White River Lodge

In the surveyor’s words

From the most serious findings on record at White River Lodge, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 25, 2022

  Based on observation, interview, and record review, the facility failed to ensure staff provided adequate supervision and interventions to prevent falls for 1 of 3 residents reviewed for falls. The resident sustained a left wrist fracture following a fall. (Resident 11) Finding includes: On 2/23/22 at 11:22 a.m., Resident 11 was observed ambulating down the hallway towards the dining room with the assistance of 2 staff. The resident was observed to be very unsteady on her feet, grabbing the handrail, and stopped in the hallway. The resident indicated that she had recently broken her wrist because she fell in her room. […]

• No harm, potential for more than minimal, patternF921Feb 25, 2022

  Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment for 9 of 12 rooms reviewed. Dark brown substances were found around bathroom toilet bases and bedroom walls were scuffed and unfinished. (Room 215, Room 217, Room 210, Room 303, Room 311, Room 315, Room 214, Room 206, Room 313) Findings include: 1. On 2/22/22 at 11:05 A.M., a dark substance was observed around the base of the bathroom toilet in Room 215. The drywall at the head of the resident's bed was observed to have scuff marks and was unfinished. 2. On 2/22/22 at 11:10 A.M., a dark substance around the base of the bathroom toilet in Room 217 was observed. The drywall at the head of the bed in Room 217 was observed to have scuff marks and was unfinished. 3. […]

• No harm, potential for more than minimal, isolatedF605Mar 27, 2026

  Based on interview and record review, the facility failed to ensure an order for an as needed (PRN) psychotropic medication was limited to 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 3)Findings include:On 3/25/26 at 2:03 p.m., Resident 3's clinical record was reviewed. The diagnoses included, but were not limited to, insomnia and anxiety. A Physician's Order, dated 11/5/25, indicated the resident was prescribed Ativan (an antianxiety medication) 0.5 milligrams (mg) every 8 hours as needed, with no stop date. During an interview on 3/27/26 at 11:45 a.m., the Corporate Administrator Consultant indicated the facility did not limit the use of as needed psychotropics to 14 days. […]

• No harm, potential for more than minimal, isolatedF695Mar 27, 2026

  Based on observations, interview, and record review, the facility failed to ensure a nasal cannula was not left on the floor for 1 of 1 resident reviewed for respiratory care. (Resident 2)Finding includes:On the following dates and times, the oxygen nasal cannula connected to tubing which was connected to a humidifying oxygen concentrator was observed on the floor in Resident 2's room beside the resident's chair: 3/24/26 at 12:08 p.m.3/25/26 at 10:57 a.m. 3/26/26 at 10:05 a.m.3/26/26 at 2:00 p.m. On the following dates and times, Resident 2 was observed sitting in the chair in her room with the oxygen nasal cannula in her nares: 3/24/26 at 1:30 p.m.3/25/26 at 1:42 p.m.3/26/26 at 11:12 a.m. On 3/25/26 at 9:40 a.m., Resident 2's clinical record was reviewed. […]

• No harm, potential for more than minimal, isolatedF791Mar 27, 2026

  Based on observation, interview, and record review, the facility failed to ensure a resident had a dental consult for assessed dental problems for 1 of 1 residents reviewed for dental care. (Resident 13)Finding includes:During an observation on 3/24/26 at 1:33 p.m., Resident 13 was observed to have broken and missing teeth. At that time, she indicated she had not seen the dentist and would like to have her broken teeth pulled for dentures.On 3/26/26 2:18 p.m., Resident 13's clinical record was reviewed. The diagnoses included, but were not limited to, left-sided hemiplegia (paralysis on one side of the body) and atherosclerotic heart disease.The Brief Oral Health Status Examination Assessment Tool, indicated the following:- On 10/21/25, Resident 13 had 1-3 decayed or broken teeth. […]