River Bend Health: Pharmacy Service Violations - NC
On the night of November 14, 2025, Nurse #1 signed out oxycodone 10 mg tablets from the controlled substance records for two residents, pulling doses at 7:30 PM for both and again at 11:30 PM for one and 10:30 PM for the other. The records showed that Nurse #2, a fellow agency nurse, signed as witness to the disposal of those tablets. Nurse #1 worked one 12-hour shift at the facility, from 7:00 PM that night until 7:00 AM the following morning. She has not been back.
Three days later, a third nurse noticed something was off. Resident #6 had oxycodone missing from the count, but the medication had not been recorded as administered on the resident's medication administration record. The resident denied taking it. That nurse brought her concern to the Director of Nursing on the morning of November 17.
By 10:30 that same night, the Director of Nursing had her answer, in writing. Nurse #2 sent an email acknowledging that she had signed the narcotic waste sheets as a witness for both Resident #6 and Resident #9 at Nurse #1's request, without watching the medications being destroyed.
The facility reported the allegation to the North Carolina Division of Health Service Regulation at 2:02 PM on November 17 and to local law enforcement twenty-eight minutes later. Both agency nurses were blocked from working at the facility that same day. Neither has worked there since.
What the inspection report cannot say is what actually happened to those tablets. The records show they were signed out. They were recorded as wasted. Nobody who signed as a witness watched them go.
Inspectors reviewed the case on January 30, 2026, as part of a complaint investigation. By then, Nurse #1 and Nurse #2 were gone, and attempts to interview either of them were unsuccessful.
The Director of Nursing told inspectors that Nurse #2 had worked multiple shifts at the facility since June 2025 but had not returned after November 15. Nurse #1, by contrast, had worked exactly one shift ever. The DON said she did not understand why Nurse #2 had signed the waste records without observing the disposal, given that visual witnessing was standard practice.
The Administrator said the same thing. She told inspectors it was expected that nurses would watch narcotics being destroyed before signing their names to the record. She said she did not know why Nurse #2 had not.
Federal inspectors cited the facility for failing to have effective systems in place for accurate narcotic reconciliation. The deficiency was tagged at a level of minimal harm or potential for actual harm.
The residents at the center of this were both prescribed oxycodone for pain. Resident #6 had a standing order for 10 mg three times daily. Resident #9 had an order for 10 mg every three hours as needed. The inspection report does not say whether either resident went without pain medication that night, or what they were told afterward.
What it does say is that a nurse asked a colleague to sign a form, the colleague signed it without looking, and the drugs disappeared into an illegible timestamp on a controlled substance log. The nurse who noticed, Nurse #3, did the right thing. She saw a number that didn't add up and she reported it.
The system that was supposed to prevent this, two nurses, one watching, one signing, required exactly the thing that didn't happen: someone paying attention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Bend Health and Rehabilitation from 2026-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
River Bend Health and Rehabilitation in Asheville, NC was cited for violations during a health inspection on January 30, 2026.
The records showed that Nurse #2, a fellow agency nurse, signed as witness to the disposal of those tablets.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.