The Haven of St. Elmo: Medication Delays From Understaffing - IL
That gap, between what the staff on the floor experienced every night and what leadership understood to be happening, is documented in an August 2025 inspection report following a complaint investigation at the 46-bed facility in rural Illinois.
A registered nurse identified in the report as V7 told the inspector on August 21 that bedtime medications, scheduled for 8 and 9 p.m., routinely weren't administered until 10 or 11 p.m. She said the reason was simple: not enough staff. On nights, she said, there was one nurse and three certified nursing assistants covering all 46 residents. She had four medication passes to complete, two full and two partial, in a single shift.
"They don't have enough staff to meet the needs of the residents timely," V7 told the inspector.
A licensed practical nurse identified as V8 confirmed the same pattern. She said she worked nights and was late with medications at times because there was only one nurse for the entire building. She wasn't able to get everything done within the required window.
The facility's own records backed them up.
An internal medication administration audit covering August 1 through August 21, 2025, documented repeated late administrations for a single resident, identified in the report as R3. Keppra, an anticonvulsant used to control seizures, was given late on August 3 and again on August 15. Hydroxyzine was late on August 3, August 15, August 16, and August 18. Aricept, used to treat dementia, was late on August 3 and August 15. Trazodone, prescribed for depression, was late on August 3 and August 15. Divalproex, another seizure medication, was late on August 3 and August 15. Mucinex was late on August 3 and August 15. Levothyroxine, a thyroid medication that requires consistent timing to work properly, was late on August 16 and August 18.
Seven different medications. Across three weeks. For one resident.
The director of nursing, identified as V2, told the inspector that the facility had one nurse on night shift and two on day shift. When the inspector asked about the late medications, V2 said she hadn't known they were being administered outside the ordered time frames until the surveyor asked for the audit report.
"She thought they had enough staff," the inspection report states, "but need to work on communication and some other things."
The medications being delayed were not incidental. Keppra and divalproex are both prescribed to control seizures, and their effectiveness depends on maintaining consistent levels in the bloodstream. Aricept is used to slow cognitive decline in dementia patients. Trazodone manages depression. Levothyroxine regulates thyroid function and is typically prescribed to be taken at the same time each day to maintain stable hormone levels. Hydroxyzine, which can be used for anxiety or as a sleep aid, was late four times in an 18-day stretch.
All of R3's medications carried a start date of April 11, 2025, meaning the prescriptions had been active for months before the August inspection captured what was happening to them.
The facility's own medication administration policy, dated October 2014, states that medications are to be administered as prescribed in accordance with good nursing principles and practices, with attention to the five rights: right resident, right drug, right dose, right route, and right time.
The nurses on night shift were getting the right resident, the right drug, the right dose, and the right route. They were running out of time.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, affecting a few residents. The citation falls under the federal tag governing pharmaceutical services and medication administration.
What the report leaves unresolved is how long the pattern ran before anyone in a supervisory role looked at the numbers. The audit covered three weeks. The medications had been ordered since April. The nurses knew. The director, by her own account, did not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Haven of St. Elmo from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 2, 2026 · Our methodology
THE HAVEN OF ST. ELMO in ST ELMO, IL was cited for violations during a health inspection on August 25, 2025.
She said the reason was simple: not enough staff.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.