The Haven of St. Elmo

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program to identify infectious disease symptoms as well as track, report, treat and isolate infected residents to prevent urinary tract infections for 4 (R1, R3, R6, R23) of 4 residents reviewed for infection control. This failure has the potential to affect all 33 residents in the facility. This failure resulted in R1 being admitted to the hospital on [DATE] for developing sepsis related to a urinary tract infection (UTI), R3 admitted to the hospital on [DATE] with developing a complicated urinary tract infection, and R23 being admitted to the hospital on [DATE] with an acute metabolic encephalopathy secondary to UTI complicated by bilateral ureter stents and history of UTI caused by a multidrug-resistant organism. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to complete skin and wound assessments for a resident at risk for skin breakdown, failed to notify the physician of a new wound, and failed to identify worsening of a wound for 1 (R1) of 1 residents reviewed for pressure ulcers in the sample of 25. This failure resulted in R1 developing a stage 2 pressure ulcer that worsened to the right buttock and developed a new stage 2 pressure ulcer to the left buttock. The Findings Include:R1's admission Record documents R1 was admitted to the facility on [DATE] with diagnoses including sepsis due to Escherichia Coli, urinary tract infection, bacteremia, type 2 diabetes mellitus, unspecified dislocation of right hip, depression, hypothyroidism, venous insufficiency, and obstructive sleep apnea. [...]

Inspectors wroteBased on interview, observation and record review the facility failed to follow standards of practice for antibiotic use for 2 (R7, R23) of 2 residents reviewed for antibiotic stewardship in the sample of 25. This has the potential to affect all 33 residents living in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple occupancy resident bedrooms for 4 (R9, R10, R19 and R24) of 4 residents reviewed for room size in a sample of 25. On 6/5/26 at 10:00 AM, V1 (Administrator) stated the dementia unit rooms 23, 24, 25, 26, 27, 28, 29, 30, 31 and main hall rooms (not on the dementia unit) 17, 18, 19, 20, 21, 22 were all waivered rooms and don't meet the proper room size requirements. On 6/5/26 at 10:15 AM, R19 and R24's double occupancy room was observed with V1, who stated the room was less than 80 square feet per resident bed. V1 used the measuring tape to measure the length and width of R19 and R24's room and stated it was 11 by 14 feet, indicating that the room was 177 square (sq.) feet (ft.), or 77 sq. ft. per bed. The measurements did not include the closet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer an antianxiety medication for 1 (R1) of 3 residents reviewed for medication errors in the sample of 9. The failure resulted in R1 developing withdrawal symptoms including nausea, vomiting, shaking, agitation, and being admitted to the local hospital for 2 days. This past noncompliance occurred between 4/22/26 and 4/29/26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely acquisition of a medication refill resulting in missed doses of a controlled substance for 1 (R1) of 3 residents reviewed for pharmacy services in the sample of 9. This past noncompliance occurred between 4/22/26 and 4/29/26.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from resident to resident sexual and physical abuse for 3 of 3 residents (R1, R2 and R3) reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of sexual abuse and physical abuse to the administrator immediately for 2 (R1 and R3) of 3 residents reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of physical abuse for 1 (R3) of 3 residents reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient staff to meet the needs of the residents timely. This failure has the potential to affect all 46 residents currently residing at the facility.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders for administration of treatments to wounds for 1 of 3 (R1) residents reviewed for pressure ulcers in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were administered in the time frame ordered for 3 of 3 (R1, R2, and R3) residents reviewed for medication administration in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to administer sliding scale insulin and monitor blood sugars as directed per physician's orders for 1 (R6) of 1 resident reviewed for insulin in a sample of 39. This failure resulted in R6 being sent to the emergency room for hyperglycemia.

Inspectors wroteBased on interview and record review the facility failed to ensure sufficient staff to provide timely care to the residents. This has the potential to affect all 42 residents who currently reside at the facility. Findings Include: The facility Resident Matrix dated 5/12/25 documents 42 resident currently reside at the facility. 1. R20's admission Record with a print date of 5/14/25 documents R20 was admitted to the facility on [DATE] with diagnoses that include hypertension, repeated falls, pain, and kidney stones. R20's MDS (Minimum Data Set) dated 2/20/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R20 is cognitively intact. This same MDS documents R20 requires supervision or touching assistance for toilet transfer and partial/moderate assistance for toilet hygiene. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the rights of 4 of 4 residents (R6, R20, R21, and R39) reviewed for dignity in the sample of 39. Findings Include: 1. R20's admission Record with a print date of 5/14/25 documents R20 was admitted to the facility on [DATE] with diagnoses that include hypertension, repeated falls, pain, and kidney stones. R20's MDS (Minimum Data Set) dated 2/20/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R20 is cognitively intact. This same MDS documents R20 requires supervision or touching assistance for toilet transfer and partial/moderate assistance for toilet hygiene. R20's current Care Plan documents a Focus area of Due to (R20)'s general weakness and unsteadiness, He is in need of staff assistance to meet his toileting needs. Date Initiated: 07/03/2023. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure toileting assistance was provided timely for 2 of 3 (R20 and R21) residents reviewed for activities of daily living in the sample of 39. Findings Include: 1. R20's admission Record with a print date of 5/14/25 documents R20 was admitted to the facility on [DATE] with diagnoses that include hypertension, repeated falls, pain, and kidney stones. R20's MDS (Minimum Data Set) dated 2/20/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R20 is cognitively intact. This same MDS documents R20 requires supervision or touching assistance for toilet transfer and partial/moderate assistance for toilet hygiene. R20's current Care Plan documents a Focus area of Due to (R20)'s general weakness and unsteadiness, He is in need of staff assistance to meet his toileting needs. Date Initiated: 07/03/2023. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a plan of care for a resident with dementia for one (R6) of one resident reviewed for dementia care in a sample of 39.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure enhanced barrier precautions were followed for 2 of 3 (R12 and R34) residents reviewed for pressure ulcers in the sample of 39. Findings Include: 1. R12's admission Record with a print date of 5/15/25 documents R12 was admitted to the facility on [DATE] with diagnoses that include a Stage 4 pressure ulcer of the sacrum. R12's MDS (Minimum Data Set) dated 2/17/25 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R12 is cognitively intact. R12's current Care Plan documents a Focus area of Enhanced barrier precautions r/t (related to) chronic wounds and indwelling catheter Date Initiated: 04/24/2024. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide at least 80 square feet per resident in two multiple occupancy resident bedrooms for 4 of 4 residents (R5, R20, R145, R146) reviewed for room size in a sample of 39.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure incontinence care was provided per current standards of practice for 2 of 3 (R2 and R3) residents reviewed for incontinence care in the sample of 7. Findings Include: 1. R2's admission Record with a print date of 3/7/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease and weakness. R2's MDS (Minimum Data Set) dated 2/15/24 documents R2 has a BIMS (Brief Interview for Mental Status) score of 06, which indicates a moderate cognitive impairment. This same MDS documents R2 is dependent on staff for toileting. R2's current Care Plan documents a Focus Area of Due to R2's general weakness, unsteadiness and impaired cognitive function, she is in need of staff assistance to complete her functional abilities. [...]