The Haven of St. Elmo: Medication Delays on Night Shift - IL
The facility's own medication audit, covering August 1 through August 21, documented the problem in writing. One resident, identified in inspection records as R3, received seven different drugs late across that stretch: Keppra, hydroxyzine, Aricept, trazodone, divalproex, Mucinex, and levothyroxine. The delays were recorded on at least 13 separate occasions over three weeks.
The nurse who raised the staffing concern, a registered nurse on night shift, told the inspector on August 21 that she covers 46 residents with three certified nursing assistants and one nurse. She said she manages four medication passes during a single night shift. An LPN who also worked nights confirmed she had fallen behind on medications when the floor ran with only one nurse, saying she wasn't able to finish within the required window.
The Director of Nurses told the inspector that day she believed staffing was adequate. She said she hadn't known medications were going out late until the inspector asked her to pull the audit report.
"I thought we had enough staff," she said, "but need to work on communication and some other things."
The medications R3 was receiving were not incidental. Keppra is used to control seizures. Aricept treats dementia. Levothyroxine regulates thyroid function. Trazodone and hydroxyzine affect sleep and anxiety. Divalproex is prescribed for seizures and mood disorders. Each has a prescribed administration time for a reason.
The Director of Nurses had access to the same audit report the inspector requested. It had been sitting there, unreviewed, while the delays continued.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
THE HAVEN OF ST. ELMO in ST ELMO, IL was cited for violations during a health inspection on August 25, 2025.
The facility's own medication audit, covering August 1 through August 21, documented the problem in writing.
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.