Resident #5, who has multiple sclerosis and Crohn's disease, received a PICC line at the hospital on October 11 for vancomycin treatment. The hospital administered the first dose at 5:47 P.M. that day and ordered the medication to continue every 12 hours for six days.
The pharmacy delivered vancomycin to the nursing home at 5:30 A.M. on October 12. But the resident didn't receive the next scheduled dose until 9:00 A.M. on October 13 — missing two consecutive doses.
At 8:17 P.M. on October 12, a nurse informed the Director of Nursing and Assistant Director of Nursing that Resident #5 needed medication through the PICC line. The nurse was told "it would not be able to be completed" and asked to call the doctor to hold the medication until 9:00 A.M. the next day.
The doctor refused.
He "did not feel comfortable holding the medication due to it being ordered on 10/11/25," according to nursing notes.
Nearly two hours later, at 9:54 P.M., another nursing note stated vancomycin was not infused because the resident had a chest port and the medication "needed to be ran by a Registered Nurse." The DON and ADON were aware of the situation, and the on-call doctor had not given an order to hold the medication.
The facility's own policy requires that "staffing schedules were arranged to ensure that medication was administered without unnecessary interruptions." Medications must be given "in accordance with prescriber orders, including any required time frame."
During an interview on November 19, the Director of Nursing confirmed the resident's vancomycin doses were not administered on October 12 at 9:00 A.M. or 9:00 P.M. "due to an RN not being available to initiate the medication."
She explained that the Assistant Director of Nursing was no longer employed at the facility and she was the only RN.
The resident's care plan, revised on November 12, acknowledged the need for IV antibiotics and included monitoring for adverse reactions, checking the site for leakage or infection, and changing dressings and tubing as ordered. The plan was updated more than a month after the medication delays occurred.
Resident #5 has intact cognition and requires staff assistance for daily activities. The 36-hour gap in antibiotic treatment came while battling a urinary tract infection that had already required emergency room treatment and hospitalization for PICC line placement.
Federal inspectors found the facility failed to ensure qualified staff were available to administer medication through the peripherally inserted central catheter. Of 36 residents in the facility, only one required IV medications, but even that single case overwhelmed the nursing home's capacity.
The violation resulted from a complaint investigation completed on November 20. Inspectors determined the staffing failure caused minimal harm or potential for actual harm to the resident.
Parkview Care Center's medication administration policy promises uninterrupted delivery of prescribed treatments. But when the only qualified nurse wasn't available, a resident with multiple chronic conditions went without critical antibiotic therapy while administrators scrambled to find coverage that never materialized until the next business day.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkview Care Center from 2025-11-20 including all violations, facility responses, and corrective action plans.