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
PM, V6 (Wound Specialist) stated he treated R1's wounds/pressure ulcers. V6 stated when he assessed R1's areas the facility implemented interventions to prevent breakdown and promote healing. V6 stated R1's wounds were a combination of pressure and diabetic/arterial wounds. V6 stated with R1's mental status and comorbidities he didn't think the areas of skin breakdown were avoidable. V6 stated R1 didn't like to keep the heel protectors in place, she was very thin, she wasn't eating well, and she had loose stools. V6 stated not getting the treatments as he ordered could have a negative impact on the healing process but he wasn't sure how significant the errors that occurred would have been. V6 stated he assessed R1's wounds on 8/11/25 and there was no signs/symptoms of infection. V6 stated with R1's age and overall physical condition he didn't believe she had the physiological ability to heal the pressure ulcer to her left heel.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Haven of St.
Elmo
221 East Cumberland St Elmo, IL 62458
SUMMARY STATEMENT OF DEFICIENCIES
.
Trazadone HCL Oral Tablet 50 mg .Give 0.5 tablet by mouth at bedtime for depression Start Date: 04/11/2025 Divalproex Sodium Oral Tablet Delayed Release 125 mg .Give 125 mg by mouth at bedtime for unspecified convulsions .Start Date: 04/11/2025 .Mucinex Oral Tablet Extended Release 12 Hour .Give 1 tablet by mouth at bedtime for cough/congestion .Start Date: 04/11/2025 .Levothyroxine Sodium Oral Tablet 125 mcg (micrograms) .Give 125 mcg by mouth in the morning for hypothyroid .Start Date: 04/11/2025 .The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents the following medications were 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.
Aricept on 8/3 and 8/15, 4. trazadone on 8/3 and 8/15, 5. divalproex on 8/3 and 8/15, 6.
Mucinex on 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
The Haven of St.
Elmo
221 East Cumberland St Elmo, IL 62458
SUMMARY STATEMENT OF DEFICIENCIES
.
Trazadone HCL Oral Tablet 50 mg .Give 0.5 tablet by mouth at bedtime for depression Start Date: 04/11/2025 Divalproex Sodium Oral Tablet Delayed Release 125 mg .Give 125 mg by mouth at bedtime for unspecified convulsions .Start Date: 04/11/2025 .Mucinex Oral Tablet Extended Release 12 Hour .Give 1 tablet by mouth at bedtime for cough/congestion .Start Date: 04/11/2025 .Levothyroxine Sodium Oral Tablet 125 mcg (micrograms) .Give 125 mcg by mouth in the morning for hypothyroid .Start Date: 04/11/2025 .The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents the following medications were 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.
Aricept on 8/3 and 8/15, 4. trazadone on 8/3 and 8/15, 5. divalproex on 8/3 and 8/15, 6.
Mucinex on 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
Facility ID: