F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interview, and record review, the facility failed to ensure scheduled medications were
administered as per physician's orders and according to accepted professional standards of practice for 5
of 5 residents reviewed for medication administration, of a total sample of 9 residents, (#5, #6, #7, #8, &
#9).
Findings:
On 8/08/24 at 12:07 PM, Licensed Practical Nurse (LPN) A was at her medication cart preparing
medications. The LPN stated she was still giving her morning medications and had three more residents to
give morning medications to. The 1st floor Unit Manager (UM), and Registered Nurse (RN) Supervisor were
seen sitting at the nurse's station. LPN A stated the UM was aware she was still giving morning
medications after 12:00 PM.
On 8/08/24 at 12:34 PM, and at 12:40 PM, LPN A was still administering her morning medications.
On 8/08/24 at 12:50 PM, the 1st floor UM stated staff had a four-hour window to administer morning
medications as directed by the facility's medication administration schedule. The UM stated he did not know
the facility's protocol if medications were administered out of that recommended timeframe.
Review of the facility's undated Medication Administration Times revealed the following, one time a day:
upon rising 6:00 AM to 10:00 AM. In the morning: 6:00 AM, in the afternoon: 12:00 PM to 5:00 PM or 2:00
PM. In the evening: prior to bed 6:00 PM to 10:00 PM. Two times per day: upon rising and prior to bed 6:00
AM to 10:00 AM and 6:00 PM to 10:00 PM.
Review of the Medication Administration Audit Reports for the day shift on 8/08/24 revealed the following:
Resident #5 received her scheduled morning medications late, between 11:58 AM to 12:16 PM, including
Carvedilol 3.125 milligram (mg) twice daily for high blood pressure, and Eliquis 2.5 mg daily for clot
prevention.
Resident #6 received her scheduled morning medications late, between 12:19 PM to 12:34 PM, including
Apixaban 5 mg every 12 hours for clot prevention, Amlodipine 5 mg daily for high blood pressure, Phenytoin
125 mg/5 milliliter (ml) give 8 ml twice daily for seizures, and Buspirone 5 mg twice daily for anxiety.
Resident #7 received her scheduled morning medications late, between 12:36 PM to 12:40 PM,
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105307
Printed: 05/28/2026
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
105307
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Parkview Rehabilitation Center at Winter Park
2075 Loch Lomond Drive
Winter Park, FL 32792
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
including Folic acid 1 mg daily.
Level of Harm - Minimal harm
or potential for actual harm
Resident #8 received her scheduled morning medications late, between 12:49 PM to 12:57 PM, including
Apixaban 5 mg every 12 hours, Furosemide 40 mg daily, Diltiazem 120 mg daily, Losartan Potassium 25
mg daily, and Metoprolol extended release 50 mg daily for high blood pressure.
Residents Affected - Some
Resident #9 received her scheduled morning medications late, between 12:41 PM to 12:47 PM, including
Acetaminophen 325 mg- 2 tablets twice daily for pain, Furosemide 20 mg daily for congestive heart failure,
Depakote 250 mg twice daily for mood disorder, Lisinopril 5 mg in the morning for high blood pressure, and
Celebrex 200 mg daily for pain.
On 8/08/24 at 12:29 PM, resident #5 stated she had just received her morning medications. The resident
said only two nurses gave her medications on time, all the others gave them late.
On 8/08/24 at 1:25 PM, the Assistant Director Of Nursing (DON) B stated the scheduled morning
medication administration time was upon rising, and the window the medications were to be given was
between 6:00 AM to 10:00 AM. She stated if medications were given after 11:00 AM, the medications were
considered late. ADON B said the facility's protocol for late administration of medication was the nurse
would notify the physician, and obtain orders as needed for the late medications. She stated the nurse
should document the communication with the physician in the resident's electronic medical record (EMR).
Review of medical records for residents #5, #6, #7, #8 and #9 revealed notification to the physician was not
done until after the surveyor discussed the late medication administration with the facility.
The policy Person- Centered Medication Administration Schedule adopted on 10/25/2021 and revised on
8/06/2024 read, Medications shall be administered according to established schedules.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105307
If continuation sheet
Page 2 of 2
