Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
observation, interview, and record review, the facility failed to ensure routine Norco (narcotic pain
medication) was available for one of two residents (Resident 1), when Resident 1 did not receive four doses
in June 2025, and nine doses in July 2025.This failure had the potential for Resident 1 to experience
psychological distress and unmanaged pain.Findings:On July 14, 2025, at 9:40 a.m., an interview was
conducted with Resident 1 in her room. Resident 1 was well-groomed and interviewable. Resident 1 stated
she has been at the facility for three years. Stated she has been using Norco for three years, which has
been effective for managing her arthritic pain and it is a routine medication for her. Resident 1 stated the
Norco is to be ordered 4 days before it runs out and when it is delayed she was always told it's either an
issue with the pharmacist, or the doctor did not sign for it. She stated in the past, Norco was pulled from the
emergency kit, but it wasn't done because the doctor needed to sign for it. Within the last month, she waited
for a day for the medication to arrive. She stated working with the RNA (Restorative Nursing Assistant specially trained nursing assistant who helps the residents with exercises to improve mobility and strength)
has been difficult due to not having her Norco available. She stated this has been an on-going
problem.During a review of Resident 1's admission Record, dated July 14, 2025, the admission Record
indicated Resident 1 was admitted to the facility on [DATE], with a diagnoses which included chronic pain
syndrome, spinal stenosis (narrowing of the spinal canal), and radiculopathy of the lumbar region
(compressed nerve root in the lower back).During a review of Resident 1's Minimum Data Set (MDS - an
assessment tool), dated May 2, 2025, the MDS indicated a Brief Interview of Mental Status (BIMS - a tool
to assess cognitive function of an individual) score of 14 (cognitively intact).During a review of Resident 1's
Physician Order, dated April 16, 2025, the Physician Order indicated an order date of April 16, 2025, for
Hydrocodone-Acetaminophen (Norco) Oral Tablet 10/325, give one tablet by mouth six times a day for pain
management.During a concurrent interview and record review on July 14, 2025, at 10:35 a.m., with the
Registered Nurse (RN), Resident 1's Medication Administration Record (MAR), dated June 2025, and July
2025, were reviewed. The MAR indicated missed doses for Hydrocodone-Acetaminophen 10/325 on the
following dates and times:June 22, 2025: 0900 (9am), 1300 (1pm), 1700 (5pm), 2100 (9pm);June 23, 2025:
0100 (1am);July 3, 2025: 0900, 1300, 1700, 2100;July 4, 2025: 0100;July 9, 2025: 0900, 1300, 1700;
andJuly 10, 2025: 0100The RN stated there was no documentation on the MAR for June or July that
indicated Resident 1 received the Hydrocodone-Acetaminophen 10/325 on the above noted dates and
times. The RN stated Resident 1's missed doses in July were due to waiting on the doctor's signature and
she was unsure of the missed doses in June.The RN stated, for a narcotic, the doctor needs to sign the
order, and the doctor will contact the pharmacy to electronically reorder the narcotic. The RN stated if there
is a delay in reordering the nurse will call the doctor to follow up, and if the medication administration is
delayed the doctor is also notified.On July 14, 2025, Resident
(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 3
Event ID:
555330
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
555330
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverside Postacute Care
8781 Lakeview Avenue
Riverside, CA 92509
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
1's progress notes were reviewed. The progress note dated 6/22/25 at 1013 (10:13 a.m.) indicated,
HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth six times a day for PAIN
MANAGEMENT NTE 3G of Acetaminophen in 24H from all sources Medication not available now.The
progress noted dated 6/22/25 at 1223 (12:23 p.m.) indicated, HYDROcodone-Acetaminophen Oral Tablet
10-325 MG Give 1 tablet by mouth six times a day for PAIN MANAGEMENT NTE 3G of Acetaminophen in
24H from all sources Medication not available now.The progress note dated 6/22/25 at 1711 (5:11 p.m.)
indicated, HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth six times a day
for PAIN MANAGEMENT NTE 3G of Acetaminophen in 24H from all sources follow up with pharmacy.The
progress note dated 6/22/25 at 2129 (9:29 p.m.) indicated, HYDROcodone-Acetaminophen Oral Tablet
10-325 MG Give 1 tablet by mouth six times a day for PAIN MANAGEMENT NTE 3G of Acetaminophen in
24H from all sources follow up with pharmacy and will deliver tonight.The progress Note dated 6/23/25 at
0202 (2:02 a.m.) indicated, HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth
six times a day for PAIN MANAGEMENT NTE 3G of Acetaminophen in 24H from all sources Medication not
on hand.There was no documentation the facility notified Resident 1's physician that Resident 1 did not
receive her Norco as ordered.During an interview on July 14, 2025, at 3:30 p.m., with the Pharmacist, the
Pharmacist stated Hydrocodone-Acetaminophen 10/325 was reordered on June 18, 2025, and was
delivered to the facility on June 22, 2025. The Pharmacist stated Hydrocodone-Acetaminophen 10/325
should have been delivered the following day (June 19, 2025) and there was no documentation indicating
why the medication was delayed.Further review of Resident 1's progress notes on July 14, 2025, indicated
the following:Progress Note dated 7/2/25 at 2139 (9:39 p.m.) indicated, Contacted pharmacy regarding
pending Norco order placed several days ago. Pharmacy stated they are still awaiting doctor's
authorization. Texted MD for sign-off and re-faxed the order to the pharmacy.Progress Note dated 7/3/25 at
1427 (2:27 p.m.) indicated, HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth
six times a day for PAIN MANAGEMENT NTE 3G of Acetaminophen in 24H from all sources Med not on
hand.Progress Note dated 7/3/25 at 1524 (3:24 p.m.) indicated, HYDROcodone-Acetaminophen Oral Tablet
10-325 MG Give 1 tablet by mouth six times a day for PAIN MANAGEMENT NTE 3G of Acetaminophen in
24H from all sources Med not on hand.Progress Note dated 7/3/25 at 1655 (4:55 p.m.) indicated,
HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 1 tablet by mouth six times a day for PAIN
MANAGEMENT NTE 3G of Acetaminophen in 24H from all sources medication not on hand.Progress note
dated 7/3/25 at 2051 (8:51 p.m.) indicated, HYDROcodone-Acetaminophen Oral Tablet 10-325 MG Give 1
tablet by mouth six times a day for PAIN MANAGEMENT NTE 3G of Acetaminophen in 24H from all
sources medication not on hand.There was no documentation after July 2, 2025, the facility followed up
with the pharmacy regarding the unavailability of Norco or notified Resident 1's physician that Resident 1
did not receive her Norco as ordered.During an interview and concurrent record review on July 14, 2025, at
2:30 p.m., with the Director of Nursing (DON), the DON stated nurses are aware to reorder medication
when there is only a 5 day supply remaining. She stated narcotics tend to take a while to receive from the
pharmacy because the doctor needs to sign the C2 form (form used for ordering controlled substances), so
nurses are to order those earlier. Nurses will follow up with the pharmacy and if the doctor has not signed
the form the nurses will notify the doctor again. The DON stated the nurses should contact the medical
director if medications are not received timely to prevent delays in medication administration. Regarding
accessing medication from the emergency kit (e-kit), the DON stated a doctor will need to sign an order.
The pharmacy will be notified by the nurse that a doctor has signed the order, and the pharmacy will give
approval for the nurse to pull medication from the e-kit.The DON further stated that according to Resident
1's progress notes, the missed doses of Norco for July 3 and 4, 2025, were due
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555330
If continuation sheet
Page 2 of 3
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
555330
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/14/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Riverside Postacute Care
8781 Lakeview Avenue
Riverside, CA 92509
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
to pending authorization from the physician. The DON stated there was no documentation the medical
director was notified, and stated the medication was not accessed from the e-kit. The DON stated on July 9,
Norco was not available in the cart for administration and that Resident 1 received Norco from the e-kit on
7/9/25 at 9 p.m. The DON stated the missed doses were a result of pending doctor authorization, according
to the progress notes. The DON stated there were no progress notes indicating the reason for the missed
doses of Norco in June and there was no documentation the medical director was notified.During further
interview with the DON on July 14, 2025, at 4:35 p.m., the DON stated this is the first time she has been
made aware of medications being delayed. She stated that if the pharmacy is not filling medication timely
the nurses are expected to call the primary doctor to inform them the medication is not received and to get
an order to pull the medication from the e-kit. She stated the nurses are to contact the medical director if
there are no results in getting the medications timely to prevent delays in medication administration.A
review of the facility's undated policy and procedure titled, MEDICATION ORDERING AND RECEIVING
FROM PHARMACY, indicated, .Medications and related products are received from the dispensing
pharmacy on a timely basis.When ordering medication that requires special processing (such as Schedule
II controlled substances).order at least (seven days) in advance of need.
Event ID:
Facility ID:
555330
If continuation sheet
Page 3 of 3
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
FAQ · About this visit
Common questions about this visit
What happened during the July 14, 2025 survey of RIVERSIDE POSTACUTE CARE?
This was a inspection survey of RIVERSIDE POSTACUTE CARE on July 14, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at RIVERSIDE POSTACUTE CARE on July 14, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.