Riverstreet Manor used a medication list from May 22, 2024, during the admission process, despite having access to an updated list from November 3, 2025, according to a December inspection report. The outdated list led staff to restart medications that the previous facility had specifically discontinued due to safety concerns.
The most serious error involved lisinopril, a blood pressure medication the resident had been taking until May 22, 2024, when doctors stopped it after the patient developed hyperkalemia. This condition causes abnormally high potassium levels that can interfere with heart rhythm and muscle function, potentially creating life-threatening complications.
But Riverstreet Manor's staff didn't know lisinopril had been discontinued. They restarted the 20 mg daily dose based on the six-month-old medication list.
The resident also received two other discontinued medications. Staff prescribed methimazole for hyperthyroidism, even though the patient's current medication list showed treatment with levothyroxine for the opposite condition — hypothyroidism. The conflicting thyroid therapies treat completely different problems: one suppresses excessive thyroid hormone production while the other supplements insufficient hormone levels.
Additionally, the facility restarted simvastatin for cholesterol management, despite the drug not appearing on the current medication list from the referring facility.
Within days, the medication errors created exactly the dangerous situation doctors had worked to prevent months earlier.
On November 11, 2025, a provider ordered laboratory testing and directed that lisinopril be discontinued. The next morning's lab results showed the resident's potassium level had climbed to 5.2 mmol/L — above the normal range of 3.5 to 5.1 mmol/L.
At 12:21 PM on November 12, the provider reviewed the elevated potassium results and immediately ordered Kayexalate, a medication specifically used to treat hyperkalemia by lowering dangerous potassium levels in the blood.
The resident had experienced hyperkalemia twice — once in May 2024, leading to lisinopril's discontinuation, and again in November 2025 after Riverstreet Manor restarted the same medication.
Nursing Home Administrator interviews on December 30, 2025, revealed the facility's medication reconciliation process had failed completely. During the first interview at 1:00 PM, the administrator acknowledged that staff used the outdated May medication list despite having access to the November update from the referring facility.
The administrator confirmed the facility violated its own medication reconciliation policy. In a follow-up interview at 1:40 PM the same day, the administrator acknowledged that the flawed process resulted in the resident receiving multiple discontinued medications, directly contributing to another episode of hyperkalemia.
Federal regulations require nursing homes to conduct thorough medication reconciliation during admission to prevent exactly these types of errors. The process involves comparing all medications a resident was taking before admission with new orders to identify and resolve discrepancies.
Riverstreet Manor's failure meant Resident 1 received medications that medical professionals had determined were unsafe months earlier. The lisinopril error was particularly concerning because the facility recreated a known dangerous condition that had already required medical intervention.
The inspection found the facility failed to ensure residents remain free from medication errors, violating multiple Pennsylvania regulations governing resident care policies, nursing services, and pharmacy services.
The resident required emergency medication to counteract the effects of a drug that should never have been restarted. Six months of careful medication management by the previous facility was undone by Riverstreet Manor's failure to use current medical information during the admission process.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverstreet Manor from 2025-12-30 including all violations, facility responses, and corrective action plans.