The Haven of St. Elmo: Medication Delays From Understaffing - IL
That's what a registered nurse told inspectors on August 21, 2025. She worked those shifts. She knew the math.
The facility's own records confirmed it. A medication administration audit covering August 1 through August 21 documented that one resident, identified in the inspection report as R3, had received seven different medications late across multiple dates. Keppra, an anti-seizure drug, was late on August 3 and August 15. Hydroxyzine was late four times: August 3, 15, 16, and 18. Aricept, used to treat dementia symptoms, was late on August 3 and August 15. Trazodone, prescribed for depression, was late on the same two dates. So were divalproex, another anti-seizure medication, and Mucinex. Levothyroxine, a thyroid medication, was late on August 16 and August 18.
Seventeen documented late administrations. Three weeks. One resident.
The registered nurse told inspectors she works nights and runs four medication passes per shift, two full and two partial. She said there are three certified nursing assistants working alongside her and one nurse. That one nurse is her.
A licensed practical nurse who also worked nights told inspectors the same thing in a separate interview. She said she was late with medications at times because there was only one nurse for 46 residents and she couldn't get everything done within the required window.
The facility schedule, reviewed by inspectors for the full month of August, showed one nurse assigned to the overnight shift from 7 p.m. to 7 a.m. every night.
The Director of Nurses knew about the one-nurse night shift. What she didn't know, she told inspectors, was that medications weren't going out on time. She said she hadn't been aware of the late administration problem until the inspector asked her to pull the audit report. She said she thought staffing was adequate. She said they needed to work on communication.
The audit report she apparently hadn't reviewed was her facility's own document.
The Haven of St. Elmo's staffing policy, which inspectors also reviewed, states that the facility will provide an adequate number of staff to successfully implement resident functions and meet resident needs. The policy has no date on it.
What that policy looked like in practice, through at least three weeks in August, was a single nurse moving through a building of 46 residents, trying to complete four medication passes before her shift ended, and not making it. The medications that slipped past their administration windows included drugs for seizures, for dementia, for depression, for thyroid function. These are not medications with wide tolerances for timing. Keppra, in particular, is prescribed on a schedule because consistent blood levels matter for seizure control.
The inspection report classifies the harm level as minimal or potential, and notes that many residents were affected. Three of the 46 residents were hospitalized at the time of the inspection.
The registered nurse who spoke to inspectors was direct about why this was happening. They don't have enough staff to meet the needs of the residents timely. That was her explanation, offered at 8:16 in the morning, presumably at the end of one of those shifts.
The Director of Nurses said they need to work on communication.
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.
That's what a registered nurse told inspectors on August 21, 2025.
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.