Rivercrest Post Acute

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 6 sampled residents (#s 2 and 22) reviewed for medication.

This placed residents at risk for adverse side effects.

Findings include:1. Resident 2 admitted to the facility in 2025 with diagnoses including depression and adjustment disorder.The 1/29/25 Care Plan indicated Resident 2 experienced pain due to a recent surgery and motor vehicle accident with multiple fractures.

Interventions included to administer medications as ordered.A 4/8/25 physician order indicate Resident 2 was to receive oxycodone 5 mg every four hours as needed for pain and 10 mg every four hours as needed for pain.

The medication was not to exceed more than 40 mg daily.A 4/24/25 progress note indicated Staff 5 (LPN) signed out a dose of oxycodone and noted Resident 2 received 50 mg of Oxycodone on 4/23/25.

The medication was to not exceed 40 mg per day. Resident 2 was notified and the on call provider was notified. Resident 2 was placed on alert.A 4/24/25 Medication Error report indicated Staff 5 signed out a dose of oxycodone and noted Resident 2 received 50 mg on 4/23/25.

The order indicated not to exceed 40 mg per day.On 11/13/25 at 12:41 PM Staff 5 stated she recalled Resident 2 had an odd order related to pain medication.

Staff 5 stated she could not recall the identified medication error and was unable to provide additional information.On 11/14/25 at 11:55 AM Staff 2 (DNS) acknowledged the findings of the medication error related to Resident 2 receiving excessive oxycodone.2. Resident 22 admitted to the facility in 2023 with diagnoses including depression.A 12/20/24 progress note indicated Resident 22 was approached with medications.

Staff 15 (LPN) said the incorrect name to the resident. Resident 22 did not hear the wrong name and took the medication. Resident 22 was administered the medication in error.

The provider was notified, and the resident was placed on alert for adverse side effects.The 12/20/24 Medication Error report indicated Resident 22 received her/his roommate's morning medication including 60 mg of duloxetine (antidepressant). Resident 22 indicated she/he felt fine.On 11/18/25 at 12:00 PM Staff 22 stated she was worked for a staffing agency and only worked in the facility for one or two shifts.

Staff 22 stated on the day of the incident she asked Resident 22 if this was her/his name [roommate's name], and she/he stated yes.

Staff 22 stated she told the resident she had her/his medication and the resident stated okay and took the medication.

Staff 22 stated when she went to give medication to the roommate, she realized she gave Resident 22 the wrong medication.

Staff 22 stated if she was not familiar with a resident and a picture was not available; she asked other staff where she could find the resident.

Staff 22 acknowledged the identified medication error.On 11/18/25 at 11:18 AM Staff 1 (Administrator) acknowledged the identified medication error that occurred related to Resident 22.

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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