Riverwalk Village

Based on observation, recorded review, and interview, the facility failed to ensure residents were assessed for and deemed appropriate to self-administer medications for 1 out of 3 residents reviewed for medication administration. (Resident J) Findings include:

During an interview and observation on 11/17/2025 at 10:28 a.m., Resident J indicated her morning medications had been given to her between 9:00 a.m. and 9:30 a.m. On the over-the- bed table, medication cup with several pills was observed.

The resident indicated she had too many pills to take in the morning at one time.

During an interview on 11/17/2025 at 10:31 a.m., LPN 6 indicated she had left the medication at the bedside during the morning medication administration pass.

She indicated medications should not be left at the bedside. LPN 6 identified the medications in the medication cup as follows: amlodipine (calcium channel blocker) tablet 2.5 mg, ascorbic acid (vitamin C) tablet 500 mg, cyanocobalamin (vitamin B-12) tablet 1,000 mcg, fluoxetine capsule (anti-depressant) 40 mg, furosemide (diuretic) tablet 40 mg, losartan (hypertensive) tablet 25 mg, magnesium gluconate (supplement) tablet 27 mg, metoprolol succinate (beta blocker) tablet 12.5 mg, pramipexole (non-ergot dopamine agonist) tablet 0.5 mg.

These medications were confirmed with physician's medication orders.

During an interview on 11/17/2025 at 2:10 p.m., LPN 3 indicated medications were only left at the bedside if there was a physician's order.Resident J's clinical record was reviewed on 11/17/2025 2:43 p.m.

Diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure with hypoxia, pulmonary edema, congestive heart failure, multiple sclerosis, chronic pain, iron deficiency anemia, depression, unspecified, gastro-esophageal reflux disease, osteoarthritis, spinal stenosis, Other abnormalities of gait and mobility, Encounter for other specified aftercare, personal history of sudden cardiac arrest, presence of cardiac pacemaker, pulmonary hypertension, unspecified, chronic pain syndrome, glaucoma, hypertension, and nonrheumatic tricuspid valve insufficiency.The clinical record lacked a physician's order to leave medications at bedside.The clinical record lacked a physician's order for the resident to self-administer medications left at bedside.A current quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact. A 11/14/25 quarterly Minimum Data Set (MDS) assessment indicated the resident was cognitively intact.

During an interview on 11/19/2025 at 11:02 a.m., the DON indicated it was the facility expectation that medications were not left at the bedside.

The DON indicated LPN 6 should not have left Resident J's medications at the bedside. A current policy, dated 2/2010, titled Medication Administration (Medication Pass Procedure) was provided by the DON ono 11/17/2025 at 1:42 p.m.

The policy indicated the following: 11.

Observed resident taking medications -Meds not left at bedside. 3.1-37(a)

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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