Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at White River Lodge during CMS and state inspections, most recent first.
A resident with insomnia and anxiety had an Ativan 0.5 mg q8h PRN order with no stop date. The facility's admin stated PRN psychotropics were not limited to 14 days, even though the facility policy required PRN psychotropic orders to be limited to 14 days unless the prescriber documented a rationale and duration for extension.
A resident receiving continuous O2 via nasal cannula for atrioventricular block and acute respiratory failure had the cannula observed on the floor beside the chair multiple times, while at other times it was in the resident's nares. The resident said staff put the cannula on when she was in her chair but she did not know if it was cleaned or replaced before use, and the DON stated it should not have been left on the floor.
A resident with left-sided hemiplegia and atherosclerotic heart disease was observed with broken and missing teeth and said she had not seen the dentist and wanted her broken teeth pulled for dentures. Oral health assessments identified 1-3 decayed or broken teeth and indicated immediate dental referral, but the record lacked documentation of a dental consult or referral after either assessment.
Surveyors found that drugs and biologicals in the medication room were not properly labeled or discarded. Two Ozempic injector pens for two residents lacked clear open or expiration dates, and a bottle of liquid Omeprazole for another resident was present past its expiration date and after being discontinued. The DON confirmed that labeling and timely disposal procedures were not followed, and the facility lacked a policy for labeling opened medications.
A resident with multiple medical conditions, including neurogenic bladder, was repeatedly observed with urinary catheter tubing and drainage bag resting on the floor while in bed and recliner. The care plan lacked instructions for catheter placement, and staff acknowledged the tubing was sometimes on the floor, contrary to facility policy requiring catheter bags to be kept off the floor.
PRN Psychotropic Medication Order Not Limited to 14 Days
Penalty
Summary
The facility failed to ensure that an order for a PRN psychotropic medication was limited to 14 days for one resident reviewed for unnecessary medications. The resident had diagnoses including insomnia and anxiety, and a physician's order dated 11/5/25 showed Ativan 0.5 mg every 8 hours as needed with no stop date. During interview, the Corporate Administrator Consultant stated the facility did not limit PRN psychotropics to 14 days. The Administrator also provided the facility's Psychoactive Medication Protocol, revised in April 2025, which stated that PRN orders for psychotropic drugs must be limited to 14 days unless the prescriber documents the rationale and duration for extending the order.
Nasal Cannula Left on Floor
Penalty
Summary
The facility failed to ensure a resident's nasal cannula was not left on the floor for Resident 2, who had diagnoses including atrioventricular block and acute respiratory failure and a physician's order for continuous oxygen therapy via nasal cannula at 2 liters per minute. Surveyors observed the oxygen nasal cannula connected to tubing and a humidifying oxygen concentrator on the floor beside the resident's chair multiple times while the resident was in her room. At other times, the resident was observed sitting in the chair with the nasal cannula in her nares. During interview, the resident stated staff put the cannula on for her when she was in her chair, but she did not know if it was cleaned or replaced before being placed in her nares. The DON stated the resident's nasal cannula should not have been left on the floor.
Failure to Obtain Dental Consult for Resident With Broken and Missing Teeth
Penalty
Summary
The facility failed to ensure a resident received a dental consult for assessed dental problems. Resident 13 was observed to have broken and missing teeth and stated she had not seen the dentist and wanted her broken teeth pulled for dentures. Her clinical record showed diagnoses including left-sided hemiplegia and atherosclerotic heart disease. The Brief Oral Health Status Examination Assessment Tool documented 1-3 decayed or broken teeth on 10/21/25 and again on 1/13/26, with both assessments indicating she needed to be referred to the dentist immediately. The record lacked documentation of a dental referral or consult after either oral assessment, and the DON stated the resident’s oral assessments were completed quarterly.
Failure to Properly Label and Discard Medications in Medication Room
Penalty
Summary
Surveyors observed that drugs and biologicals in the facility's medication room were not properly labeled or discarded according to accepted professional standards. Specifically, two Ozempic injector pens for two residents were found in the medication room refrigerator without clear open or expiration dates. One pen had a date written on the box, but the DON could not confirm if it was the open or expiration date, while the other pen had no date at all. The DON confirmed that all opened medications should be labeled with both an open date and an expiration date, and that Ozempic pens should be discarded 56 days after first use. Additionally, a bottle of liquid Omeprazole for another resident was found with an expiration date that had already passed, and the DON verified that the medication should have been discarded. The medication had also been discontinued prior to the survey but was still present in the medication room. Review of the facility's policy on storage and disposal of medications revealed that while it addressed disposal of outdated medications, it did not specify procedures for labeling medications when opened. The Administrator was unable to provide a policy regarding labeling of opened medications.
Failure to Maintain Proper Catheter Tubing Placement
Penalty
Summary
Surveyors observed that the facility failed to implement proper infection control practices for a resident with an indwelling urinary catheter. Over multiple days, the resident was seen in both bed and recliner with the urinary catheter tubing and drainage bag resting on the floor. These observations were made on several occasions, indicating a repeated failure to maintain catheter tubing and drainage bag placement according to infection control standards. The resident involved had diagnoses including diabetes mellitus, cerebral infarction, and neurogenic bladder, and had a physician's order for monthly catheter changes. The resident's care plan addressed urinary retention but did not include instructions for proper placement of the catheter tubing while in bed or recliner. During an interview, a CNA acknowledged that the catheter tubing was sometimes on the floor and confirmed that it should not be. The facility's catheter management policy specified that collecting bags should always be kept below the level of the bladder and not resting on the floor, but this policy was not followed in practice.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Health Campus | 0.6 mi | ★★★★★ | 4 | 0 |
| Majestic Care Of Bedford | 1.4 mi | ★★★★★ | 10 | 0 |
| Westview Nursing And Rehabilitation Center | 1.9 mi | ★★★★★ | 3 | 0 |
| Core Of Bedford | 3.2 mi | ★★★★★ | 20 | 0 |
| Mitchell Manor | 7.7 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.