River Bend Health And Rehabilitation
River Bend Health and Rehabilitation in Asheville, NC — inspection on January 30, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Nursing, the Tennessee Board of Nursing, the pharmacy, and the Medical Director had been notified of the misappropriation of narcotics. An interview on 1/30/26 at 8:38 AM with Nurse #3 revealed she had reported her concerns to the DON after she noticed that Resident #6 had some as needed Oxycodone medication missing.
She stated he denied taking the pain medication and they were not signed as administered on the MAR. An interview on 1/30/26 at 9:51 AM with the Pharmacist revealed she remembered the misappropriation of resident narcotics in November.
She stated the pharmacy did not participate in the investigation and the facility replaced all unaccounted-for narcotic medications at facility expense. An interview on 1/30/26 at 10:04 AM with the Administrator revealed she felt this was not the first time Nurse #1 had taken narcotics from a facility.
She stated he had been reported to local law enforcement, the North Carolina Board of Nursing and to the Tennessee Board of Nursing where he was originally licensed.
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IDENTIFICATION NUMBER:
A.
Building
COMPLETED
01/30/2026
STREET ADDRESS, CITY, STATE, ZIP CODE
River Bend Health and Rehabilitation
213 Richmond Hill Drive Asheville, NC 28806
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident #6's narcotic record revealed Nurse #1 (an agency nurse) had signed out one (1) oxycodone 10 mg tablet on 11/14/25 at 7:30 PM and 11:30 PM.
Review of Resident #6's narcotic record revealed Nurse #2 (an agency nurse) signed as a witness to Nurse #1's disposal of one (1) oxycodone 10 mg tablet on 11/14/25 at an illegible time. b. Resident #9 was admitted to the facility on [DATE].
The physician's order dated 11/06/25 revealed Resident #9 had an order to receive oxycodone 10 mg tablet every 3 hours as needed for pain.
Review of Resident #9's narcotic record revealed Nurse #1 had signed out one (1) oxycodone 10 mg tablet on 11/14/25 at 7:30 PM and 10:30 PM.
Review of Resident #9's narcotic record revealed Nurse #2 signed as a witness to Nurse #1's disposal of one (1) oxycodone 10 mg tablet on 11/14/25 at an illegible time.
Review of the initial report of alleged misappropriation dated 11/17/25 revealed the facility became aware of the allegation of misapproprriation of residents' property on 11/17/25 at 9:00 AM when Nurse #3 reported a concern to the Director of Nursing (DON) about as needed narcotics being signed out for a resident who usually did not ask for pain medication.
The facility reported the allegation to the North Carolina Division of Health Service Regulation (DHSR) on 11/17/25 at 2:02 PM and the local law enforcement on 11/17/25 at 2:30 PM.
The investigation report dated 11/21/25 revealed on 11/17/25 that the DON was notified by Nurse #3 that as needed pain medication was signed out for a resident who did not usually request it. A review of the narcotic sign out sheet revealed Nurse #2 had signed as a witness to Nurse #1's disposal of narcotic medications for Residents #6 and #9. An interview on 1/30/26 at 8:38 AM with Nurse #3 revealed she had reported her concerns about excessive pain medication being signed out for residents by Nurse #1 to the DON after she noticed that Resident #6 had some as needed oxycodone medication missing.
Nurse #2 stated Resident #6 denied taking the pain medication and they were not signed as administered on the MAR.
Review of an email dated 11/17/25 at 10:30 PM from Nurse #2 to DON showed Nurse #2 communicated she had signed the narcotic sheets as a witness to the disposal of medications for Residents #6 and #9 at Nurse #1's request without observing the medication disposal.
Attempts to interview Nurse #1 and Nurse #2, who were both no longer employed at the facility, were unsuccessful. An interview on 1/29/26 at 1:46 PM with the DON revealed Nurse #2 was an agency nurse who had worked multiple shifts at the facility since 6/12/25 but had not worked at the facility since 11/15/25.
The DON explained Nurse #1, who was also an agency nurse that worked only one 12-hour shift at the facility from 7:00 PM on 11/14/25 until 7:00 AM on 11/15/25M.
The DON stated when Nurse #3 signed the narcotic sheet, she noticed the number of narcotics signed out, became concerned and reported it to the DON.
The DON further stated she contacted Nurse #2 who told her she signed as the narcotic waste witness without visualizing the waste. An interview on 1/30/26 at 10:04 AM with the Administrator revealed Nurse #1 and Nurse #2 were blocked from working at the facility as of 11/17/25.
She stated it was the standard practice for nurses to visually witness narcotic medication being wasted prior to signing as a witness on the narcotic sheet and she did not know why Nurse #2 had not.
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