Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Elk Haven Nursing Home during CMS and state inspections, most recent first.
An opened vial of Aplisol was found in the B Wing med room past the discard timeframe listed in the manufacturer’s guidelines. An RN confirmed the open date and acknowledged that the vial should have been discarded. The facility policy also stated that outdated drugs and biologicals must not be used.
Outdated supplements and thickened water were found in the B Wing pantry refrigerator. Facility policy required opened supplements to be refrigerated and discarded after 4 days, but an opened Med Pass and two containers of thickened water were kept past their discard dates. An LPN confirmed the items were outdated and should have been discarded.
Unmarked resident clothing was left on racks in the laundry department, and staff did not take the items to resident units to help identify the owners. The Laundry Aide said residents or family could search for missing items in laundry, but there was no process for residents who could not report missing clothing, and the NHA confirmed staff did not have a process to return unmarked personal clothing to the correct resident.
A resident with anxiety and other medical conditions received PRN Lorazepam on multiple occasions without documented attempts of non-pharmacological interventions beforehand, contrary to facility policy. The DON confirmed the absence of such documentation in the clinical record.
The facility did not update care plans for two residents to reflect changes in their care, including the initiation of oxygen therapy for one resident and the discontinuation of anticoagulant medication for another. The DON confirmed that care plans were not reviewed or revised as required.
A facility failed to ensure resident privacy during a wound dressing change. Despite the facility's policy requiring privacy during treatment procedures, two LPNs changed a resident's wound dressing while the roommate was awake and observing. Both an LPN and the DON confirmed that the privacy curtain should have been used.
A facility failed to develop a comprehensive care plan for a resident with multiple diagnoses, including lower back pain, despite having several physician's orders for pain management. The absence of a documented care plan for pain was confirmed by the DON, violating the facility's policy requiring such plans within 21 days of admission.
A facility failed to maintain proper respiratory care for a resident with COPD, high blood pressure, and diabetes. The facility's policy required changing oxygen cannulas or masks every 30 days, and physician orders specified changing the tubing on the 15th of each month. However, observations revealed that the tubing had not been changed since 3/15, as confirmed by an LPN.
A resident with a history of stroke and dementia, requiring two-person assistance for transfers, was neglected when a nursing assistant transferred them alone, contrary to their care plan. This resulted in the resident suffering spiral fractures of the right tibia and fibula, leading to hospitalization.
Outdated Aplisol Left in Medication Room
Penalty
Summary
The facility failed to appropriately discard an outdated medication in the B Wing medication room. Review of the facility policy on storage of medications stated that discontinued, outdated, or deteriorated drugs and biologicals shall not be used and must be returned to the dispensing pharmacy or destroyed. Manufacturer guidelines for Aplisol stated that an opened vial should be discarded within 30 days after opening. During observation of the B Wing medication room, an opened vial of Aplisol was found with an open date of 4/10/26. During the observation, an RN confirmed that the vial had been opened on that date and acknowledged that it should have been discarded.
Outdated supplements and thickened water found in pantry refrigerator
Penalty
Summary
Food was not stored in accordance with food safety standards in one of three resident pantries reviewed, the B Wing pantry. A facility policy dated 1/27/26 stated that unit refrigerators are to be stocked with supplements and snacks, that bulk milk, juices, drinks, and supplements are to be dated when opened and discarded after four days, and that non-perishable items are to be discarded according to the use-by date if properly sealed, stored at the correct temperatures, and without signs of deterioration. Another policy dated 1/27/26 stated that nutritional supplements must be kept refrigerated at 34-40 degrees Fahrenheit once opened and are good for four days from the time opened. During an observation on 5/26/26 at 2:20 p.m., the B Wing pantry refrigerator contained an opened Med Pass supplement dated opened 5/20/26, one cardboard container of thickened water dated opened 5/24/26 with a use-by date of 5/21/26, and one cardboard container of thickened water dated opened 5/25/26 with a use-by date of 5/21/26. An LPN confirmed at the time that the opened Med Pass was outdated and should have been discarded on 5/24/26, and that the outdated containers of thickened water should have been discarded on 5/21/26.
Unmarked Resident Clothing Left in Laundry Without a Process to Identify Owners
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by not ensuring resident personal belongings were properly identified and protected from loss. A facility policy titled Resident Property-Missing/Damaged, dated 1/27/26, stated that the facility was responsible for ensuring the safety and security of all resident personal belongings. During observation of the laundry department on 5/28/26 at 9:48 a.m., surveyors found one full rack and one partial rack of unmarked resident personal clothing. During interview, the Laundry Aide confirmed that unmarked laundry was not taken to the units so staff, residents, or family could identify the owner of the clothing. The aide stated that staff and family could come back to laundry to look through items reported missing, that there was no process for returning unmarked clothing to residents who could not report missing items, and that after unmarked items remained on the racks for a while, staff would identify residents in need of similar-sized clothing and mark the items for them without first identifying the original owner. The Nursing Home Administrator confirmed that residents and/or family could look for missing items in the unmarked clothing, that there was no process for residents or families who could not report missing clothing, and that staff did not take unmarked clothing to resident units to try to identify the owner.
Failure to Attempt Non-Pharmacological Interventions Before PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted prior to administering a PRN psychotropic medication to a resident. According to the facility's Psychotropic Medication Policy, non-pharmacological interventions and gradual dose reductions should be implemented unless contraindicated before starting or continuing psychotropic medications. However, review of the clinical record for a resident with diagnoses including osteomyelitis, anxiety, and anemia showed that Lorazepam was administered on four occasions in May 2025 without documentation of any non-pharmacological interventions being attempted beforehand. The Medication Administration Record confirmed the use of PRN Lorazepam on specific dates, and the clinical record lacked evidence of alternative interventions prior to each administration. During an interview, the Director of Nursing acknowledged that the clinical record did not contain documentation of non-pharmacological interventions before giving the PRN psychotropic medication, as required by facility policy.
Failure to Update Care Plans to Reflect Current Resident Care and Services
Penalty
Summary
The facility failed to review and revise comprehensive care plans to accurately reflect the current care and services for two residents. For one resident with diagnoses including diabetes, gastroesophageal reflux disease, and hypothyroidism, the clinical record showed a physician's order for oxygen therapy at 2 LPM via nasal cannula, both routinely and as needed. However, the resident's care plan for cardio and respiratory issues did not include any intervention for the current use of oxygen, indicating that the care plan was not updated to reflect this change in treatment. Another resident, diagnosed with Parkinson's disease, major depressive disorder, and moderate intellectual disabilities, had their anticoagulant medication Eliquis discontinued. Despite this change, the resident's care plan continued to include interventions related to the use of Eliquis, and was not revised to reflect the discontinuation of the medication. The Director of Nursing confirmed during interviews that both care plans were not reviewed or revised to reflect the residents' current care and services, as required by facility policy.
Failure to Ensure Resident Privacy During Wound Dressing Change
Penalty
Summary
The facility failed to ensure resident privacy during a wound dressing change for one of the residents reviewed. The facility's policy on Privacy/Dignity, dated January 10, 2024, mandates that staff must promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures. However, during an observation on June 5, 2024, at 10:45 a.m., it was noted that two LPNs conducted a wound dressing change on a resident's right heel and foot while the resident's roommate was awake and watching the procedure. This was confirmed during interviews with one of the LPNs and the Director of Nursing, both acknowledging that the privacy curtain should have been pulled to ensure the resident's privacy.
Failure to Develop Comprehensive Pain Management Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as R58, who was admitted with multiple diagnoses including pleural effusion, arthritis, lower back pain, and restless leg syndrome. Despite having several physician's orders for pain management with acetaminophen, the resident's clinical record lacked evidence of a comprehensive care plan addressing pain management. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of such a care plan in the resident's records. The facility's policy, dated January 10, 2024, mandates the establishment of a comprehensive person-centered care plan within 21 days of admission, which should include necessary and appropriate care, services, and accommodation of resident needs and preferences. However, for Resident R58, this requirement was not met, as evidenced by the lack of a documented care plan for managing the resident's pain, despite multiple physician's orders for pain medication over several months.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment for a resident, identified as R29, who was reviewed for respiratory care. The facility's policy, dated 1/10/24, required oxygen cannulas or masks to be changed every 30 days. Resident R29, admitted with chronic obstructive pulmonary disease, high blood pressure, and diabetes, had physician orders dated 4/5/21 to change oxygen tubing on the 15th of each month. However, observations on 6/2/24 and 6/4/24 revealed that the oxygen tubing had a piece of white tape with the date 3/15/24, indicating it had not been changed as ordered. This was confirmed by an LPN during an interview on 6/4/24.
Neglect in Resident Transfer Leads to Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, resulting in actual harm. The resident, who had a history of stroke, heart disease, falls, and dementia, required total two-person assistance with transfers as per their care plan. However, on the day of the incident, the resident was transferred with the assistance of only one person, contrary to the care plan requirements. The resident began experiencing right ankle pain, which was initially assessed with no visible marks or redness. Despite being administered pain medication, the resident's condition worsened throughout the day, with increased swelling, redness, and tenderness in the right leg. Eventually, the resident was sent to the hospital, where they were diagnosed with spiral fractures of the right tibia and fibula. The facility's investigation revealed that a nursing assistant had transferred the resident alone, not adhering to the care plan that required two-person assistance. This failure to follow the care plan resulted in the resident's injury, and the nursing assistant's employment was subsequently terminated.
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 42 citations issued within 25 miles in the last 12 months — 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 Saint Marys
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pinecrest Manor | 0.2 mi | ★★★★★ | 3 | 0 |
| Highland View Rehabilitation & Healthcare Center | 17 mi | ★★★★★ | 7 | 0 |
| Guy And Mary Felt Manor, Inc | 18.7 mi | ★★★★★ | 0 | 0 |
| Lutheran Home At Kane, The | 19.6 mi | ★★★★★ | 6 | 0 |
| Christ The King Manor | 23.5 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Elk Haven Nursing Home.
100% money-back within 48 hours.
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.