The Haven Of St. Elmo
THE HAVEN OF ST. ELMO in ST ELMO, IL — inspection on August 25, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
assessed R1's wounds on 8/11/25 and there was no signs/symptoms of infection. V6 stated with
145857 08/25/2025
The Haven of St.
Elmo 221 East Cumberland St Elmo, IL 62458
cough/congestion .Start Date: 04/11/2025 .Levothyroxine Sodium Oral Tablet 125 mcg (micrograms)
administered late to R3. 1.
Keppra on 8/3 and 8/15, 2. hydroxyzine on 8/3, 8/15, 8/16, and 8/18, 3.
8/3 and 8/15, 7. levothyroxine on 8/16 and 8/18/25. On 8/21/25 at 8:16 AM, V7 (Registered Nurse/RN) stated they don't have enough staff to meet the needs of the residents timely. V7 stated she works night shift and the bedtime medications (8 pm and 9 pm) don't get administered until 10 pm or 11pm. V7 stated there are 46 residents with three currently in the hospital. V7 stated she has four medication administration passes on night shift (two full and two partial). V7 stated they have three Certified Nurses working on night shift and one nurse. On 8/21/25 at 3:40 PM, V8 (Licensed Practical Nurse/LPN) stated she worked night shift and she was late administering medications at times because they only had one nurse for the 46 residents and she wasn't able to get all of the medications administered in the allowable time frame. On 8/21/25 at 2:32 PM, V2 (Director of Nurses/DON) stated they have one nurse on night shift and two on day shift. V2 stated she wasn't aware medications were not being administered within the ordered time frame until this surveyor asked for the report. V2 stated she thought they had enough staff but need to work on communication and some other things.
The facility schedule was reviewed from 8/1 to 8/31/25 and documents one nurse working from 7 pm to 7 am.
The facility undated Staffing Policy documents .It is the policy of this facility to provide an adequate number of staff to successfully implement resident functions to meet resident needs.
145857 08/25/2025
The Haven of St.
Elmo 221 East Cumberland St Elmo, IL 62458
cough/congestion .Start Date: 04/11/2025 .Levothyroxine Sodium Oral Tablet 125 mcg (micrograms)
administered late to R3. 1.
Keppra on 8/3 and 8/15, 2. hydroxyzine on 8/3, 8/15, 8/16, and 8/18, 3.
8/3 and 8/15, 7. levothyroxine on 8/16 and 8/18/25. On 8/21/25 at 8:16 AM, V7 (Registered Nurse/RN) stated they don't have enough staff to meet the needs of the residents timely. V7 stated she works night shift and the bedtime medications (8 pm and 9 pm) don't get administered until 10 pm or 11pm. V7 stated there are 46 residents with three currently in the hospital. V7 stated she has four medication administration passes on night shift (two full and two partial). V7 stated they have three Certified Nurses working on night shift and one nurse. On 8/21/25 at 3:40 PM, V8 (Licensed Practical Nurse/LPN) stated she worked night shift and she was late administering medications at times because they only had one nurse for the 46 residents and she wasn't able to get all of the medications administered in the allowable time frame. On 8/21/25 at 2:32 PM, V2 (Director of Nurses/DON) stated they have one nurse on night shift and two on day shift. V2 stated she wasn't aware medications were not being administered within the ordered time frame until this surveyor asked for the report. V2 stated she thought they had enough staff but need to work on communication and some other things.
The facility Medication Administration Policy dated 10/25/2014 documents, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .
Five Rights- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.