Health inspection·August 25, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Diabetes, Impaired mobility, Inevitable effect(s) of aging. Malnutrition, Vascular issues R1's Order Recap Report dated 6/1/25 to 8/31/25 documents a physician order for Left ext (exterior) heel- Betadine daily leave OTA (open to air) every day shift for Diabetic Foot ulcer Start Date 06/05/2025. R1's Treatment Administration Records (TAR) dated 6/1/25 to 6/30/25 documents a physician order of, left ext heelbetadine daily leave OTA every day shift for Diabetic Foot ulcer Start Dated 06/05/2025.D/C (discontinue) Date: 06/24/2025. On 8/21/25 at 2:05 PM, V4 (Assistant Director of Nurse/ADON) stated she wasn't sure why V6 (Wound Specialist) progress note documented an order to cover the wound on the left heel with a border foam dressing. V4 stated when they did the treatment with V6 they left it open to air. V4 stated she should have clarified the order. R1's Wound Specialist note dated 6/23/25 documents under Wound Assessments, .Wound #2 Buttock gluteal fold is an acute Partial Thickness Dermatologic/Rash acquired on 06/16/2025 and has received a status of Not Healed measurements are 7.5 cm length x 8 cm width x 0.01 cm depth .no slough and no eschar present. The wound is improving .Wound Orders: Wound #2 Buttock gluteal fold, Cleanse wound with: Wound cleanser .Apply barrier cream/ointment daily .Additional Orders: .Barrier cream/ointment 3 x (times) per day and after incontinent episodes Due to the medical complexity of this patient any skin breakdown is a clinically expected outcome .R1's Order Recap Report dated 6/1/2025 to 8/31/2025 documents the following physician orders, Buttocks- apply A & D ointment q (every) shift et (and) after incont (incontinent) everyday and night shift for MASD (moisture associated skin damage .Start date 06/17/25 .R1's TAR dated 06/01/2025 to 06/30/2025 documents a physician order of, ButtocksMASD- apply A & D ointment q shift et (and) after incont (incontinence) every day and night shift for MASD Start Date: 06/17/2025 This TAR documents initials indicating the ointment was administered twice daily. On 8/21/25 at 2:05 PM, V4 (ADON) stated the barrier cream the facility uses is A & D ointment. V4 stated R1's physician order was to apply the ointment every day and night shift. After reviewing R1's Wound Specialist notes documenting the order to apply the barrier cream three times daily, with V4 she stated the facility nursing staff works 12 hour shifts so the facility only has two shifts. V4 stated she should have clarified the order. R1's TAR dated 6/1/2025 to 6/30/2025 documents a physician order for Silver sulfadiazine External Cream 1 % (Silver Sulfadiazine/SSD) Apply to buttocks topically every day and night shift for preventative. Start Date: 06/03/2025 D/C Date: 06/17/2025. R1's Wound Specialist progress note dated 7/7/25 documents under Wound Assessments, .Wound #2 Buttock gluteal fold is an acute Partial Thickness Dematologic/Rash acquired on 06/16/2025 and has received a status of Not Healed .measurements are 3.8 cm length x 6.5 cm width x 0.01 cm depth .The wound is improving. Under Wound Orders this progress note documents the following order, Apply barrier cream/ointment .Bordered foam or ABD (abdominal pads) with tape .R1's TAR dated 7/1/25 to 7/31/25 documents a physician order of, Silver Sulfadiazine Cream 1% apply to left et (and) rt (right) buttocks topically every day shift for stage 2 pressure ulcer cover with comfort foam dressing. Start Date: 07/07/2025 D/C Date 07/14/25 there are initials indicating this treatment was administered on 7/7, 7/9, 7/10, 7/12, and 7/13/25. There is no physician order documented for Silver Sulfadiazine treatment on R1's Wound Specialist progress notes. On 8/12/25 at 2:05 PM, after reviewing R1's 6/1 to 6/30/25 TAR with V4 (ADON) this surveyor asked where the order for the SSD came from since it wasn't documented on R1's Wound Specialist progress notes, V4 (ADON) stated V6 (Wound Specialist) told her to apply SSD to R1's buttocks while he was at the facility assessing R1. V4 stated she didn't know why it wasn't documented as an order on V6's notes. After reviewing R1's 7/1 to 7/31/25 Wound Specialist notes with V4, this surveyor asked where the order for the SSD came from since it wasn't documented on R1's Wound Specialist progress note and V4 stated she wasn't sure why the SSD remained on R1's 7/1-7/31/25 TAR. On 8/21/25 at 12:28 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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. Event ID: Facility ID: 145857 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure sufficient staff to meet the needs of the residents timely. This failure has the potential to affect all 46 residents currently residing at the facility. Findings include:1.R1's admission Record with a print date of 8/21/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, adult failure to thrive, mild protein calorie malnutrition, diabetes mellitus, mild intellectual disability, anemia, cognitive communication deficit, hemiplegia, hemiparesis, history of falls, edema, dementia, and peripheral vascular disease. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 07, indicating a severe cognitive deficit. R1's Order Recap Report dated 6/1/25 to 8/31/25 includes the following physician orders. Insulin Glargine subcutaneous solution 100 unit/ml (milliliters) (Insulin Glargine) Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with Hyperglycemia .Start Date: 07/04/2025 .The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents R1's Insulin Glargine ordered to be administered at bedtime was administered late on 8/4/25, 8/7/25, 8/15/25, and 8/17/25. 2. R2's admission Record with a print date of 8/21/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include muscular dystrophy, methicillin resistant staphylococcus aureus, diabetes, quadriplegia, anemia, depression, hypertension, colostomy, and acquired absence of right and left leg below the knee. R2's MDS dated [DATE] documents a BIMS score of 14, indicating R2 is cognitively intact. R2's Order Summary Report Active Orders as of 8/21/25 includes the following physician orders. Insulin Glargine solution Pen-injector 100 unit/ml Inject 70 unit two times a day for diabetes. Start Date: 07/17/2025 .Colestid Oral Tablet .Give 1 tablet by mouth two times a day related to hyperlipidemia. Start Date 06/28/25 .Enoxaparin Sodium Injection Prefilled Syringe Kit 40 mg (milligrams)/0.4 ml .Inject 40 milligram intramuscularly at bedtime for Prophylaxis .Start Date: 06/28/2025 .Sertraline HCL Oral Tablet 100 mg .Give 100 mg by mouth at bedtime for depression .Start Date: 06/28/2025 .Melatonin Oral tablet 3 mg .Give 4.5 mg by mouth at bedtime for insomnia .Start Date: 06/28/2025 Apixaban Oral Tablet 5 mg .Give 1 tablet by mouth two times a day for Blood Thinner .Start Date 08/13/2025 .Metoprolol Tartrate Oral Tablet 25 mg .Give 0.5 tablet by mouth two times a day related to Essential (Primary) Hypertension .Start Date: 08/20/2025 Trazadone HCL Oral Tablet 50 mg .Give 1 tablet by mouth at bedtime for sleep .Start Date: 08/13/2025 Potassium Chloride ER Tablet Extended Release 20 MEQ (milliequivalent) Give 1 tablet by mouth two times a day for hypokalemia .Start Date: 08/13/2025 The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents the following medications were administered late to R2 1.Insulin Glargine on 8/2 - 8/5, 8/9 - 8/11, 8/14 - 8/16, 8/18, 8/19, and 8/21/25. 2. Colestid on 8/2 - 8/5, 8/9 - 8/11, and 8/13 - 8/20. 3. Enoxaparin on 8/5, 8/13, 8/14, 8/19, and 8/20. 4. Sertraline on 8/5, 8/14, 8/18, 8/19, and 8/21. 5. Melatonin on 8/5, 8/13, 8/14, 8/18, 8/19, and 8/20. 6. Apixaban on 8/13-8/19. 7. Metoprolol on 8/13 8/18 and 8/20. 8. Trazadone on 8/13, 8/14, and 8/17. 8. Potassium Chloride on 8/13- 8/16, 8/18 - 8/20. 3. R3's admission Record with a print date of 8/21/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include paraplegia, immobility syndrome, vitamin deficiency, Alzheimer's disease, and peripheral vascular disease. R3's MDS dated [DATE] documents a BIMS score of 13, indicating R3 is cognitively intact. R3's Order Summary Report dated 8/21/25 includes the following orders, Keppra Oral Tablet 1000 MG . Give 1000 mg by mouth at bedtime for unspecified convulsions .Start Date: 4/11/2025 .hydroxyzine HCL Oral Tablet 25 mg .Give 25 mg by mouth at bedtime for anxiety disorder Start Date 04/11/2025 .Aricept Oral Tablet 10 mg .Give 10 mg by mouth at bedtime for dementia .Start Date: 04/11/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete . 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. Event ID: Facility ID: 145857 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure medications were administered in the time frame ordered for 3 of 3 (R1, R2, and R3) residents reviewed for medication administration in the sample of 11. Findings include:1.R1's admission Record with a print date of 8/21/25 documents R1 was admitted to the facility on [DATE] with diagnoses that include metabolic encephalopathy, adult failure to thrive, mild protein calorie malnutrition, diabetes mellitus, mild intellectual disability, anemia, cognitive communication deficit, hemiplegia, hemiparesis, history of falls, edema, dementia, and peripheral vascular disease. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 07, indicating a severe cognitive deficit. R1's Order Recap Report dated 6/1/25 to 8/31/25 includes the following physician orders. Insulin Glargine subcutaneous solution 100 unit/ml (milliliters) (Insulin Glargine) Inject 5 unit subcutaneously at bedtime related to Type 2 Diabetes Mellitus with Hyperglycemia .Start Date: 07/04/2025 .The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents R1's Insulin Glargine ordered to be administered at bedtime was administered late on 8/4/25, 8/7/25, 8/15/25, and 8/17/25. 2. R2's admission Record with a print date of 8/21/25 documents R2 was admitted to the facility on [DATE] with diagnoses that include muscular dystrophy, methicillin resistant staphylococcus aureus, diabetes, quadriplegia, anemia, depression, hypertension, colostomy, and acquired absence of right and left leg below the knee. R2's MDS dated [DATE] documents a BIMS score of 14, indicating R2 is cognitively intact. R2's Order Summary Report Active Orders as of 8/21/25 includes the following physician orders. Insulin Glargine solution Pen-injector 100 unit/ml Inject 70 unit two times a day for diabetes. Start Date: 07/17/2025 .Colestid Oral Tablet .Give 1 tablet by mouth two times a day related to hyperlipidemia. Start Date 06/28/25 .Enoxaparin Sodium Injection Prefilled Syringe Kit 40 mg (milligrams)/0.4 ml .Inject 40 milligram intramuscularly at bedtime for Prophylaxis .Start Date: 06/28/2025 .Sertraline HCL Oral Tablet 100 mg .Give 100 mg by mouth at bedtime for depression .Start Date: 06/28/2025 .Melatonin Oral tablet 3 mg .Give 4.5 mg by mouth at bedtime for insomnia .Start Date: 06/28/2025 Apixaban Oral Tablet 5 mg .Give 1 tablet by mouth two times a day for Blood Thinner .Start Date 08/13/2025 .Metoprolol Tartrate Oral Tablet 25 mg .Give 0.5 tablet by mouth two times a day related to Essential (Primary) Hypertension .Start Date: 08/20/2025 Trazadone HCL Oral Tablet 50 mg .Give 1 tablet by mouth at bedtime for sleep .Start Date: 08/13/2025 Potassium Chloride ER Tablet Extended Release 20 MEQ (milliequivalent) Give 1 tablet by mouth two times a day for hypokalemia .Start Date: 08/13/2025 The facility Medication Admin Audit Report dated 8/1/25 to 8/21/25 documents the following medications were administered late to R2 1.Insulin Glargine on 8/2 - 8/5, 8/9 - 8/11, 8/14 - 8/16, 8/18, 8/19, and 8/21/25. 2. Colestid on 8/2 - 8/5, 8/9 - 8/11, and 8/13 - 8/20. 3. Enoxaparin on 8/5, 8/13, 8/14, 8/19, and 8/20. 4. Sertraline on 8/5, 8/14, 8/18, 8/19, and 8/21. 5. Melatonin on 8/5, 8/13, 8/14, 8/18, 8/19, and 8/20. 6. Apixaban on 8/13-8/19. 7. Metoprolol on 8/13 8/18 and 8/20. 8. Trazadone on 8/13, 8/14, and 8/17. 8. Potassium Chloride on 8/13- 8/16, 8/18 - 8/20. 3. R3's admission Record with a print date of 8/21/25 documents R3 was admitted to the facility on [DATE] with diagnoses that include paraplegia, immobility syndrome, vitamin deficiency, Alzheimer's disease, and peripheral vascular disease. R3's MDS dated [DATE] documents a BIMS score of 13, indicating R3 is cognitively intact. R3's Order Summary Report dated 8/21/25 includes the following orders, Keppra Oral Tablet 1000 MG . Give 1000 mg by mouth at bedtime for unspecified convulsions .Start Date: 4/11/2025 .hydroxyzine HCL Oral Tablet 25 mg .Give 25 mg by mouth at bedtime for anxiety disorder Start Date 04/11/2025 .Aricept Oral Tablet 10 mg .Give 10 mg by mouth at bedtime for dementia .Start Date: 04/11/2025 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145857 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145857 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/25/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Haven of St. Elmo 221 East Cumberland St Elmo, IL 62458 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete . 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 Event ID: Facility ID: 145857 If continuation sheet Page 7 of 7