Park View Rehab Center: Medication Dosing Errors - IL
That was just the first twenty minutes of a single medication pass.
On September 10, 2025, inspectors watched Nurse V13 prepare the noon medications. One of the first was Sucralfate oral suspension, ordered at 1 gram per 10 milliliters for a resident identified as R1, who had active gastritis, duodenitis, and a care plan tied to gastrointestinal hemorrhage. V13 held the medicine cup in the air and poured. At eye level, the cup appeared to read 10 milliliters. When V13 set it down on a flat surface, it read 15.
V13 carried the cup into R1's room anyway, told the resident which medications had been prepared, and was about to administer them when an inspector asked V13 to check the measurement again on a stable surface. V13 looked, removed 5 milliliters, and gave R1 the correct dose. Without that interruption, a resident being treated for a gastrointestinal bleed would have received half again the prescribed amount of their stomach medication.
Nineteen minutes later, V13 was preparing medications for R110 and could not find the resident's blister pack of Hydroxyzine. V13 had administered the last pill that morning. V13 reordered it through the electronic medical record, went to R110's room, and told the resident the medication wasn't available but would arrive from the pharmacy by evening. Then V13 marked the medication pass complete and moved on.
V13 did not call R110's physician. The Director of Nursing, V2, had told inspectors that morning that nurses are required to inform the physician whenever a medication is held or not administered. V13 did not do that.
Twelve minutes after that, at 12:32 PM, V13 pulled a bottle of Simethicone from the top right drawer of the medication cart to fill R30's noon dose. The order called for two tablets of Simethicone 80 milligrams. The bottle on the cart read 125 milligrams. V13 did not notice. There were exactly two pills left in the bottle, which matched the quantity needed, and V13 would have administered them if an inspector had not pointed out the discrepancy.
When V13 searched the cart, the medication room, and the supply stock on other floors, there was no 80-milligram Simethicone anywhere in the building. V13 then said something that reframed the entire afternoon: V13 had already given R30 two pills from that same 125-milligram bottle during the morning medication pass. R30 had received the wrong strength twice.
V13 said V13 did not know the dosage was different.
The facility's own physician, identified as V4, was asked about the consequences of medication errors elsewhere in the inspection. When asked specifically about a different resident's antipsychotic, Risperidone, V4 said it would "definitely" not be good if a nurse increased or exceeded the ordered dose. V4 said the resident would experience increased sedation and systemic slowing. On the question of holding Metoprolol Succinate, a heart medication, without notifying a physician, V4 said the decision to hold or not administer that drug is complicated enough that V4 needs to trend a resident's blood pressure, heart rate, and symptoms over three to four days before making a call. The nurses, V4 said, need to inform V4 when they are not giving it.
The Director of Nursing laid out the standard clearly when inspectors interviewed V2 that morning, before any of the medication pass had been observed. V2 said nurses have a two-hour window around scheduled administration times, should reorder medications before they run out, and must contact the physician whenever a medication is withheld. V2 described the five rights of medication administration: right patient, right medication, right dosage, right route, right time.
By 1:12 PM, V13 had come up short on four of the five in a single afternoon, across three residents, in front of inspectors.
R30 had already swallowed the wrong dose twice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park View Rehab Center from 2025-09-12 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: June 29, 2026 · Our methodology
PARK VIEW REHAB CENTER in CHICAGO, IL was cited for violations during a health inspection on September 12, 2025.
That was just the first twenty minutes of a single medication pass.
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.