Riverview Village

Based on interview and record review, the facility failed to ensure residents' (Resident C and Resident F) medication administration accurately reflected the administration of narcotic pain medication for 2 of 3 residents reviewed for medical records.

Findings include:1.The clinical record for Resident C was reviewed on 11/20/25 at 11:40 a.m.

The resident's diagnoses included, but were not limited to, restless leg syndrome, depression and osteoarthritis.

The physician's order, dated 5/19/25, indicated the resident was to receive Tramadol (narcotic pain medication) 50 mg (milligrams) every 6 hours for pain at 8:00 a.m., 2:00 p.m., 8:00 p.m. and 2:00 a.m.

Review of the October 2025 and November 2025 controlled substance record indicated the resident received the medication on the following dates and times: 10/03/25 at 8:00 p.m., 10/30/25 at 2:00 a.m., 11/01/25 at 2:00 a.m., 11/05/25 at 8:00 p.m., 11/07/25 at 8:00 p.m., and 11/11/25 at 8:00 a.m.

The October 2025 and November 2025 medication administration record lacked documentation that the pain medication was administered.

During an interview, on 11/20/25 at 4:12 p.m., Licensed Practical Nurse (LPN) 5 indicated when a narcotic pain medication was administered, the nurse should sign the medication as administered on the controlled substance record and the medication administration record. 2.

The clinical record for Resident F was reviewed on 11/20/25 at 1:59 p.m.

The resident's diagnoses included, but were not limited to, diabetes and hypertension.

The physician's order, dated 10/1/25, indicated the resident was to receive Tramadol 50 mg three times a day for pain at 8:00 a.m., 2:00 p.m. and 8:00 p.m.

Review of the October 2025 and November 2025 controlled substance records and medication administration records indicated the following: -On 10/01/25 at 8:00 p.m., the medication was signed out as administered on the controlled substance record but not on the MAR.-On 10/10/25 at 8:00 a.m., the medication was signed out as administered on the controlled substance record but not on the MAR.-On 10/11/25 at 2:00 p.m., the medication was signed out as administered on the MAR but not on the controlled substance record.-On 11/07/25 at 2:00 p.m., the medication was signed out as administered on the MAR but not on the controlled substance record.-On 11/10/25 at 2:00 p.m., the medication was signed out as administered on the MAR but not on the controlled substance record. On 11/20/25 at 4:30 p.m., the Director of Nursing provided a current copy of the document titled Controlled Substances: Storage, Documentation, Inventory and Destruction (Includes Fentanyl Patch Removal and Destruction) dated November 2024. It included, but was not limited to, Policy.It is the policy of this facility that all controlled substances will be.recorded.Documentation.When a controlled substance is administered to a resident, it must be recorded in the residents Medication Administration Record. 3.1-50(a)(2)

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.

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