Health inspection·December 30, 2025

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 Event ID: Facility ID: 395691 If continuation sheet Page 2 of 4 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 395691 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 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records, select facility policy, and staff interview it was revealed that the facility failed to assure that one of 10 residents reviewed were free of significant medication errors. (Resident 1)Findings include: A review of a facility policy, entitled Reconciliation of Medications on Admission last reviewed by the facility on May 2, 2025, defined the medication reconciliation process as the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescriptions. The policy further detailed the steps in completing a medication reconciliation which included gathering the information needed to reconcile the medication list by using the approved medication reconciliation form, the discharge summary from the referring facility, the admission order sheet, and all prescription and supplement information obtained from the resident/family during the medication history. The policy further explained that the medication reconciliation process is used to ensure that all medications, routes, and dosages on the list are appropriate for the resident and his/her condition. The policy explained that medication reconciliation helps to ensure the medications, routes and dosages have been accurately communicated to the Attending Physician and care team. The steps portion of the policy directed staff to ask the resident or responsible party to list all physician and pharmacies from which he or she obtained medications. The policy revealed that if there was a discrepancy between documentation, the staff member was to contact the nurse from the referring facility, contact the physician from the referring facility, discuss the findings with the resident/family, contact the residents outside provider and pharmacies for an accurate list of current medications. The policy then directed staff to document any discrepancy on the medication reconciliation form, what actions were taken by the nurse to resolve the discrepancy, and document whether the discrepancy was resolved or not. A review of the clinical record revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include hypertension (a condition blood pushes too forcefully against artery walls) and hypothyroidism (a condition when the thyroid gland doesn't make enough thyroid hormone). A review of Resident 1's clinical record revealed that upon admission, records were obtained from the referring facility which included a current medication list dated November 3, 2025. The list included the following medications:Sennoside 8.6mg-1 tablet by mouth twice a day for constipation.Pantoprazole 40mg- 1 tablet by mouth daily for acid reflux.Tiotropium 2.5mcg- 2 inhalations by mouth daily for breathing.Bacitracin 500units/gm ointment- apply moderate amount topically twice a day for skin infection.Aspirin 81mg- take one tablet by mouth daily every day for heart health.Oxybutynin 5mg- take one tablet by moth twice a day for overactive bladder.Levothyroxine 175mg- take one tablet by mouth every day at 6am for thyroid hormone replacement.Fluticasone/Salmeterol- inhale 1 puff by mouth twice a day for breathing. Semaglutide 0.25mg/0.375ml- Inject 0.5mg subcutaneously once weekly for diabetes.Hydrophilic cream- apply small amount topically every day for dry skin.Oxycodone 10mg- Take one tablet every 4 hours for pain.Losartan 50mg- Take one half tablet by mouth daily for blood pressure.Gabapentin 300mg- take one capsule by mouth three times a day for pain.Magnesium oxide 400mg- take one tablet by mouth daily for low magnesium.Famotidine 20mg- take one tablet by mouth twice daily.Finasteride 5mg- take one tablet by mouth daily for prostate.Apixaban 5mg- take 1 tablet every 12 hours for atrial fibrillation (an irregular heartbeat).Acetaminophen 325mg- take one tablet every 4 hours as needed for pain.Allopurinol 300mgtake one tablet by mouth daily for gout (an inflammatory disease). Ferrous Gluconate 324mg- take one tablet every other day for iron replacement.Furosemide 40mg- take one tablet by mouth daily for swelling and blood pressure.Tamsulosin 0.4mg- take one capsule by mouth twice a day for enlarged prostate (male reproductive gland).Further Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395691 If continuation sheet Page 3 of 4 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 395691 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], 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. Event ID: Facility ID: 395691 If continuation sheet Page 4 of 4