River Bend Health And Rehabilitation

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

River Bend Health and Rehabilitation

213 Richmond Hill Drive Asheville, NC 28806

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

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 and staff interviews, the facility failed to have effective systems in place for accurate reconciliation of narcotics medications when Nurse #2 signed narcotic records as witness to wasting without visually observing narcotic medications being wasted for 2 of 6 residents reviewed for misappropriation of residents' property (Residents #6 and #9).Findings included: a. Resident #6 was admitted to the facility on [DATE REDACTED]. The physician's order dated 10/27/25 revealed Resident #6 had an order to receive one oxycodone (narcotic pain medication) 10 milligram (mg) tablet three times daily for pain.

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 REDACTED]. 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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