Staff D, an LPN at Riverwood Healthcare & Rehabilitation Center, held Resident #85's oxycodone on August 21st at 6:00 PM because the patient "appeared drowsy or lethargic." She marked a "7" on the medication administration record but admitted during an August 28th interview that "she must have forgotten to document a note."
The facility's expectation was clear: nurses were supposed to administer medications as ordered, and if unable to do so, contact the physician and their supervisor.
Physician #1 told inspectors on August 28th that she did not recall being contacted about Resident #85's oxycodone medication earlier that week. If the facility had run out of the prescribed medication, she said they should obtain necessary doses from their emergency supply until the pharmacy could refill the prescription. "It was not her practice to hold a medication if the facility had run out of it."
The medication withholding extended beyond a single incident. Staff Q, another LPN, remembered checking a "7" on July 26th at midnight for Resident #85's scheduled oxycodone dose "because he was sleeping." She had not written a note or taken any other actions, despite admitting there had been times when medications for her residents were not available.
Staff R, an LPN, said if she charted a "7" for the resident's scheduled oxycodone at midnight on June 17th, "she believed it would have been because he was sleeping, and she assumed that was sufficient documentation." She did not contact the doctor or take any other action steps.
The facility's staffing problems compounded the medication errors. Staff O, an LPN who had worked at the facility for only a couple of months, wasn't sure whether he gave Resident #85's oxycodone on August 26th at 6:00 AM. He wasn't sure why he would have documented a "9" in the electronic medical record.
Staff O revealed he "had not been provided any orientation or education to the facility." He didn't believe the facility had an automated medication dispensing machine, and if they did, he did not have access to it.
Staff P, another LPN, had worked in the facility only one time. She did not recall Resident #85 or whether she had administered a dose of oxycodone at 12:00 PM on June 27th. Like Staff O, she "had never had access to the automated medication dispensing machine and did not receive any education or orientation from the facility."
She was not provided with any information regarding an on-call nurse or a phone number for the Director of Nursing.
The pattern of withholding medication without proper procedures violated federal requirements for pharmaceutical services. Multiple nurses made independent decisions to skip scheduled pain medication doses based on their own assessments, without consulting physicians who had prescribed the medications or following proper documentation protocols.
During the August 29th inspection, the Regulatory Compliance Consultant acknowledged the facility's failures, stating "they needed to ensure their residents received the care they needed, especially when it came to pain management."
The inspection found that nurses were marking medication administration records with codes indicating doses were held, but failing to follow through with required notifications to physicians or proper documentation of their reasoning. This left residents like #85 without prescribed pain relief during periods when nurses subjectively determined they appeared too drowsy or were sleeping.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to some residents. The deficiency occurred during a complaint investigation completed on August 29, 2025.
The medication administration failures highlighted broader systemic problems at the facility, including inadequate staff orientation, limited access to medication dispensing systems, and unclear protocols for contacting medical providers when nurses made decisions to withhold prescribed treatments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverwood Healthcare & Rehabilitation Center from 2025-08-29 including all violations, facility responses, and corrective action plans.
Additional Resources
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