Riverstreet Manor

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident's Medication Administration Record in response to the grievance; however, the Nursing Home Administrator confirmed no further action was taken to resolve the grievance. An interview with the Nursing Home Administrator on December 30, 2025, at 1:40 PM, reviewed the above findings and confirmed the facility did not resolve Resident 1's grievance regarding the receipt of prescribed oxycodone prior to discharge. 28 Pa. Code 201.18 (e)(1) Management. 28 Pa Code 211.10 (c) Resident care policies.28 Pa.

Code 211.12 (c)(d)(3)(5) Nursing services

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Riverstreet Manor

440 North River Street Wilkes-Barre, PA 18702

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

review of Resident 1's clinical record revealed the facility failed to ensure an accurate and complete medication reconciliation was completed upon admission, resulting in the resident being placed on medications that had been previously discontinued.A review of Resident 1's clinical record revealed that upon admission, the resident was placed on the following medications that were not included on the current medication list provided by the referring facility:Methimazole 10 mg, administer one half tablet by mouth every Saturday and Sunday for hyperthyroidism (a condition in which the thyroid gland produces excessive thyroid hormone), despite referring facility documentation indicating the resident was being treated with levothyroxine 175 mcg for hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), representing conflicting thyroid therapies.Simvastatin 40 mg, one tablet by mouth in the evening for high cholesterol, despite the medication not being included on the current medication list from

the referring facility.Lisinopril 20 mg, one tablet by mouth every morning for hypertension, despite the most recent medication list documenting the resident was being treated with losartan for blood pressure control.A review of the referring facility's clinical documentation revealed that lisinopril 20 mg was discontinued on May 22, 2024, due to an episode of hyperkalemia (a condition in which potassium levels in

the blood are abnormally elevated, which can interfere with heart rhythm and muscle function and may result in life-threatening complications). The referring documentation further confirmed that methimazole and simvastatin were also discontinued at that time. A review of Resident 1's progress notes revealed a nursing entry dated November 11, 2025, at 4:38 PM, documenting that the provider ordered laboratory testing to be completed on November 12, 2025, and directed that lisinopril be discontinued. A review of Resident 1's laboratory results dated [DATE REDACTED], at 7:35 AM, revealed the resident's potassium level was elevated at 5.2 mmol/L (normal range 3.5-5.1mmol/L).A review of Resident 1's progress notes revealed a note dated November 12, 2025, at 12:21 PM, documenting that the provider was notified of the elevated potassium level, reviewed the laboratory results, and issued a new order to administer Kayexalate, a medication used to treat hyperkalemia by lowering potassium levels in the blood. An interview with the Nursing Home Administrator conducted on December 30, 2025, at 1:00 PM, revealed that a medication list dated May 22, 2024, was utilized during the admission medication reconciliation process, despite the referring facility's clinical record containing an updated medication list dated November 3, 2025. The Nursing Home Administrator confirmed the facility failed to reconcile medications in accordance with facility policy, resulting in Resident 1 receiving multiple discontinued medications, including lisinopril, which contributed to another episode of hyperkalemia. An additional interview with the Nursing Home Administrator on December 30, 2025, at 1:40 PM, confirmed the above findings and acknowledged that the medication reconciliation process was not completed as required by facility policy, resulting in the facility's failure to ensure the resident was free from a medication error. 28 Pa. Code 211.10 (c) Resident Care Policies 28 Pa. Code 211.12 (d)(5) Nursing Services. 28 Pa. Code 211.9 (a)(1)(d) Pharmacy Services.

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