River View Nursing: IV Medication Safety Failures - PA
Federal inspectors found that River View Nursing and Rehabilitation Center violated Pennsylvania nursing standards by allowing five different LPNs to give IV medications to Resident 101 between April 16 and April 22, despite having no written policies authorizing such practices and no evidence that staff received required education.
Employee 1, an LPN, told inspectors on April 24 that she "never administered medications through residents' intravenous lines at the facility based on facility policy." Yet she signed the medication record on April 16 indicating she had given the IV antibiotic Meropenem, even though an RN actually administered the drug. "Employee 1 indicated she was never educated at the facility on the administration of intravenous medications," inspectors wrote.
Under Pennsylvania law, LPNs can only perform IV therapy after completing board-approved education programs and receiving ongoing supervision from registered nurses or physicians. The facility's administrator and director of nursing admitted they had no written policies allowing LPNs to handle IV medications and could not provide documentation that any LPN had completed required training.
The medication falsification occurred while Resident 101 received treatment for a urinary tract infection. A physician ordered the powerful antibiotic Meropenem on April 16, to be given intravenously every eight hours for seven days. Five different LPNs signed medication records claiming they administered the drug, though at least one admitted she never actually gave it.
Director of nursing confirmed that facility policy required "the nurse administering the medications are to sign the MAR indicating it was administered." The systematic falsification of medication records continued for nearly a week before inspectors discovered it.
Meanwhile, the facility's infection control program had effectively ceased functioning. The infection preventionist told inspectors she hadn't been able to analyze infectious disease data since October 2024, falling six months behind on tracking potential outbreaks.
"She indicated the last time she was able to fully analyze infectious disease was October 2024," the report states. Her handwritten surveillance logs from November 2024 through March 2025 lacked basic information like resident room numbers, infection symptoms, onset dates, and whether infections originated in the facility or community.
This surveillance failure became dangerous when Resident 56 tested positive for respiratory syncytial virus on April 22. Despite a physician's order at 12:17 PM requiring immediate contact precautions, staff failed to implement basic infection control measures for over 24 hours.
Inspectors observed Resident 56's room at 1:30 PM, 2:20 PM, and again the next morning at 8:10 AM. No contact precaution signs were posted outside the room. No protective equipment was available for staff. An LPN working April 23 told inspectors she was "unaware that Resident 56 required contact precautions."
The facility only implemented contact precautions around 11:00 AM on April 23, after inspectors inquired about the missing safeguards. By then, staff and visitors had potentially been exposed to RSV for nearly 24 hours without protection.
Resident 56 has severe cognitive impairment with a mental status score indicating he cannot understand or follow basic safety instructions. The facility's own policy requires contact precautions for RSV patients, including gloves and gowns that must be removed before leaving the room to prevent spreading the virus.
Other assessment failures put residents at risk. Inspectors found that three residents had inaccurate federally mandated assessments used to plan their care. Resident 2's February assessment incorrectly stated he didn't receive blood thinners, though medication records showed he received Apixaban daily. Resident 40's assessment falsely indicated infections with drug-resistant organisms and pneumonia that never occurred. Resident 47's assessment missed five days of insulin injections he actually received.
The facility also failed a Vietnam veteran with post-traumatic stress disorder. Resident 55 told inspectors he served two tours in Vietnam and had nightmares every night before receiving Prazosin medication in March. Despite his PTSD diagnosis and medication specifically for trauma-related nightmares, his care plan contained no interventions to minimize triggers or prevent re-traumatization.
"The facility failed to develop and implement an individualized person-centered plan to address this resident's diagnosis of PTSD according to standards of practice," inspectors wrote. The administrator and director of nursing admitted they couldn't demonstrate the facility provided trauma-informed care.
Respiratory care failures affected Resident 2, who has chronic respiratory failure and requires a tracheostomy to breathe. A February pulmonary consultation ordered continuous humidification, oxygen as needed, and twice-daily vest therapy to clear lung secretions. When inspectors observed the resident on April 24, he was receiving no humidification despite doctor's orders requiring it even on room air.
The facility had not obtained the ordered SmartVest device two months after the prescription. An RN confirmed "the resident had not yet received a SmartVest" and acknowledged humidification wasn't being provided. Only after inspectors inquired did the facility contact the pulmonary doctor, who confirmed on April 25 that humidification was essential "to keep secretions moist and easier for the resident to cough the secretions out or be suctioned."
Another resident received unnecessary antibiotics for eight days without clinical justification. Resident 47 returned from an emergency room visit on March 24 with a prescription for Cephalexin, supposedly for a urinary tract infection. But urine cultures showed "no significant growth," indicating no bacterial infection. The facility administered 25 doses of antibiotics through April 1 despite having no documented symptoms of UTI.
The infection preventionist confirmed "the clinical record did not contain documentation of a clinical rationale supporting the continued use of Cephalexin." The administrator acknowledged the facility was responsible for ensuring residents don't receive unnecessary antibiotics but couldn't provide justification for the treatment.
These violations occurred at a 120-bed facility that markets itself as providing skilled nursing and rehabilitation services. The inspection found systemic failures across multiple departments, from nursing supervision to infection control to medication management. Staff repeatedly signed false documentation, ignored physician orders, and failed to implement basic safety protocols while administrators couldn't demonstrate compliance with fundamental care standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River View Nursing and Rehabilitation Center from 2025-04-25 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 20, 2026 · Our methodology
RIVER VIEW NURSING AND REHABILITATION CENTER in WILKES BARRE, PA was cited for violations during a health inspection on April 25, 2025.
"Employee 1 indicated she was never educated at the facility on the administration of intravenous medications," inspectors wrote.
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.