Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Haven Of St. Elmo during CMS and state inspections, most recent first.
A resident with anxiety and intact cognition missed multiple scheduled doses of ordered diazepam because the medication was not available while staff waited on a refill script. Nursing notes documented repeated missed administrations over several days, and the resident developed withdrawal symptoms including shaking, agitation, nausea, vomiting, weakness, and inability to eat. The resident was sent to the ER and hospitalized with diazepam withdrawal.
A resident with anxiety and other chronic conditions missed several doses of diazepam after the facility did not obtain a timely refill for the controlled substance. Staff and family reported repeated attempts to get the prescription signed, but the medication was not secured before the resident developed withdrawal symptoms and was sent to the ER. Interviews showed nursing staff did not verify the refill or contact alternate prescribers such as the medical director or on-call physician when the ordering physician was unavailable.
The facility failed to protect residents from resident-to-resident sexual and physical abuse and did not fully document all incidents. A male resident with dementia and a female resident with Alzheimer’s disease, both cognitively impaired, were found in a closed room with the female performing oral sex on the male, as observed and interrupted by a CNA and reported to an RN. In a separate event, a cognitively intact resident reported that the same male resident entered his room, slammed the door, and slapped him in the face, which was corroborated by a CNA and partially documented by an LPN. However, the cognitively intact resident’s record contained no documentation of the physical altercation, and the facility’s internal report characterized the sexual incident as not substantiated as willful abuse despite the observed conduct and the residents’ cognitive impairments.
The facility failed to immediately report allegations of sexual and physical abuse to the administrator as required by its abuse policy. In one incident, a resident was found in a female resident’s room with his penis in her mouth, and although staff separated them and documented the event, the administrator was not notified at the time and the note was later lined out as incomplete. In a separate event, the same resident entered another male resident’s room, slammed the door, and the second resident, who was alert, reported being slapped in the face and informed an LPN; the resident was removed from the room, but the DON and administrator were not informed of the alleged hitting until the following day via staff reports and email.
The facility failed to thoroughly investigate an allegation of physical abuse when one resident entered another resident’s room, slammed the door, and was reported to have slapped the other resident in the face. A CNA observed the events surrounding the altercation and reported the incident to an LPN, but the facility did not obtain a written statement from the CNA or document that required interviews were completed. Leadership relied on the LPN’s progress note as the only staff statement and could not provide in-service documentation for the involved LPN and CNA, contrary to the facility’s abuse investigation procedures.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as observed and documented by surveyors.
The facility did not provide pharmaceutical services to meet residents' needs and failed to employ or obtain the services of a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident with diabetes did not receive prescribed sliding scale insulin or consistent blood glucose monitoring due to an unacknowledged physician order in the EHR, resulting in hyperglycemia and hospitalization. Nursing staff believed the order was discontinued, and the MAR showed missed insulin administrations over several days.
The facility did not provide enough nursing staff to meet resident needs, as evidenced by two residents experiencing delays in toileting assistance and incontinent episodes due to slow call light response. Staff interviews confirmed that CNA coverage was often inadequate, with non-certified personnel sometimes monitoring residents on specialized units. Review of staffing schedules showed shifts with fewer CNAs than required by the facility's own assessment, and leadership acknowledged that staffing levels and records were insufficient and inaccurate.
Several residents with cognitive capacity and documented care needs experienced delays in toileting assistance due to inadequate staffing, leading to incontinence episodes. Additionally, after a single resident sustained a burn while smoking, all residents who smoked were required to wear safety aprons and have their smoking materials locked away, regardless of individual risk assessments. These actions were implemented without individualized reassessment, resulting in a failure to respect residents' rights to dignity and self-determination.
Two residents who required staff assistance for toileting experienced delays in receiving help, resulting in incontinent episodes while waiting for staff to respond to call lights. Both residents were cognitively intact and had care plans specifying the need for timely toileting support. Staff and the DON confirmed that insufficient staffing, particularly on nights and weekends, led to these delays.
A resident with a diagnosis of dementia and moderate cognitive impairment did not have a care plan addressing dementia or related care needs. The resident was repeatedly observed sitting unengaged in the dementia unit, and staff confirmed the absence of dementia-specific interventions in the care plan, despite facility policy requiring such planning.
Staff did not follow enhanced barrier precautions for two residents with pressure ulcers, as LPNs and CNAs provided wound care using gloves and hand hygiene but failed to wear gowns during high-contact care activities, despite clear care plan instructions, physician orders, and posted signage requiring both gown and glove use.
Two shared resident rooms were found to be below the required 80 sq. ft. per resident, with measurements confirming insufficient space. Although residents did not voice concerns and no complaints were documented, the deficiency was identified through observation and measurement during the survey.
The facility did not provide the required 8 hours of RN coverage per day, 7 days a week, affecting all 43 residents. The administrator admitted to the lack of coverage and absence of a policy. An LPN confirmed frequent RN absences on weekends, and the nursing schedule for several months showed multiple dates without the required RN coverage.
The facility failed to provide prescribed mechanical soft diets to four residents with severe cognitive impairments and specific dietary needs. Despite documented dietary orders, residents were served meals that did not meet the required texture, such as unground meatloaf and unchopped vegetables. This oversight occurred over several days, with the Director of Nursing acknowledging the failure to follow dietary guidelines.
The facility failed to provide timely assistance with meals for three residents with severe cognitive impairments and other medical conditions. Despite care plans indicating dependency on staff for eating, residents were left without immediate help, consuming minimal food. Staffing challenges were noted, with only two CNAs available to assist multiple residents during meals.
A resident with GERD and other medical conditions experienced frequent vomiting and regurgitation during meals, which was observed by staff but not documented or reported to the physician. Despite staff awareness, the issue was not communicated to the DON, highlighting a failure in following the facility's policy for notifying physicians of changes in condition.
A resident with multiple diagnoses was prescribed psychotropic medications without documented attempts at gradual dose reductions (GDR) or rationale for not doing so. Despite reminders from the pharmacist, the facility lacked documentation from the physician regarding GDRs, violating facility policy that requires such reductions unless clinically contraindicated.
A facility failed to maintain aseptic technique during catheter care for a resident with a neurogenic bladder. A CNA placed a water basin and washcloths on a toilet lid and used a dropped squeeze bottle without disinfecting it, contrary to infection control policies. The Infection Preventionist confirmed these actions did not meet facility expectations.
The facility did not post the required daily nurse staffing data, including the facility's name, date, census, and staff hours, in a prominent place accessible to residents and visitors. The Administrator was unaware of this requirement, and an LPN confirmed the absence of posted data. This oversight could impact all 43 residents.
The facility did not meet the required minimum square footage per resident in two multiple occupancy rooms, affecting four residents. Measurements showed that the rooms did not provide the necessary 80 square feet per resident. Despite this, no concerns were raised by residents or their families, and observations indicated adequate space for residents' needs.
Failure to Administer Ordered Diazepam
Penalty
Summary
The facility failed to administer diazepam 5 mg by mouth four times daily to a resident with diagnoses including anxiety disorder, insomnia, cerebral infarction, type 2 diabetes mellitus, and unsteadiness on feet. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the care plan identified anxiety with an intervention for anti-anxiety medication per physician orders. The physician order summary showed diazepam had been ordered for anxiety disorder and later discontinued on 4/28/2026. Progress notes and medication administration records documented that the resident’s diazepam was not available and was not administered beginning on 4/22/2026 at 9:43 PM and continuing through multiple scheduled doses on 4/23/2026, 4/24/2026, and 4/25/2026. Nursing notes repeatedly recorded that the medication was not available, that staff were waiting on an order or script, and that the resident remained without the medication for several days. Staff interviews indicated multiple requests had been sent to the physician’s office for the refill, but the medication was still not obtained during that period. The resident developed symptoms documented by staff and family including shaking, agitation, nausea, vomiting, weakness, diarrhea, and inability to eat. Family reported the resident had been without diazepam for 3 to 4 days and requested transfer to the emergency room. The resident was sent to the hospital on 4/26/2026 and the hospital discharge paperwork listed Valium (diazepam) withdrawal as the reason for admission. Staff interviews confirmed the resident had been out of diazepam and was hospitalized for withdrawal symptoms after the missed doses.
Delayed Controlled Substance Refill Led to Missed Diazepam Doses
Penalty
Summary
The facility failed to ensure timely acquisition of a refill for a controlled substance, resulting in missed doses of diazepam for one resident. The resident was admitted with diagnoses including type 2 diabetes mellitus without complications, unsteadiness on feet, cerebral infarction, insomnia, and anxiety disorder. The resident’s MDS documented intact cognition with a BIMS score of 15 and identified use of an antianxiety medication. The physician order summary showed diazepam 5 mg by mouth four times daily for anxiety disorder, with the order later discontinued on 4/28/2026. Multiple staff and family interviews described that the resident had been without diazepam for several days before being sent to the emergency room. The family member stated the resident had not been receiving the medication for 3 to 4 days and had asked repeatedly about the refill while being told the facility was waiting for a script to be signed by the physician. The resident stated the medication helped reduce agitation and that he noticed increased agitation when he was not receiving it. Nursing staff confirmed they knew the medication was unavailable and that refill requests had been sent to the physician’s office, but the signed prescription was not obtained in time. Staff interviews showed that the refill process was not completed through alternate prescribers when the physician was unavailable. The RN stated multiple requests were sent to the physician’s office and that she did not verify receipt or contact the medical director. The ADON stated the nursing staff should have followed up and could have contacted the on-call physician or medical director. The DON stated the resident was admitted to the hospital for withdrawal symptoms from not taking diazepam as ordered. The physician stated the facility should have contacted the medical director or on-call physician when the refill issue arose. The pharmacist stated the pharmacy had documentation of the prescription request, that the script had been sent unsigned, and that a verbal order from an appropriately credentialed physician or NP could have been accepted.
Failure to Protect Residents From Sexual and Physical Abuse and Incomplete Documentation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident sexual and physical abuse. One incident involved a male resident with dementia and a female resident with Alzheimer’s disease, both with documented cognitive impairment and care plan focus areas related to risk for abuse or impaired cognition. According to staff interviews and progress notes, a CNA observed the male resident in the female resident’s room with his pants down and the female resident’s mouth on his penis. The CNA immediately intervened, separated the residents, and reported the incident to the RN. The RN’s original progress notes documenting the sexual act and the female resident’s subsequent aggressive behavior were later lined out as incomplete and re-entered as late entries with the explicit description of the oral sexual act removed from the male resident’s note, though it remained in the female resident’s note. The same male resident was also involved in a separate physical altercation with another male resident who was cognitively intact and had a care plan focus area indicating risk for abuse due to a prior stroke. The cognitively intact resident reported that the male resident entered his room, slammed the door, and slapped him across the face when he asked for the door to be opened. A CNA corroborated that she saw the male resident enter the room, heard the cognitively intact resident yell, and, upon opening the door, found the two residents separated, with the cognitively intact resident stating he had been slapped and the male resident rubbing his hand and complaining about being told to leave the bathroom. The CNA reported the incident to an LPN, and the LPN documented in the male resident’s progress note that the male resident had entered another resident’s room, slammed the door, and that the other resident stated he had been struck in the face. Despite these events, there were documentation and reporting deficiencies. The facility’s final reportable event for the sexual incident concluded that the event was not substantiated as willful abuse, citing no observed force, coercion, threat, or distress and an established friendly relationship between the two cognitively impaired residents. Both residents later denied any knowledge or memory of the incident when interviewed. The cognitively intact resident’s electronic health record contained no documentation of the physical altercation in which he reported being slapped by the male resident, even though staff acknowledged the incident and it was described in the male resident’s progress note and in staff interviews. The facility’s abuse prevention policy affirms residents’ rights to be free from abuse and requires prevention of abuse and mistreatment, yet the incidents and incomplete or absent documentation demonstrate failures in protecting residents from sexual and physical abuse and in fully documenting and reporting these events.
Failure to Immediately Report Allegations of Sexual and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately report allegations of sexual and physical abuse to the administrator as required by its Abuse Prevention Policy. For one resident, an RN documented that the resident was found in a female resident’s room with his penis in her mouth; the residents were separated and the involved resident was taken to the dining room with staff, with no adverse effects noted. This progress note was later lined out as incomplete documentation. The Vice President of Operations reported receiving an email from the DON the following day describing that staff had entered the room and observed the female resident sitting on the bed with the male resident standing in front of her with his pants down and her lips on his penis. The report indicates that the administrator was not notified immediately at the time of the incident, contrary to the facility’s policy requiring immediate reporting of any incident, allegation, or suspicion of abuse to the administrator. The deficiency also includes a separate incident in which the same resident entered another male resident’s room, slammed the door, and the second resident reported being struck in the face. A progress note by an LPN documented that staff observed the first resident standing in the room yelling, and the second resident stated he had been hit; the first resident was redirected to the dining room. The second resident, who was alert to person, place, and time, confirmed in interview that the first resident came into his room, slammed the door, and slapped him across the face, and that he reported this to the LPN, after which the first resident was removed from the room. Another LPN stated she learned of the physical altercation the following morning from an RN, and the DON stated she had only been told that the first resident went into the second resident’s room and slammed the door, not that he had hit the other resident. The Vice President of Operations stated she was notified by email the day after the altercation that an alleged physical altercation had occurred the previous evening, indicating that the allegation of physical abuse was not reported to the administrator immediately as required by policy.
Failure to Thoroughly Investigate Resident-on-Resident Physical Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of physical abuse between residents as required by its Abuse Prevention Policy. On 4/13/2026, an LPN documented that one resident (R1) had been walking around the facility, entered another male resident’s (R3’s) room, and slammed the door. Staff were alerted and observed R1 standing in R3’s room yelling, and R3 stated that R1 had struck him in the face. A CNA (V19) redirected R1 out of the room and offered him a snack and drink. R3, who was alert to person, place, and time, later stated that R1 came into his room, slammed the door, and slapped him across the face when he asked R1 to open the door. R3 reported that staff then removed R1 from his room. During interviews, the CNA reported she had seen R1 enter R3’s room, heard R3 yell after the door was slammed, and upon entering the room found the residents separated, with R3 stating that R1 had slapped him and R1 rubbing his hand. The CNA stated she notified the LPN of the incident and that R3 repeated the same account to her. The DON acknowledged that the LPN and CNA did not attend prior in-services and that she did not follow up with them, and also stated she had not been asked to gather statements from these staff regarding the altercation. The Vice President of Operations stated she believed all documents related to the altercation had been sent to the surveyor, used the LPN’s progress note as the LPN’s statement, and was unaware that the CNA had been present during the incident. The facility was unable to provide any written statement from the CNA about the physical altercation or in-service documentation with signatures from the LPN or CNA, despite the facility’s Abuse Prevention Policy requiring that the investigator attempt to interview and obtain information from anyone likely to have direct knowledge of the incident.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on every shift, as observed and documented by surveyors.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Administer Sliding Scale Insulin and Monitor Blood Glucose
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and multiple comorbidities did not receive sliding scale insulin and appropriate blood glucose monitoring as ordered by the physician. The resident's Medication Administration Records (MAR) for several days showed no documentation of sliding scale insulin administration at scheduled times, despite an active physician order. The resident was also not consistently monitored for blood glucose levels during this period. Progress notes indicated that the sliding scale insulin order was not acknowledged in the electronic health record, leading nursing staff to believe it was discontinued, and as a result, the resident did not receive the prescribed insulin. This failure to administer insulin and monitor blood sugars resulted in the resident experiencing hyperglycemia, with blood sugar levels documented as high as 541, and ultimately being sent to the emergency room for evaluation and treatment. Interviews with nursing staff and the physician confirmed that the sliding scale insulin order was not confirmed in the system and was therefore not administered. The administrator acknowledged that orders should be reviewed and reentered correctly to ensure continuity of care, and that the resident should have received the sliding scale insulin as directed.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple reports from residents and staff, as well as a review of staffing schedules. Two cognitively intact residents with significant care needs, including assistance with toileting due to weakness, unsteadiness, and a history of falls, reported frequent delays in staff response to call lights, resulting in incontinent episodes while waiting for assistance. Both residents' care plans required staff support for toileting, with one requiring assistance every two hours or sooner upon request. Staff interviews corroborated these concerns, with CNAs and other personnel stating that there were not always enough staff to meet residents' needs in a timely manner. It was reported that call lights were not answered promptly and that non-certified staff, such as housekeepers, were sometimes assigned to monitor residents on the Alzheimer's unit due to staffing shortages. These non-certified staff members indicated they were not trained to provide care or handle resident behaviors and only performed basic monitoring while completing their regular duties. A review of staffing schedules and facility assessment tools revealed discrepancies between scheduled and actual staffing levels, with documented instances of only one or two CNAs present during certain shifts, despite the facility's own assessment indicating a need for more staff. The Director of Nursing and the Administrator both acknowledged that the number of CNAs on duty was insufficient to provide timely care, particularly on nights and weekends, and that staffing records were not always accurate.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
The facility failed to honor the rights of four residents to a dignified existence and self-determination, specifically regarding timely toileting assistance and the imposition of smoking restrictions. Two cognitively intact residents, both with documented needs for staff assistance with toileting, reported frequent delays in call light response, sometimes waiting up to thirty minutes for help. These delays resulted in incontinent episodes, as confirmed by both residents and staff, who acknowledged insufficient staffing, particularly on nights and weekends. Facility policy requires prompt response to call lights, but this was not consistently followed. Additionally, the facility implemented a blanket policy requiring all residents who smoke to wear plastic safety aprons and to smoke only under supervision, following an incident where one resident burned himself. Multiple residents, including those assessed as safe to smoke independently and with no history of burns, were required to wear the aprons and had their smoking paraphernalia locked away. These residents expressed discomfort and dissatisfaction with the new restrictions, stating they had not been reassessed individually after the incident and did not understand the need for the change. Staff interviews confirmed that the decision to require aprons and restrict smoking was made by facility administration after the burn incident, without individualized reassessment for each resident. Documentation showed that some residents' care plans and smoking safety screens did not indicate a need for adaptive equipment or supervision, yet the restrictions were applied universally. This resulted in a failure to respect residents' autonomy and dignity, as required by their rights.
Failure to Provide Timely Toileting Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to provide timely toileting assistance for two residents who required staff support for activities of daily living. One resident, with diagnoses including hypertension, repeated falls, pain, and kidney stones, was assessed as cognitively intact and required supervision or assistance for toilet transfer and hygiene. The resident's care plan specified the need for staff assistance due to general weakness and a history of falls. The resident reported that staff response to call lights could take up to half an hour, particularly on weekends, resulting in episodes of incontinence while waiting for help. Another resident, also cognitively intact and diagnosed with muscle wasting, lack of coordination, acute kidney failure, and chronic pain syndrome, required substantial assistance for toileting. The care plan directed staff to assist the resident to the restroom every two hours or sooner upon request. This resident reported frequent delays in staff response to call lights, leading to repeated incontinent episodes. Multiple staff members, including CNAs and the Director of Nursing, confirmed that staffing shortages, especially on nights and weekends, contributed to delays in answering call lights and providing timely toileting assistance.
Failure to Develop Dementia Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing the dementia diagnosis and related care needs for a resident with a documented history of dementia. The resident's admission record included multiple diagnoses, such as type 2 diabetes mellitus, dysphagia, major depressive disorder, dementia, and anxiety disorder. The Minimum Data Set (MDS) assessment indicated moderate cognitive impairment with a BIMS score of 12. Despite these findings, the resident's current care plan did not address dementia or any associated care needs. Observations over several days showed the resident sitting in the dementia unit dining room without any engagement or activities, and staff interviews confirmed fluctuations in the resident's cognitive status. The Care Plan Coordinator acknowledged that the care plan lacked any interventions or goals related to dementia care, and the facility's own policy required comprehensive evaluation and care planning for individuals with dementia. The deficiency was identified through record review, staff interviews, and direct observation.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions were followed for two residents with pressure ulcers. For one resident with a Stage 4 sacral pressure ulcer and an indwelling catheter, both the LPN and CNA provided wound care treatment using gloves and performed hand hygiene according to current standards, but did not wear gowns as required by the resident's care plan, physician orders, and facility policy. The care plan and signage outside the resident's room specifically instructed staff to don gowns and gloves during high-contact care activities, including wound care for chronic skin openings. Similarly, another resident with a Stage 3 pressure ulcer, a blister, and a laceration, was observed receiving wound care from an LPN and CNA who also failed to wear gowns during the procedure, despite the resident's care plan and physician orders indicating the need for enhanced barrier precautions. Both residents had clear documentation and signage indicating the requirement for gown and glove use during high-contact care, but staff did not adhere to these protocols during observed treatments.
Failure to Provide Required Square Footage in Shared Resident Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet per resident in two multiple occupancy bedrooms, affecting four residents. Observations revealed that the rooms in question were shared by two residents each and contained beds, dressers, recliners, walking assistive devices, and over-bed tables, resulting in limited space for movement. Measurements taken by the Maintenance Director confirmed that the rooms were 154 sq. ft. (77 sq. ft. per resident) and 150.7 sq. ft. (75.4 sq. ft. per resident), both below the required 80 sq. ft. per resident for multiple occupancy rooms. Interviews with the affected residents indicated that none expressed concerns about the room size. The Administrator acknowledged that rooms 19-31 did not meet the 80 sq. ft. per resident requirement and that residents were not notified of this at admission. The facility's records confirmed the occupancy of these rooms, and no concerns were documented in Resident Council Minutes or during the survey interviews with residents or families. Despite the lack of complaints, the deficiency was identified based on direct measurement and regulatory requirements.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day, 7 days a week, as required. This deficiency was confirmed through interviews and record reviews. The facility's administrator acknowledged the lack of RN coverage and admitted there was no policy in place to ensure the required coverage. A Licensed Practical Nurse (LPN) reported that during the weekend of July 20-21, 2024, there was no RN on duty, and this was a frequent occurrence on weekends. The nursing schedule for May, June, and July 2024 showed multiple dates where the facility did not meet the required RN coverage, affecting all 43 residents residing in the facility.
Failure to Provide Prescribed Mechanical Soft Diets
Penalty
Summary
The facility failed to provide food with the prescribed mechanical soft texture for four residents, each with specific dietary needs due to their medical conditions. These residents, identified as having severe cognitive impairments and various diagnoses such as dementia, dysphagia, and Alzheimer's disease, were served meals that did not meet their dietary requirements. For instance, one resident with no teeth and at risk for dental complications was served unground meatloaf and unchopped broccoli, which they did not consume. Another resident, who had poor dental health and was at risk for dental complications, was also served meals that did not adhere to the mechanical soft texture requirement. This included unground meatloaf and large pieces of vegetables, which were not suitable for their dietary needs. Similarly, a third resident with neurocognitive disorder and muscle wasting was served meals that did not meet the prescribed texture, including unground meatloaf and unchopped vegetables. The facility's failure to adhere to the dietary orders was observed over several days, with meals consistently not prepared according to the mechanical soft texture guidelines. Despite having documented dietary orders and care plans specifying the need for mechanically altered diets, the facility did not follow these instructions, leading to residents being served inappropriate meals. The Director of Nursing acknowledged that the food should have been prepared according to the recipes and guidelines, which were not followed in these instances.
Failure to Provide Timely Assistance with Meals
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living, specifically eating, for three residents with severe cognitive impairments and other medical conditions. Resident 30, diagnosed with dementia, Alzheimer's disease, and other conditions, was observed on two occasions receiving her meal without assistance, resulting in her consuming less than 5% of her food. Despite her care plan indicating she is dependent on staff for eating, staff members delayed in providing the necessary assistance, and at one point, another resident attempted to help her. Similarly, Resident 33, with diagnoses including neurocognitive disorder and Parkinson's disease, was also left without immediate assistance during meal times, despite being documented as dependent for eating. Resident 21, with Alzheimer's disease and other health issues, experienced delays in receiving help with meals as well. The Director of Nursing acknowledged that residents should not wait 20 minutes or more for assistance and noted staffing challenges, with only two CNAs available to assist multiple residents needing help during meals.
Failure to Monitor and Report GERD Symptoms
Penalty
Summary
The facility failed to monitor and report episodes of vomiting and food regurgitation for a resident diagnosed with multiple conditions, including Alzheimer's disease, dementia, and Gastro-Esophageal Reflux Disease (GERD). The resident's care plan included monitoring and documenting signs and symptoms of GERD, but these episodes were not recorded in the electronic medical record, nor was the physician notified. Observations over several days showed the resident regurgitating food during meals, and staff members, including CNAs and an LPN, were aware of the issue but did not ensure it was documented or communicated to the physician. Interviews with staff revealed that the vomiting had been occurring for some time, with increased frequency in recent weeks. Despite this, the Director of Nursing was unaware of the situation, indicating a breakdown in communication within the facility. The Speech Language Pathologist had previously evaluated the resident and suggested that the issue might be related to GERD medication, recommending a barium study, but no referral was made. The facility's policy requires notifying the physician of changes in condition, which was not followed in this case.
Failure to Document Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R24, was free from unnecessary psychotropic medications. R24 was admitted with diagnoses including major depressive disorder, schizophrenia, insomnia, and nutritional anemia. The resident's medication regimen included Doxepin, Quetiapine, and Alprazolam, all of which required gradual dose reductions (GDR) as per facility policy. However, there was no documentation of attempted GDRs or any rationale or contraindication for not attempting GDRs for these medications in R24's medical record. The Director of Nursing (V2) acknowledged the lack of documentation from the Mental Health Family Nurse Practitioner (V13) regarding GDRs for the medications. The Pharmacist (V21) confirmed sending multiple reminders to the facility about the need for GDRs, but noted a gap in documentation from the physician. The facility's policy mandates that residents on psychotropic drugs should receive GDRs and behavioral interventions unless clinically contraindicated, with attempts encouraged at least twice yearly. Despite these requirements, the facility did not maintain the necessary documentation to support compliance with GDR protocols for R24.
Failure to Maintain Aseptic Technique During Catheter Care
Penalty
Summary
The facility failed to maintain aseptic technique during catheter care for a resident with a neurogenic bladder requiring an indwelling Foley catheter. The resident, who is cognitively intact, was admitted with multiple diagnoses including type 2 diabetes mellitus, urinary tract infection, chronic kidney disease, and flaccid neuropathic bladder. The facility's policy required catheter care per facility guidelines every 24 hours. However, during an observation, a CNA was seen placing a water basin and washcloths on a toilet lid in a hallway bathroom before using them for catheter care, which is against infection control practices. Additionally, the CNA dropped a squeeze bottle containing soap and water on the hallway floor and then placed it on the resident's bedside table without disinfecting the area or replacing the bottle. The Infection Preventionist Nurse confirmed that the facility's expectations were not met, as staff should not place supplies on potentially contaminated surfaces and should replace any items that become contaminated. The CNA involved had received training on catheter and perineal care upon hiring but did not adhere to the facility's infection control policies during the observed incident. The facility's policies on infection prevention and urinary catheter care emphasize the importance of aseptic techniques and routine hygiene to prevent infections, which were not followed in this case.
Failure to Post Daily Nurse Staffing Data
Penalty
Summary
The facility failed to prominently post the daily nurse staffing data, which includes essential information such as the facility's name, date, census, and the total number and actual hours worked per shift for both licensed and unlicensed staff responsible for resident care. This deficiency was observed on multiple occasions, including specific times on 7/21/2024, 7/22/2024, and 7/23/2024, where the Daily Nurse Staffing data sheet was not posted in a location readily accessible to residents and visitors. During an interview, the Administrator admitted to being unaware of the requirement to post this data, and a Licensed Practical Nurse confirmed that she had never seen the staffing data posted while working at the facility. This oversight has the potential to affect all 43 residents residing in the facility.
Facility Fails to Meet Room Size Requirements for Multiple Occupancy Rooms
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in two multiple occupancy rooms, affecting four residents. Observations and measurements conducted on 7/23/2024 revealed that the rooms shared by the residents did not meet the regulatory requirement of 80 square feet per resident. Specifically, the room shared by two residents measured 154 square feet, equating to 77 square feet per resident, while another room measured 150.7 square feet, equating to 75.4 square feet per resident. These measurements were confirmed by the Maintenance Director using a tape measure. During the survey, the facility's Administrator acknowledged that rooms 19-31 did not meet the required space per resident and were certified for double occupancy. Despite this, there were no concerns or negative feedback from the residents or their families regarding the room sizes, as documented in interviews and Resident Council Minutes from the past six months. The facility's Daily Census sheet confirmed that several residents resided in these non-compliant rooms. Observations during the survey indicated that adequate space existed to meet the medical and personal needs of the residents in these rooms.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 40 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near St Elmo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Care Center | 5.3 mi | ★★★★★ | 7 | 1 |
| Fayette County Hospital | 14.1 mi | ★★★★★ | 6 | 0 |
| Vandalia Healthcare & Senior Living | 15 mi | ★★★★★ | 7 | 0 |
| Effingham Healthcare & Senior Living | 16.6 mi | ★★★★★ | 6 | 0 |
| Lakeland Rehab & Healthcare Center | 17.2 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.