Riverside Village Healthcare Center

services of a licensed pharmacist.

interview and record review, the facility failed to ensure accurate reconciliation of medications on

oxygen therapy was not reflected in the physician order for a resident admitted on oxygen.

This failure has the potential to result in lack of physician oversight, which could negatively affect the resident's current health condition.Findings: On August 12, 2025, at 9 a.m., an unannounced visit to the facility was conducted to investigate quality care issues. A review of Resident 1's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included Encephalopathy (a declining ability to reason, concentrate and memory loss), chronic systolic cardiac failure (the heart weakens and cannot pump adequate blood through the body), ischemic cardiomyopathy (due to damage from lack of oxygen to the heart muscle), atherosclerotic heart disease (a buildup of plaque that causes the heart blood vessels to narrow), non-rheumatic aortic valve stenosis (heart valve does not open fully and heart must work harder) and difficulty walking. A review of Resident 1's admission Assessment Summary, dated July 10, 2025, at 17:47 (5:47 p.m.), indicated, .admitted to the facility with oxygen 2 lpm (liters per minute) via nasal canula in place.A review of the physician's orders dated July 10, 2025, through July 15, 2025, did not indicate that the resident was oxygen therapy. On August 12, 2025, at 12 p.m., during an interview and record review, the Director of Nursing (DON) confirmed that Resident 1's record lacked any physician order for oxygen upon admission or subsequently.

The DON stated the resident used oxygen continuously during her stay, as indicated in the admission summary, and acknowledged that the order should have been included in the admission orders.

She stated the licensed nurse should have verified the orders for accuracy and contacted the physician for the oxygen order at that time.A review of the facility's policy and procedure titled, Reconciliation of Medications on Admission, dated July 2017, indicated, .to ensure medication safety by accurately accounting for resident's medication, routes and dosages upon admission or readmission to the facility.

Preparation 1.

Gather the information needed to reconcile the medication list .c. admission order sheet .Medications reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process .if a there is a discrepancy.contact the physician to resolve the discrepancy.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE