Parkway Manor

F-F761), which require that medications be administered to one patient at a time and securely stored until use. Leaving multiple patients' medications exposed and unattended creates a high risk for cross-contamination, medication errors, and misadministration, and reflects a systemic failure in clinical oversight.

On 4/21/25 at 12:34 PM, V22 (Family Member) stated she was at the facility visiting Resident R1 and saw V6 (LPN/Licensed Practical Nurse) and another unknown nurse preparing medications for multiple residents at one time by placing the medications in small clear medication cups, labeling the cup with the resident name, and leaving the cups sitting unattended on top of the medication carts.

On 4/22/25 at 10:14 AM, V11 (Certified Nursing Assistant) stated she had seen unknown nurse's prepare medications in advance using little medication cups. V11 stated they sometimes set them up in cups, wrote

the residents name on them, and then dispensed a couple at a time.

On 4/22/25 at 10:35 AM, when asked if he prepared medications in advance of administration, V6 (LPN/Licensed Practical Nurse) stated if he had multiple residents sitting at a table he would prepare all of their medications in medication cups and write their names on them. V6 stated then he would take all of the medication cups to the residents sitting at the table at the same time.

On 4/22/25 at 11:50 PM, V2 (Director of Nurses) stated nursing staff are not supposed to pop the medications out of the pharmacy cards prior to administration. V2 stated they should take each resident their medication prior to preparing the next resident's medications. V2 stated they should prepare a resident's medications, administer the medication, sign the medication administration record indicating it was administered, then move to the next resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 145841 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 145841 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Parkway Manor 3116 Williamson County Parkway Marion, IL 62959

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 0761 The facility policy Medication Administration using eMAR (electronic medication administration record) dated 11/11 documents, Objective: 1. To provide the resident with those medications deemed necessary by the Level of Harm - Minimal harm or physician 11. Documentation of meds (medications) given will be done in a consistent manner by the nurse potential for actual harm documenting preparation and administration of the medicine on the eMAR .Documentation on the eMAR will be done at the time of administration of the medication. Residents Affected - Many

The National Coordinating Council for Medication Error Reporting and Prevention website found at https://www.nccmerp. org/recommendations-health-care-organizations-reduce-medication-errors-associated-related-devices documents under, Recommendations for Healthcare Organizations to Reduce Medication Errors Associated with the Label, Labeling, and Packaging of Pharmaceutical (Drug) Products and Related Devices documents

These recommendations apply to healthcare systems, hospital systems, individual hospitals, long-term care facilities, and other organized health care settings. The Council recommends the following: Healthcare organizations should develop processes to ensure that all medications are labeled prior to administration to a patient per USP (United States Pharmacopeial Convention) General Chapter 7 Labeling, the term 'labeling' includes all labels and other written, printed, or graphic matter on a medication ' s immediate container or on, or in, any package or wrapper in which it is enclosed, except any outer shipping container.The term 'label' is that part of the labeling on the immediate container. All clinician-prepared medications or solutions should be labeled, unless the medication or solution is prepared at the patient ' s bedside and is immediately administered to the patient without any break in the process. In accordance with State/Federal Laws and Regulations, healthcare organizations should employ machine-readable systems (e.g., bar coding) in the management of the medication use process. Healthcare organizations should utilize industry standards to ensure machine-readable validity meets industry quality standards. Healthcare organizations should have procedures in place to address gaps and failure modes in the use of machine-readable systems. Healthcare organizations should have policies and procedures developed for repackaging of medications that will clarify labeling and include a bar code to help prevent errors. Systematic approaches, including Healthcare Failure Mode and Effects Analysis (HFMEA) and root cause analysis (RCA), should be implemented within the healthcare organization to identify and evaluate actual and potential causes of errors related to labeling and packaging (e.g., failure to use bar code scanning, barcodes that don ' t scan, and situations where patient armbands cannot be applied). These systematic approaches should be accompanied with guidance related to monitoring, auditing, and quality improvement initiatives (e.g., PDSA-Plan-Do-Study-Act) to ensure changes improve the labeling of medications to reduce medication errors. Healthcare organizations should develop and implement (or provide access to) education and training programs for healthcare professionals, technical support personnel, patients, and families/caregivers that address methods for reducing and preventing medication errors associated with the information provided on an organization ' s medication labeling .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 145841