Inspection·May 2, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and policy review, the facility failed to ensure staff accurately documented the administration of a resident's narcotic medications in the medical record. This affected one (#802) out of three residents reviewed for medication administration. The facility census was 172. Findings include: Review of medical record for Resident #802 revealed an admission date of 03/05/24 with diagnoses of paraplegia, incomplete, and pain in thoracic spine. Review of the plan of care dated 03/06/24 revealed Resident #802 is a paraplegic and to administer medications per medical providers orders and to observe for side effects and effectiveness. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #802 cognitively intact. Review of physician's order dated 03/07/24 revealed and order for Oxycodone HCl Oral Capsule 5 milligram (mg) give 2 capsules by mouth every 4 hours as needed for pain. Review of the Narcotic Sheet for Oxycodone HCl Oral Capsule 5 milligram (mg) for Resident #802 revealed two capsules were signed out on 03/13/24 at 6:30 A.M., 03/16/24 at 9:45 A.M., 03/18/24 at 12:55 P.M., 03/19/24 at 12:15 A.M., 03/21/24 at 2:00 A.M., 03/21/24 at 6:00 A.M., 03/24/24 at 1:30 A.M., 03/24/24 at 1:30 P.M., 03/26/24 at 2:00 A.M., 03/26/24 at 6:00 A.M., 03/29/24 at 1:30 P.M., 04/01/24 at 1:30 P.M., 04/03/24 at 12:00 A.M., 04/04/24 at 2:00 A.M., 04/06/24 at 1:45 A.M., 04/06/24 at 3:50 P.M., 04/07/24 at 2:00 P.M., 04/08/24 at 1:30 P.M., 04/09/24 at 2:00 P.M., 04/10/24 at 2:00 A.M., 04/10/24 at 6:00 A.M., and 04/11/24 at 2:30 P.M. Review of Resident #802's Medication Administration Record (MAR) for March 2024 revealed the Oxycodone HCl Oral Capsule 5 milligram (mg) two capsules was not signed off as administered on 03/13/24 at 6:30 A.M., 03/16/24 at 9:45 A.M., 03/18/24 at 12:55 P.M., 03/19/24 at 12:15 A.M., 03/21/24 at 2:00 A.M., 03/21/24 at 6:00 A.M., 03/24/24 at 1:30 A.M., 03/24/24 at 1:30 P.M., 03/26/24 at 2:00 A.M., 03/26/24 at 6:00 A.M., and 03/29/24 at 1:30 P.M. Review of Resident #802's MAR for April 2024 revealed the Oxycodone HCl Oral Capsule 5 milligram (mg) two capsules were not signed off as administered on 04/01/24 at 1:30 P.M., on 04/03/24 at 12:00 A.M., on 04/04/24 at 2:00 A.M., on 04/06/24 at 1:45 A.M., on 04/06/24 at 3:50 P.M., on 04/07/24 at 2:00 P.M., on 04/08/24 at 1:30 P.M., on 04/09/24 at 2:00 P.M., on 04/10/24 at 2:00 A.M., on 04/10/24 at 6:00 A.M., and on 04/11/24 at 2:30 P.M. (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365877 Printed: 05/15/2026 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 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405 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)