Cycle 1
Health 2025-05-20 · Fire 2025-05-20
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
St Elmo, IL
The Haven Of St. Elmo
1-star overall rating with 3-star inspections with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
221 East Cumberland, St Elmo, IL
(618) 829-5581
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Haven Healthcare
Operator or chain grouping
Approved since
1995-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 1 overall / 2 health / 1 staffing / 1 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.16
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.25
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
2.42
CMS adjusted total nurse staffing hours
Case-mix index
1.78
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
12,670
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9810
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.92
Baseline 16.41% · Performance 20.08% · Measure score 2.92 · Achievement 2.92 · Improvement 0
Healthcare-associated infections
0
Baseline 5.82% · Performance 8.64% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.99
Baseline 58.70% · Performance 59.61% · Measure score 0.99 · Achievement 0.99 · Improvement 0
Adjusted total nurse staffing
0.55
Baseline 1.99 hours · Performance 2.39 hours · Measure score 0.55 · Achievement 0 · Improvement 0.55
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.46% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 15.79% · Lower 95% interval 7.15% |
| Discharge to community | 42.45% |
50.57%
8.1 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 30.77% · Lower 95% interval 28.55% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 41 · Denominator 41 |
| Falls with major injury | 2.44% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 41 |
| Discharge self-care score | 42.31% |
53.69%
11.4 pts worse
|
Numerator 11 · Denominator 26 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 13 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 41 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.64% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 14.29% · Lower 95% interval 5.36% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 39 |
| Staff flu vaccination coverage | 30.88% |
42%
11.1 pts worse
|
Numerator 21 · Denominator 68 |
| Discharge function score | 38.46% |
56.45%
18 pts worse
|
Numerator 10 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16% |
25.2%
9.2 pts worse
|
Numerator 4 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.8 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.3
0.2 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.4 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
89.6%
7.3 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 97.7% · Q3 97.4% · Q4 100.0% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.9% |
91.6%
2.3 pts better
|
95.5%
1.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.3%
2.9 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 6.8% · Q3 7.9% · Q4 5.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 73.2% |
50.3%
22.9 pts worse
|
11.4%
61.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.8% · Q2 75.0% · Q3 73.0% · Q4 68.8% · 4Q avg 73.2% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
6.5%
0.2 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 7.5% · Q3 16.2% · Q4 0.0% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.0% |
18.5%
12.5 pts worse
|
19.6%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 27.9% · Q3 29.7% · Q4 42.1% · 4Q avg 31.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.0% |
22.8%
6.8 pts better
|
16.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 18.2% · Q3 13.8% · Q4 13.8% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.3% |
17.2%
0.9 pts better
|
16.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.2% |
15.0%
6.8 pts better
|
14.9%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 12.8% · Q3 5.7% · Q4 0.0% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.3% |
1.7%
5.6 pts worse
|
1.7%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 12.5% · Q3 2.6% · Q4 2.6% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
21.3%
3.2 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 24.1% · Q3 32.5% · Q4 16.8% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
5.2%
0.9 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 7.3% · Q3 7.2% · Q4 2.3% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.2% |
68.8%
3.4 pts better
|
81.7%
9.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 58.8% · Q2 68.2% · Q3 74.1% · Q4 92.0% · 4Q avg 72.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.2% |
14.0%
10.2 pts worse
|
12.0%
12.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 27.0% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.0% |
2.3%
4.7 pts worse
|
1.6%
5.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 45.5% |
63.0%
17.5 pts worse
|
79.7%
34.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 45.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
26.2%
1.5 pts better
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 29.7% · Expected 28.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2024-07-24
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
1 health deficiencies
Top issue: Environmental (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-20
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-06-17
F · Potential for more than minimal harm
2024-07-24
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-07-24
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-24
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-08-05
F · Potential for more than minimal harm
2024-07-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-07-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-08-09
F · Potential for more than minimal harm
2024-07-24
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-05
F · Potential for more than minimal harm
2023-05-11
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-06-15
F · Potential for more than minimal harm
2023-05-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-06
F · Potential for more than minimal harm
2023-05-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-06-20
F · Potential for more than minimal harm
2023-05-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-07
E · Potential for more than minimal harm
2023-05-11
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-02
E · Potential for more than minimal harm
2023-05-11
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-06-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-25
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-08-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-13
D · Potential for more than minimal harm
2025-08-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-13
G · Actual harm
2025-05-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-02
F · Potential for more than minimal harm
2025-05-20
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-02
E · Potential for more than minimal harm
2025-05-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-20
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-05-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-02
B · Minimal harm
2025-05-20
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-06-04
F · Potential for more than minimal harm
2024-07-24
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-24
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-07-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-05
C · Minimal harm
2024-07-24
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-05
B · Minimal harm
2024-07-24
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-03-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-03-11
B · Minimal harm
2023-05-11
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-05-25
Penalties and ownership
What sits behind the stars
Ownership
Glat, David
5% Or Greater Indirect Ownership Interest · Individual
Nathan And Shirley Rothner Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Blain, Michelle
Operational/Managerial Control · Individual
Ecapital Healthcare Corp
Operational/Managerial Control · Organization
Ecapital Healthcare Corp
5% Or Greater Security Interest · Organization
Flick, John
Operational/Managerial Control · Individual
Glat, David
Operational/Managerial Control · Individual
Haven Healthcare Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Haven Healthcare Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Israel, Levi
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Lutheran Care Center
Altamont, IL
5-star overall rating with 4-star inspections with $19,208 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Fayette County Hospital
Vandalia, IL
4-star overall rating with 5-star inspections with $18,233 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Vandalia Healthcare & Senior Living
Vandalia, IL
1-star overall rating with 2-star inspections with 20 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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