's) general weakness, unsteadiness and severe cognitive
impairment, she is in need of staff assistance to complete her functional abilities with an intervention dated
02/14/24 of (R21's) usual performance to complete her eating is dependent. R21's MDS dated [DATE]
documents no BIMS score was attempted due to resident is rarely/never understood. Section GG of the
same MDS documents R21's eating performance as dependent.
On 07/21/24 at 11:45 AM, R21 received her food covered and set in front of her on the table. At 12:02 PM,
V17 (certified nurse aide/CNA) started assisting R21 with her meal.
On 07/22/24 at 11:42 AM, R21's food was set in front of her. At 12:03 PM, V17 (CNA) started assisting R21
with her lunch.
On 07/22/24 after delivering R21's, R30's and R33's food V18 (CNA) and V17 (CNA) were observed
delivering other residents food and assisting them with their chairs and walkers.
On 07/24/24 at 12:12 PM, V2 (Director of Nursing) stated that residents should not have to wait 20 minutes
or more to receive assistance with their meals and the assistance should not have to be continually
interrupted due to another resident is spilling a drink, standing up or needing other assistance. V2 stated
they typically only have two CNA's on the unit for lunch and have three residents that need assistance, so if
other residents stand up when they shouldn't, are falling asleep, or need their walker the residents that
need assistance get interrupted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 2 of 16
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
07/24/2024
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation and record review the facility failed to monitor and report vomiting and food
regurgitation episodes for 1 (R29) of 11 resident reviewed for dining in a sample of 35.
Residents Affected - Few
Findings include:
R29's face sheet documents diagnoses including: Alzheimer's disease, dementia, disorder of urea cycle
metabolism, anemia, cerebrovascular disease, hemiplegia and hemiparesis following cerebral infarction
affecting left non-dominant side, Gastro-Esophageal Reflux Disease (GERD), syncope and collapse, and
presence of cardiac pacemaker.
R29's care plan documents a focus area dated 05/11/22 of (R29) has the diagnosis of GERD and is in
need of a proton pump inhibitor medication to treat his condition with a goal of Through the continued use
of his gastric medication, (R29) will remain free of GERD complications through next review. Documented
interventions dated 03/12/21 include monitor/document/report PRN (as needed) s/sx (signs or symptoms)
of GERD: belching, coughing/chocking when laying down, heartburn, dyspepsia, N/V (nausea/vomiting)
indigestion, regurgitation, increased salivation, swallowing problems, bitter taste in mouth, dysphagia,
substernal chest pain, and increased gag response and Proton pump inhibitor medication per doctor's
orders. Monitor/document side effects and effectiveness.
R29's Minimum Data Set (MDS) assessment dated [DATE] documents in Section C, Cognitive Patterns, a
Brief Interview for Mental Status (BIMS) score of 03 indicating severe cognitive impairment. Section K,
Swallowing/Nutritional Status, of the same MDS does not note any swallowing disorders.
R29's Medication Review Report with a print date of 7/24/24 documents an order dated 8/6/20 for
Pantoprazole Sodium (Proton-Pump Inhibitor) Tablet Delayed Release 40 milligrams (mg), 1 tablet by
mouth one time a day related to GERD and an order dated 11/3/21 for a mechanical soft texture diet, thin
consistency, offer fortified pudding or equivalent with lunch and supper.
On 07/21/24 at approximately 12:05 PM, R29 was observed regurgitating/vomiting a portion of his food
back onto his lunch plate. V18 (CNA) removed the soiled plate.
On 07/22/24 at approximately 11:49 AM and 11:51 AM, R29 was observed regurgitating/vomiting a large
portion of his food back onto his lunch plate. V18 (CNA) came over handed him paper towels and removed
the plate. R29 was offered a fresh plate of food but declined.
On 07/23/24 at 11:38 AM, R29 was observed with his food at lunch. At 11:47 AM, R29 shook his head no
when asked if he was going to eat some lunch. At 12:05 PM, R29 had not eaten any of his food.
On 07/22/24 at 12:48 PM, V6 (Licensed Practical Nurse/LPN) stated R29 did vomit up some of his food
yesterday but not as much as today. V6 stated she was told about it a few months ago when it first started.
On 07/22/24 at 12:50 PM, V17 (Certified Nurse Aide/CNA) stated she has seen R29 vomit up his food a
few times before the last couple days. V17 said she does not know if V20 (Speech Language
Pathologist/SLP) is aware, but they do tell the nurse on duty.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 3 of 16
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
07/24/2024
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 07/22/24 at 12:54 PM, V18 (CNA) stated R29 does throw up his food often, previously it was only
sometimes but the last couple weeks it has been more often. V18 said they have told V6 (Licensed Practical
Nurse). V18 said she has told V22 (Former Special Care Unit Manager) about a month ago before she left.
V8 said she has also mentioned it to V20 (SLP) in the past.
On 07/22/24 at 1:40 PM, V16 (Minimum Data Set Coordinator) stated he is not aware of any concerns with
R29's swallowing issues or food regurgitation concerns.
R29's electronic medical record did not document any episodes of R29 regurgitating/vomiting his food or a
physician being notified of R29 having this concern.
On 07/23/24 at 11:36 AM, V20 (SLP) stated R29 throwing up in his food does not happen that often. V20
said she looked through the progress notes and did not see anything documented about it. V20 stated she
has evaluated R29 for that concern in the past and she had talked to nursing about it in the past and did not
believe it was an issue with swallowing but might be an issue with his GERD (Gastroesophageal Reflux
Disease) medication and stated she felt it was a concern R29's physician needed to address. V20 stated
she could recommend a barium study be done but R29 would have to be referred to her.
On 07/24/24 at 12:12 PM, V2 (Director of Nursing/DON) stated they do not have any documentation for
R29 about him eating and vomiting his food back up because she did not know about it. V2 said that V22
(Former Special Care Unit Manager) did not pass it on to her. V2 said the doctor should have been notified
especially since it is still going on.
The facility policy dated 11/13/18 titled, Physician-Family Notification - Change in Condition documents in
part: Purpose: to ensure that medical care problems are communicated to the attending physician or
authorized designee and family/responsible party in a timely, efficient, and effective manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 4 of 16
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
07/24/2024
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)
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
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.
Based in interview and record review the facility failed to provided the services of a Registered Nurse for 8
consecutive hours per day 7 days a week. This failure has the potential to effect all 43 residents living at this
facility.
Findings Included:
On 7/23/2024 at 1:10pm, V1 (Administrator) said the facility did not have the required 8 hours per day 7
days a week of Registered Nurse coverage. V1 said they did not have a policy for Registered Nurse
coverage.
On 7/22/2024 at 8:30am, V10 (Licensed Practical Nurse) said she worked the weekend of 7/20/24 and
7/21/24 and the facility did not have a Registered Nurse working on either of those days. V10 said
frequently the facility does not have Registered Nurse coverage on the weekends she works.
The facility nursing schedule for May, June and July of 2024 revealed the facility did not have the required 8
hours of Registered Nurse coverage for the following dates: 5/11, 5/25, 5/26, 6/8, 6/9, 6/22, 6/23, 6/29,
6/30, 7/6, 7/20, and 7/21.
The Long Term Care Facility Application for Medicare and Medicaid (Form CMS 671) dated 7/22/24
documents there are 43 residents residing in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 5 of 16
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
07/24/2024
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)
F 0732
Post nurse staffing information every day.
Level of Harm - Potential for
minimal harm
Based on interview, record review and observations, the facility failed to prominently post the daily nurse
staffing data which includes the facility's name, date, census and the total number and actual hours worked
per shift for licensed and unlicensed staff responsible for resident care. This failure has the potential to
affect all 43 residents who reside at this facility.
Residents Affected - Many
Findings included:
On 7/21//2024 at 11:00am and 1:00pm, the facility was observed to not have a Daily Nurse Staffing data
sheet posted in a prominent place readily accessible to residents and visitors.
On 7/23/2024 at 10:00ampm, V1 (Administrator) said She didn't know the facility was not posting Daily
Nurse Staffing data and thus have not been doing it.
On 7/22/2024 at 10:30am, V10 (Licensed Practical Nurse) said she works the dayshift at this facility as a
full time nurse. V10 said she has never seen the Daily Nurse Staffing data posted while working at this
facility.
On 7/22/2024 at 9:30am and 2:00pm the facility did not have a Daily Nurse Staffing data sheet posted in a
prominent place readily accessible to residents and visitors.
On 7/23/2024 at 9:30am and 12:00pm the facility did not have a Daily Nurse Staffing data sheet posted in a
prominent place readily accessible to residents and visitors
The Long Term Care Facility Application for Medicare and Medicaid (Form CMS 671) dated 7/22/24
documents there are 43 residents residing in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 6 of 16
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
07/24/2024
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on interview and record review the facility failed to ensure residents were free from unnecessary
psychotropic medications for 1 (R24) of 5 residents reviewed for unnecessary medications in a sample of
35.
Findings Included:
R24's admission Record documents an admission date of 8/2/23 with diagnoses including major
depressive disorder, recurrent, mild; schizophrenia, unspecified; insomnia, and nutritional anemia,
unspecified.
R24's Medication Review Report with a print date of 7/24/24 documents an order for Doxepin 6 milligrams
(MG) 1 tablet at bedtime with a start date of 8/29/2023, Quetiapine Fumarate 300MG 1 tablet daily with a
start date of 8/04/2023, and Alprazolam (Xanax) 2MG tablet three times a day with a start date of
8/17/2023.
On 7/22/2024 at 1:03 PM, V2 (Director of Nursing) stated that R24 had a comprehensive list of gradual
reduction review reminders for psychotropic and sedative mediations on 2/26/2024 that included Quetiapine
300 MG, Doxepin 6 MG and Xanax 2 MG form from the pharmacy. V2 stated she has no documentation
from V13 (Mental Health Family Nurse Practitioner/FNP) on the gradual dose reduction for Quetiapine,
Doxepin and Xanax.
On 7/24/2024 at 9:08 AM, V21 (Pharmacist) stated she sends the recommendation reminders for the
gradual drug reduction (GDR) forms to the facility. V21 stated the facility should maintain all documentation
on the GDR's from the pharmacy and physicians recommendations. V21 stated she did send over a GDR
form for R24 for Quetiapine 300MG, Doxepin 6MG, and Alprazolam 2MG with dates from 11/23/2023,
1/25/2024 with next evaluation date of 2/2024. V21 stated she sent a reminder for the GDR on these same
medications on 2/26/2024 with next evaluation dates of 8/2024. V21 stated she also sent a reminder form
dated 3/27/2024 on the same medications documenting the next evaluation date of 8/2024. V21 stated she
does show a gap of information missing on R24's gradual drug reductions from the physician on
Quetiapine, Doxepin and Xanax, and doesn't have documentation from the physician on these medications.
R24's Pharmacy Consultation Report dated 11/23/2023 and 1/25/2024 documented Quetiapine 300MG 1
tablet daily and Alprazolam 2MG 1 tablet three times a day with next evaluation due 2/2024. Pharmacy
Consultation Reports dated 2/26/2024 and 3/27/2024 documented Quetiapine 300MG 1 tablet daily,
Doxepin 6MG 1 tablet daily, and Alprazolam 2MG 1 tablet three times daily with last GDR date of 2/26/2024
and next evaluation 8/2024.
R24's Medication Administration Record (MAR) for July 2024 documents administration of Quetiapine
300MG 1 tablet daily, Doxepin 6MG 1 tablet daily, and Alprazolam 2MG 1 tablet three times daily being
administered.
There is no documentation in R24's Medical Record documenting an attempted GDR or a rationale or
contraindication for the GDR for Quetiapine, Doxepin and Xanax.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 7 of 16
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
07/24/2024
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
The facility policy titled Psychotropic Medication-Gradual Dosage Reduction (revision date 2/1/18)
documents under Gradual Dosage Reduction (GDR) that residents who use psychotropic drugs shall
receive gradual dose reductions and behavior interventions, unless clinically contraindicated, in an effort to
discontinue or reduce the medications. A gradual dose reduction shall be encouraged at least twice yearly
unless previous attempts at reduction have been unsuccessful or reduction is clinically contradicted .The
physician has documented the clinical rational for why an additional attempted dose reduction at that time
would be likely to impair the resident's function or increased distressed behavior.
Event ID:
Facility ID:
145857
If continuation sheet
Page 8 of 16
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
07/24/2024
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)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to provide food with the prescribed texture of
mechanical soft for 4 residents (R30, R29, R33 and R10) of 4 residents reviewed for diets in a sample of
35.
Findings include:
1. R30's face sheet documents diagnoses including: dementia, dysphagia, Alzheimer's disease, and protein
calorie malnutrition.
R30's Medication Review Report dated 07/24/24 documents a dietary order dated 07/11/22 of regular diet:
mechanical soft texture with an order status of active.
R30's care plan documents a focus area dated 07/11/22 of: R30 has no teeth and does not use dentures
and as a result she is noted to be at risk for dental complications. Documented interventions include:
therapeutic mechanically altered diet per doctor's orders. R30's care plan also documents a focus are of:
R30 is in need of a therapeutic increased calorie diet to meet her nutritional needs with a dated initiated of
12/20/22. Documented interventions include: therapeutic increased calorie, mechanically altered diet per
doctor's order, offer subs (substitutions) for food items not liked and or eaten.
R30's Minimum Data Sheet (MDS) dated [DATE] documents a BIMS (Brief Interview of Mental Status)
score of 03, indicating R30 has severe cognitive impairment.
On 07/21/24 at 11:45 AM, R30 was served brown sugar meatloaf that was not ground and did not have
gravy over the top, and broccoli florets that were not chopped. Some of the broccoli florets and pieces
observed measured approximately 1.5 inches wide at the floret portion by 2 inches long. R30 did not eat
any of the broccoli florets and pieces of the broccoli were measured from R30's uneaten food.
On 07/22/24 at 11:35 AM, R30 was served carrots that were not soft chopped. The carrots were
approximately 1.75 inches wide by 1.0 inch long. R30 did not eat any of the carrots and pieces of the
carrots were measured from 30's uneaten food.
On 07/23/24 at 11:37 AM, R30 was served Italian blend vegetables that were not soft chopped. The Italian
blend vegetables had pieces that were over 2 inches in length. R30 did not eat any of the Italian blend
vegetables and pieces were measured from 30's uneaten food.
2. R29's face sheet documents diagnoses including: Alzheimer's disease, dementia, cerebrovascular
disease, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and
gastro-esophageal reflux disease.
R29's Medication Review Report dated 07/24/24 documents a dietary order dated 11/03/21 of general diet:
mechanical soft texture with an order status of active.
R29's care plan documents a focus area dated 05/11/22 of R29 is in need of a therapeutic diet to meet his
nutritional needs with an intervention dated 07/30/22 of: diet order of mechanical soft
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 9 of 16
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
07/24/2024
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)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
texture, thin consistency, fortified pudding with lunch and supper. R29's care plan also documents a focus
area dated 02/12/24 of: R29 has his own teeth which are noted to be in poor overall condition and as a
result he is noted to be at an increased risk for dental complications. Documented interventions include:
therapeutic mechanically altered diet per doctor's orders dated 2/12/24.
Residents Affected - Some
R29's MDS dated [DATE] documents a BIMS score of 03, indicating R29 has severe cognitive impairment.
On 07/21/24 at approximately 11:47 AM, R29 was served brown sugar meatloaf that was not ground and
did not have gravy over the top, and broccoli florets that were not chopped. Some of the broccoli florets
were approximately 1.5 inches wide at the floret portion by 2 inches long.
On 07/22/24 at approximately 11:39 AM, R29 was served carrots that were not soft chopped. The carrots
were approximately 1.75 inches wide by 1.0 inch long.
On 07/23/24 at approximately 11:40 AM, R29 was served Italian blend vegetables that were not soft
chopped. The Italian blend vegetables had pieces that were over 2 inches in length.
3. R33's face sheet documents diagnoses including: neurocognitive disorder with Lewy bodies, muscle
wasting and atrophy, anorexia, Parkinson's disease without dyskinesia, dementia, Alzheimer's disease,
cerebral infarction, and hemiplegia and hemiparesis following cerebral infarction affecting right dominant
side.
R33's Medication Review Report dated 07/24/24 documents a dietary order dated 04/10/23 of no added
salt diet: mechanical soft texture with an order status of active.
R33's care plan documents a focus area dated 05/01/23 of: R33 is in need of a therapeutic mechanically
altered increased calorie diet to meet his nutritional needs with an intervention dated 05/01/23 of:
therapeutic increased calorie, mechanically altered diet per doctor's orders, offer subs (substitutes) for food
items not liked and or eaten.
R33's MDS dated [DATE] documents no BIMS was conducted due to resident is rarely/never understood.
On 07/21/24 at approximately 11:48 AM, R33 was served brown sugar meatloaf that was not ground and
did not have gravy over the top, and broccoli florets that were not chopped. Some of the broccoli florets
were approximately 1.5 inches wide at the floret portion by 2 inches long.
On 07/22/24 at approximately 11:39 AM, R33 was served carrots that were not soft chopped. The carrots
were approximately 1.75 inches wide by 1.0 inch long.
On 07/23/24 at approximately 11:40 AM, R33 was served Italian blend vegetables that were not soft
chopped. The Italian blend vegetables had pieces that were over 2 inches in length.
4. R10's face sheet documents diagnoses including: Alzheimer's disease, dysphagia, type 2 diabetes
mellitus, dementia, nutritional deficiency, and gastro-esophageal reflux disease.
R10's Medication Review Report dated 07/24/24 documents a dietary order dated 05/18/24 of general diet:
mechanical soft texture, nectar consistency, double portions with an order status of active.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 10 of 16
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
07/24/2024
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)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
R10's care plan documents a focus area dated 05/17/21 of R10 is in need of a therapeutic mechanically
altered diet to meet his nutritional needs with an intervention dated 03/24/23 of: LCS (Low Concentrated
Sweets) diet, mechanical soft texture, thin consistency, double portions to assist with weight maintenance,
and offer fortified pudding between meals. R10's care plan documents a focus area dated 05/17/21 of R10
has no teeth and does not use dentures so as a result he is noted to be at an increased risk for dental
complications with an intervention dated 03/21/19 of: therapeutic mechanically altered diet per doctor's
orders, offer subs for food items not liked or eaten.
R10's MDS dated [DATE] documents a BIMS score of 00, indicating R10 has severe cognitive impairment.
On 07/21/24 at approximately 11:50 AM, R10 was served brown sugar meatloaf that was not ground and
did not have gravy over the top, and broccoli florets that were not chopped. Some of the broccoli florets
were approximately 1.5 inches wide at the floret portion by 2 inches long.
On 07/22/24 at approximately 11:40 AM, R10 was served carrots that were not soft chopped. The carrots
were approximately 1.75 inches wide by 1.0 inch long.
On 07/23/24 at approximately 11:37 AM, R10 was served Italian blend vegetables that were not soft
chopped. The Italian blend vegetables had pieces that were over 2 inches in length.
The facility document titled Diet Spreadsheet dated Day 22 documents: dental soft (mechanical soft)
ground brown sugar meatloaf with gravy, mashed potatoes and gravy, soft chopped broccoli, cream pie,
and soft dinner roll/margarine.
The facility document titled, ground brown sugar meatloaf with gravy day 22 documents in part: 6. Place
prepared meatloaf in a washed and sanitized food processor; grind to the size and texture of fine
hamburger. Place in steam table pans and add a small amount of prepared broth or gravy to keep moist. To
serve: portion #8 dip of moist, ground meat onto plate and ladle appropriate amount of gravy/sauce over
the top to keep moist.
The facility document titled, soft chopped broccoli day 22 documents in part: 4. Chop broccoli into bit-sized
pieces. Transfer to steam table pans. Cover and hold until ready to serve.
The facility document titled, Diet Spreadsheet day 23 documents: dental soft (mech soft) ground lemon
chicken with sce (sauce), soft rice pilaf with gravy or sauce, soft chopped vegetables, and mixed fruit dump
cake.
The facility document titled, soft chopped vegetables day 23 documents in part: 3. Drain carrots slightly,
leaving enough liquid in pan to retain heat. Chop carrots into bite-sized pieces.
The facility document titled, Diet Spreadsheet day 24 documents: dental soft (mech soft): beef ravioli with
marinara sauce, soft chopped Italian blend vegetables, butterscotch bars, garlic bread, soft.
The facility document titled, soft chopped Italian blend vegetables day 24 documents in part: 4. Chop
vegetables into bite-sized pieces. Transfer to steam table pans. Cover and hold until ready to serve.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 11 of 16
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
07/24/2024
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)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On 07/24/24 at 12:23 PM, V2 (Director of Nursing) stated the food should follow the recipes in the kitchen
and the meat ground and the vegetables chopped for the mechanical soft diet.
The facility policy dated 2017 documents in part: the section titled, General Principles & Guidelines: 4. Meat
is ground or chopped into bite-sized pieces (1/2 inch or smaller) and should be mixed or served with gravy,
broth or another type of moistening agent. 6. Vegetables are cooked soft, moist and fork tender with no
large chunks or pieces. The section titled, Food Guide: documents in part: vegetables: all vegetables should
be chopped or diced into bite-sized pieces (1/2 inch or smaller).
Event ID:
Facility ID:
145857
If continuation sheet
Page 12 of 16
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
07/24/2024
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)
F 0880
Provide and implement an infection prevention and control program.
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 maintain aseptic technique while performing
catheter for 1 of 2 residents (R6) reviewed for catheter/ incontinence care in a sample of 35.
Residents Affected - Few
Findings include:
R6's Face Sheet documents an admission date to the facility of 3/18/24 with diagnoses including: type 2
diabetes mellitus without complications, urinary tract infection, site not specified, muscle weakness, chronic
kidney disease, and flaccid neuropathic bladder, not elsewhere classified.
R6's Order Summary Report with a print date of 7/24/24 documents an order of catheter care per facility
policy every 24 hours as needed dated 5/20/2024.
R6's Care Plan dated 7/05/2024 documents a focus area of (R6) has the diagnosis of Neurogenic bladder
and is in need of an indwelling, foley catheter to meet his urinary drainage needs. Documented
interventions include Catheter care as scheduled per facility policy with an initiation date 2/21/24.
R6's Minimum Data Set (MDS) dated [DATE] documents in section C, Cognitive Patterns, a Brief Interview
for Mental Status (BIMS) score of 14, indicating R6 is cognitively intact. Section H, Bladder and Bowel, of
the same MDS documents that R6 has an indwelling catheter.
On 07/22/24 at 2:05PM, V5 (Certified Nurse Assistant/CNA) was observed providing perineal and
indwelling urinary catheter care for R6. V5 gathered supplies and sat the water basin and 4-5 washcloths
down on the toilet lid in the hallway bathroom while washing her hands with soap and water, then filled the
basin with warm water. V5 then picked up supplies from the toilet lid and started walking down the hallway
to R6's room. V5 dropped the squeeze bottle that held soap and water for perineal care on the hallway floor
outside R6's room. V5 then entered R6's room and placed the water basin and washcloths on R6's bedside
table with no barrier or disinfecting process to the area. V5 then exited R6's room to the hallway, placed her
barrier gown on, picked up the squeeze bottle containing soap and water, re-entered R6's room and placed
the squeeze bottle on the bedside table with the other supplies. V5 sanitized her hands and donned gloves.
V5 explained procedure to R6 prior to starting care. V5 started care with supplies.
On 7/23/2024 at 11:30 AM, V11 (Infection Preventionist Nurse) stated the expectation is for staff to follow
the facility policy and procedure with infection control practices during perineal care/catheter care. V11
stated she would expect staff not to place basin and wash clothes on a toilet lid prior to using them for
perineal/catheter care. V11 stated she would expect new supplies to be gathered if contaminated. V11
stated her expectations would be to obtain a new soap and water squeeze bottle after being on the floor
and a barrier to be placed or disinfecting process completed on the bedside table prior to placing supplies
for perineal/urinary catheter care.
On 7/24/2024 at 8:53 AM, V5 (CNA) stated she has been employed with this facility for a year. V5 stated
she did have training on indwelling catheter, genital, and perineal care upon hiring.
The facility policy titled Infection Prevention and Control Program (revision date 11/28/2017) documents
under Guidelines step 4 that each departmental policy and procedure manual includes specific infection
control measures, sanitation and aseptic techniques as they relate to the responsibilities
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 13 of 16
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
07/24/2024
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)
F 0880
and function of the particular department.
Level of Harm - Minimal harm
or potential for actual harm
The facility policy titled Urinary Catheter Care (revision date 2/14/19) documents Purpose: to establish
guidelines to reduce the risk of or prevent infections in resident with an indwelling catheter. Step 16 under
guidelines documents Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or
showering) is appropriate. (Source: CDC Guidelines for Prevention of Catheter Associated Urinary Tract
Infections 2009) Encrustations on the foley catheter should be removed from the meatus outward with
clean wash cloth, rinsed with clean water on an as needed basis.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 14 of 16
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
07/24/2024
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)
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 at least 80 square feet per resident in
two multiple occupancy resident bedrooms. This affected 4 of 4 (R6, R23, R28 and R11) residents reviewed
for room sizes in a sample of 35.
Findings include:
Observation on 7/23/2024 at 9:00am revealed R6 and R23 share a bedroom with two beds, two dressers, a
recliner, two walking assistive devices, two over the bed tables and had limited area to move around inside
the room.
Observations on 7/23/2024 at 9:05am revealed R28 and R11 share a bedroom with two beds, one large
recliner, two dressers, two walking assistive devices, to over the bed tables and had limited area to move
around inside the room.
During a tour with V7 (Maintenance Director) on 7/23/2024 at 9:00am, V7 was asked to measure R6, R23,
R28 and R11's bedroom sizes. V7 used a measuring tape to measure the length and with of R6 and R23's
bedroom and stated, 11 by 14 feet (which is the equivalent to 154 sq. ft. (square feet)/77 sq. ft. per resident
bed). At approximately 9:05am, V7 measured R28 and R11's bedroom with a tape measure and stated, 11
by 13.7 feet (which is the equivalent to 150.7 sq. ft./75.4 sq. ft. per resident bed).
On 7/24/2024 at approximately 10:15am, when asked V1 (Administrator) was asked if residents were
notified during admission that some of the rooms in the facility did not meet the requirement of having 80 sq
ft per resident, V1 stated no. V1 said rooms 19-31 did not meet the required 80 sq ft per resident bed and
rooms 19-31 are all certified for double occupancy.
The facility's Daily Census sheet with print date of 7/20/2024 documents R2, R6, R7, R10, R11, R15-R17,
R20, R21, R23, R28-R30, R32-R35, R38 and R43 currently reside in rooms 19-31.
Inquiries regarding the size of these rooms during the survey form 7/21/2024 to 7/24/2024 found no
concerns or negative interviews from residents or families of residents who reside in the waivered rooms.
On 7/23/2024 at 9:30am R6, R23, R32, R11 and R28 all voiced no concerns with the size of their rooms
during interviews.
Observations and measurements of these rooms during the survey, determined adequate space exists to
meet the medical and personal needs of the residents living in these waivered rooms.
Review of Resident Council Minutes form the past 6 months indicated no concerns related to the size of the
rooms included in the waiver.
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)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 15 of 16
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
07/24/2024
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)
F 0912
room [ROOM NUMBER]: 148.4 sq ft = (74.2 sq ft per resident bed)
Level of Harm - Potential for
minimal harm
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)
Residents Affected - Some
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)
room [ROOM NUMBER]: 150.87 sq ft = (75.44 sq ft per resident bed)
room [ROOM NUMBER]: 152.28 sq ft = (76.14 sq ft per resident bed)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145857
If continuation sheet
Page 16 of 16
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Back to topCitations
19 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F727 - Except when waived under paragraph (f) or (g) of this section, the
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.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F758 - Medication Errors
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.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0025GeneralS&S Fpotential for harm
Create arrangements with other facilities to receive patients.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0041GeneralS&S Fpotential for harm
Implement emergency and standby power systems.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
- 0927GeneralS&S Fpotential for harm
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
FAQ · About this visit
Common questions about this visit
What happened during the July 24, 2024 survey of THE HAVEN OF ST. ELMO?
This was a inspection survey of THE HAVEN OF ST. ELMO on July 24, 2024. The surveyor cited 19 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE HAVEN OF ST. ELMO on July 24, 2024?
Yes, 19 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.