Parkway Manor: Medication Safety Failures - Marion, IL
That was April 21. Inspectors arrived the next day.
The family member, identified in inspection records only as V22, told inspectors she had been visiting her relative when she saw the licensed practical nurse, identified as V6, and another nurse working together to pre-fill cups for multiple residents simultaneously. The cups sat there, on the cart, waiting.
A certified nursing assistant at the facility confirmed it wasn't a one-time lapse. V11 told inspectors she had seen nurses do this before — set up medications in cups, write names on them, and then deliver a few at a time. She described it as something she had witnessed from unknown nurses on multiple occasions.
V6, the LPN seen by the family member, didn't deny it when inspectors asked him directly. He said that if several residents were sitting together at a table, he would prepare all of their medications at once, label the cups, and carry them all out to the table together. He said it was easier that way.
The facility's own Director of Nurses said that was not how it was supposed to work. V2 told inspectors that nurses are not supposed to pop medications out of pharmacy blister cards before they are ready to administer them to a single resident. The correct process, she said, is to prepare one resident's medications, walk them to that resident, give them the medications, sign the electronic record confirming administration, and only then return to prepare the next resident's medications. One resident at a time, start to finish.
That process had not been followed.
The gap between what the Director of Nurses described and what was actually happening on the floor is the center of what inspectors documented. Medications were being pre-staged in open cups, labeled by hand, and left unattended on carts before anyone had received them. The cups were not sealed. They were not secured. They were sitting out.
The risk in that practice is not theoretical. When medications are removed from their original packaging and placed into unlabeled or hand-labeled cups before administration, the chance of a mix-up increases — the wrong cup reaching the wrong resident, a cup being disturbed or contaminated, a dose being given without any confirmation that the right medication reached the right person at the right time. The facility's own electronic medication administration policy required that documentation happen at the time of administration, not before, and not in batches.
Inspectors cited the facility under F761, the federal tag governing medication storage and administration safety. The deficiency was classified as having the potential for actual harm and was noted as affecting many residents.
Parkway Manor's internal policy on medication administration using its electronic records system, dated November 2011, states that documentation must be completed at the time of administration. The practice V6 described and V11 confirmed made that impossible — medications were being prepared in advance, before any documentation could accurately reflect what had been given and when.
The National Coordinating Council for Medication Error Reporting and Prevention, whose guidance was cited in the inspection record, recommends that medications only be labeled outside their original packaging if they are prepared at a patient's bedside and immediately administered without any break in the process. What inspectors found at Parkway Manor was the opposite: medications removed from packaging, placed in cups, labeled, and then left on a cart while nurses attended to other tasks.
V22, the family member who first reported what she saw, had come to the facility to visit a relative. She watched a nurse prepare medications for people she did not know and leave them sitting out in the open. She reported it.
Her relative is still a resident there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkway Manor from 2025-04-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
PARKWAY MANOR in MARION, IL was cited for violations during a health inspection on April 23, 2025.
Inspectors arrived the next day.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.