Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bear Mountain Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to provide scheduled outside group activities for residents who said such outings were very important to them. Several cognitively intact residents reported feeling sad, depressed, angry, trapped, or like prisoners because they had not been able to leave the facility for group outings for many months or over a year. The ADON/Activities Director and Administrator stated the facility had only one van that held two residents in wheelchairs and was primarily used for medical appointments, which limited outside activities to one outing during the review period.
Failure to obtain informed consent for psychotropic medications was identified for two residents. One resident with anxiety and severe cognitive impairment was started on Buspirone without documentation that the RP was informed in advance of the risks and benefits, and the RP later said he was only contacted after the medication had already been started. Another resident with depression and anxiety had orders for Duloxetine and Buspirone, but there was no consent form showing the resident had been informed of the risks and benefits; the resident did not recall any consent discussion, and the DON said the consents had been missed.
Expired naloxone nasal spray was found in a locked overflow drawer of the West-Front hall med cart during observation with the Unit Manager. The package was labeled for a resident no longer at the facility and had been overlooked despite routine cart checks by nurses, Medication Aides, and Unit Managers. The DON confirmed the drawer was used infrequently for extra controlled meds, and the Administrator stated discontinued or expired meds should not remain on carts.
A resident with Type-2 diabetes and severe cognitive impairment was prescribed Janumet XR (metformin-sitagliptin extended release) upon admission, but facility staff entered and administered only metformin immediate release, omitting the sitagliptin component and the extended-release formulation. The error occurred because a nurse entered and confirmed the admission orders without a required second nurse review, resulting in the resident not receiving the prescribed combination medication for several days.
A resident with multiple complex medical conditions had abnormal lab results, including high sodium, elevated liver enzymes, and a high white blood cell count, which were not communicated to the provider when received. Nursing staff did not document notification or recall reporting the results, and the Physician Assistant did not review the labs until several days later. The process for reviewing and reporting lab results was not followed due to staff transitions and the absence of the DON, resulting in a failure to promptly notify the provider of critical findings.
A resident who was dependent on staff for eating and had a history of dysphagia and malnutrition was assisted with feeding by a nurse aide who stood beside the bed rather than sitting at eye level, despite a chair being available. The resident expressed discomfort with this approach, and staff interviews revealed a lack of awareness regarding the dignity issue associated with standing while providing feeding assistance.
A resident with a history of stroke, insomnia, and bipolar disorder missed one dose of five evening medications after nursing staff failed to properly readjust medication orders when changing administration times. The DON updated the orders in the system but did not set the new start date correctly, resulting in the medications not appearing for administration that evening. The resident did not experience any reported adverse effects.
Two residents with known behavioral issues became agitated and began yelling at each other in a common area while staff were distracted by an unusual event outside. Despite care plans outlining interventions for agitation, staff did not intervene, resulting in one resident being struck on the hand with a cellphone and sustaining a skin tear.
The facility failed to accurately code MDS assessments for three residents, resulting in incorrect documentation of PASARR Level II status and high-risk drug class usage, including anticoagulants, antipsychotics, and opioids. Errors included misclassifying aspirin as an anticoagulant and failing to record completed PASARR evaluations, as confirmed by staff interviews and record reviews.
A resident with a newly diagnosed serious mental illness, specifically bipolar disorder, was not referred for a PASARR Level II evaluation as required. Despite documentation of the diagnosis and a physician's order for Depakote, the facility did not initiate the referral process, and staff interviews confirmed the oversight and lack of adherence to established procedures.
A resident with an indwelling urinary catheter was observed on multiple occasions with the catheter drainage bag and drainage valve resting on the floor, contrary to care plan instructions and infection control protocols. Staff interviews confirmed that the bag and valve should be kept off the floor, but the assigned nurse aide had not checked the catheter bag during her shift, and the assigned nurse was unaware of the issue.
Failure to Provide Scheduled Outside Group Activities
Penalty
Summary
The facility failed to ensure that group activities were planned outside of the facility for residents who stated that going out in a group setting was very important to them. Record review, the activity calendar, and resident interviews showed that only one outside activity was scheduled over the reviewed period, while residents repeatedly reported that they had not been taken out for group activities for many months or over a year. Seven of nine residents reviewed for activities were identified as expressing a need and desire for outside group activities, including going to restaurants, shopping, and socializing in the community. Resident assessments showed that each of the residents reviewed was cognitively intact and had indicated that activities outside of the facility were important or very important to them. During the Resident Council meeting, residents stated that not being able to leave the facility made them feel sad, depressed, angry, trapped, or like prisoners. Several residents said they wanted to go to restaurants, order their own meals, shop, or simply get out of the building and see something other than the same surroundings. One resident who was observed becoming tearful during the meeting excused himself from the discussion. The Activities Director stated that since she began working at the facility, she had only been able to schedule one outside activity because of transportation issues. She explained that the facility had only one van, which held two residents in wheelchairs and was primarily used for medical appointments. She reported that she had raised the transportation issue with Administration several times and had tried to arrange alternate transportation, but those efforts were unsuccessful. The Administrator confirmed that there had been no activities scheduled outside of the facility in over a year because of transportation limitations and acknowledged that residents had shared their frustration about not being able to go out.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent and inform residents or their representatives in advance of the risks and benefits of psychotropic medications before starting them for 2 of 5 residents reviewed for unnecessary medications. One resident with anxiety disorder and severely impaired cognitive skills for daily decision making had an active order for Buspirone for agitation/restlessness, but the medical record contained no documentation that the Responsible Party was informed in advance of the risks and benefits of starting the medication. The resident’s Responsible Party later stated he was only called after the medication had already been started and had not previously been informed that the resident was receiving Buspirone. For the same resident, the Unit Manager stated she entered the Buspirone order into the record and knew the Responsible Party was supposed to be notified and consent obtained, but said the DON was responsible for obtaining consents. The DON stated she reviewed new orders daily and was responsible for obtaining psychotropic medication consents, but acknowledged the Buspirone consent had been missed and took full responsibility for not obtaining it. A second resident with depression and anxiety disorder had active orders for Duloxetine and Buspirone, but the medical record contained no consent form showing the resident had been informed in advance of the risks and benefits of either medication. The resident stated she knew the medications had been started for depression and anxiety but did not remember discussing risks and benefits or signing a consent form. The DON stated she normally explained psychotropic medications and obtained signed consent from the resident or Responsible Party, but said these consents for Duloxetine and Buspirone had been missed.
Expired Naloxone Found in Locked Medication Cart Drawer
Penalty
Summary
The facility failed to discard an expired naloxone nasal spray package from the West-Front hall medication cart. During observation of the cart with the Unit Manager, a locked third drawer on the right side was found to contain a plastic bag with an unopened package of two naloxone nasal spray bottles labeled for a resident no longer at the facility, with a pharmacy dispense date of 5/7/22 and a manufacturer expiration date of 6/30/24. The Unit Manager stated she had worked on that cart many times but had never seen the package before, and explained that the drawer was an extra locked drawer used infrequently for overflow controlled medications. The DON confirmed that the third drawer was used for extra controlled medication storage and was infrequently accessed. She stated nurses and Medication Aides were supposed to check medication carts at the beginning of their shifts for discontinued or expired medications to remove and dispose of them or return them to the pharmacy, and that Unit Managers also periodically checked the carts. The DON said the naloxone package had been overlooked and should have been removed when the resident was discharged. The Administrator stated residents should have current medications as dispensed by the pharmacy and that discontinued or expired medications should not remain on the carts because they could cause a mix up or be given to residents when no longer effective.
Failure to Transcribe and Implement Hospital Discharge Orders for Diabetes Medication
Penalty
Summary
A deficiency occurred when the facility failed to accurately transcribe and implement a hospital discharge order for diabetes management for a resident with Type-2 diabetes mellitus and severe cognitive impairment. The hospital discharge summary specified an order for Janumet XR (metformin-sitagliptin extended release), but the facility entered and administered only metformin immediate release, omitting both the sitagliptin component and the extended-release formulation. The medication administration record showed the resident received only metformin 1000 mg once daily for several days following admission, rather than the prescribed combination medication. Interviews with facility staff and the consulting pharmacist confirmed that the order for Janumet XR was not entered or administered, and that metformin and Janumet XR are not equivalent medications. The pharmacist described this as a significant medication error, as the resident did not receive the intended glycemic control. The DON and Administrator both acknowledged that the facility's two-step order entry and verification process was not followed, as the same nurse entered and confirmed the orders without a second nurse's review, leading to the error.
Failure to Notify Provider of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the medical provider of abnormal laboratory results for a resident with multiple complex medical conditions, including Type-2 diabetes, hypertension, long-term anticoagulant use, metabolic encephalopathy, pancreatic cancer, hypo-osmolality, hyponatremia, anemia, hypothyroidism, and a urea cycle disorder. The resident was admitted with severe cognitive impairment and had physician orders for a comprehensive metabolic panel (CMP) and complete blood count (CBC) with differential. Laboratory samples were collected and results, which included several abnormal values such as high sodium, high chloride, elevated glucose, elevated liver enzymes, high white blood cell count, and low hemoglobin and hematocrit, were reported to the facility in the early morning hours. Despite the presence of multiple abnormal and potentially critical lab values, there was no documentation in the resident's electronic medical record from the time the results were received through several days afterward indicating that staff had notified the medical provider. Interviews with nursing staff revealed uncertainty about the process for receiving and communicating lab results, especially during a period when the Director of Nursing (DON) was on vacation and agency nurses were covering shifts. Nurses stated that abnormal results should be called to the provider immediately and documented, but none recalled receiving or reporting the results for this resident. The Physician Assistant (PA) confirmed that the results should have been reported to the on-call provider and that she did not review the labs until several days after they were received. The DON and Administrator both acknowledged that the process for ensuring lab results were reviewed and communicated to providers was not followed during this period. The DON explained that unless nurses specifically checked the electronic medical record or were informed during shift change, they might not be aware of new lab results. The Administrator noted that oversight was lacking due to staff transitions and the absence of the DON, and that unit managers were supposed to follow up on labs but there was only one unit manager available at the time. There was no evidence that the abnormal lab results were communicated to a provider in a timely manner.
Failure to Maintain Resident Dignity During Feeding Assistance
Penalty
Summary
Staff failed to promote care in a dignified manner for a resident who required assistance with eating. The resident, who had diagnoses of dysphagia and malnutrition and was cognitively intact, was observed during breakfast being fed by a nurse aide who stood beside the bed rather than sitting at eye level. The resident was positioned at a 45-degree angle in bed, and although a folding chair was available in the room, the nurse aide did not use it. The resident later expressed that she did not like staff standing over her while assisting with feeding. Interviews with facility staff revealed that the nurse aide was unaware that standing while feeding a resident was a dignity issue, citing conflicting training from previous workplaces. The unit manager and director of nursing both stated that their expectation was for staff to sit at eye level with residents during feeding assistance to maintain dignity, but could not explain why this expectation was not met in this instance.
Missed Medication Dose Due to Improper Order Readjustment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that medication orders were properly readjusted after being updated, resulting in a resident missing one dose of five prescribed medications. The resident, who had a history of stroke, insomnia, and bipolar disorder, was cognitively intact and able to communicate his needs. He expressed dissatisfaction with receiving medications late at night, prompting the unit manager to communicate his concerns to the physician. The physician approved changing the administration time of the resident's evening medications to an earlier hour, and the orders were updated accordingly. However, during the process of discontinuing the old medication orders and entering new ones, the Director of Nursing did not adjust the start date for the new orders, causing a gap in medication administration. As a result, the resident did not receive his scheduled doses of atorvastatin, depakote, ezetimibe, melatonin, and trazodone on the evening following the order change. Staff interviews confirmed that the medications did not appear on the electronic medication administration record for that evening, and the resident did not receive them. The resident did not report any adverse effects and remained alert and oriented.
Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
Staff failed to effectively intervene when two residents became agitated and began yelling at each other in a common area, resulting in one resident sustaining a skin tear after being struck on the hand with a cellphone by another resident. Both residents had documented histories of behavioral issues, including aggression and agitation, and their care plans included specific interventions to address escalating behaviors. Despite these documented risks and interventions, staff present in the lobby did not redirect or separate the residents when signs of agitation and verbal confrontation began. On the day of the incident, several residents and staff were gathered in the lobby watching bears outside the facility entrance. One resident, who was cognitively impaired and had a history of violent behaviors, became agitated after another resident, who was cognitively intact but anxious and verbally aggressive, began yelling about the bears. The two residents exchanged shouts of "shut up" before the cognitively impaired resident approached and struck the other with a cellphone. Staff present at the time were distracted by the bears and did not intervene to de-escalate the situation or remove either resident from the area prior to the physical altercation. Interviews with staff confirmed that they were aware of both residents' behavioral histories and care plan interventions but did not act to prevent the escalation. Staff acknowledged that they could have redirected or separated the residents but were focused on the unusual event of the bears outside. The incident resulted in a skin tear to one resident, which required first aid, and highlighted a lapse in supervision and adherence to established care plan interventions for residents with known behavioral risks.
Inaccurate MDS Coding for PASARR and High-Risk Drug Classes
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for several residents in the areas of Preadmission Screening and Resident Review (PASARR) and high-risk drug class usage, specifically anticoagulant, antipsychotic, and opioid medications. For one resident with high blood pressure and peripheral vascular disease, the MDS assessment incorrectly indicated anticoagulant use during the assessment period, while the Medication Administration Record (MAR) showed only aspirin was administered, not an anticoagulant. Another resident with cerebral infarction and bipolar disorder had completed a PASARR Level II assessment, but the annual MDS assessment failed to reflect this, and the quarterly MDS inaccurately coded the resident as receiving anticoagulant, antipsychotic, and opioid medications, despite the MAR showing none were administered during the relevant period. A third resident with a history of cerebrovascular accident was also incorrectly coded in the MDS as receiving anticoagulants, when only aspirin was ordered. Interviews with the MDS Coordinator revealed a misunderstanding regarding the classification of aspirin as an anticoagulant and acknowledged these coding errors. The Director of Nursing and the Administrator both stated their expectations for accurate MDS coding, but the assessments were not completed in accordance with established medication categories and PASARR evaluation status.
Failure to Refer Resident for PASARR Level II Evaluation After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed serious mental illness for a Pre-admission Screening and Annual Resident Review (PASARR) Level II evaluation. The resident was admitted with a diagnosis that included bipolar disorder, and medical records showed a new diagnosis of bipolar disorder was documented shortly after admission. A physician's order was placed for Depakote to address mood symptoms related to this diagnosis. Despite these developments, the annual Minimum Data Set (MDS) assessment indicated the resident was not considered by the state PASARR Level II process to have a serious mental illness, and no referral for a Level II evaluation was made. Interviews with facility staff, including the MDS Coordinator, Social Services Director (SSD), Corporate MDS Director, Administrator, and Director of Nursing (DON), confirmed that the process for referring residents with new serious mental health diagnoses for PASARR Level II screening was not followed. The SSD, who was responsible for making such referrals, acknowledged the oversight and could not provide an explanation for why the referral was missed. Other staff members confirmed their expectation that the referral should have been made according to regulatory guidance.
Catheter Drainage Bag and Valve Found Resting on Floor
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive uropathy and an indwelling urinary catheter was observed multiple times with the catheter drainage bag and drainage valve resting on the floor. The resident's care plan specified that the catheter bag and tubing should be positioned below the level of the bladder and away from the entrance room door. Despite this, observations on three separate occasions in one day revealed that the drainage bag was hanging from the bed frame but the drainage valve was unsecured and in contact with the floor, and at one point, the entire bag was on the floor beside the bed. Interviews with staff, including the nurse aide assigned to the resident, the assigned nurse, the DON, and the Administrator, confirmed that facility policy and standard practice require catheter bags and drainage valves to be kept off the floor to prevent contamination. The nurse aide admitted she had not checked the catheter bag during her shift, and the assigned nurse was unaware of the issue. Both the DON and Administrator acknowledged that the observed practice was not in accordance with infection control protocols.
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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 Asheville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerald Ridge Health And Rehabilitation | 2.8 mi | ★★★★★ | 19 | 1 |
| River Bend Health And Rehabilitation | 3.7 mi | ★★★★★ | 4 | 0 |
| The Laurels Of Summit Ridge | 4.3 mi | ★★★★★ | 2 | 0 |
| Elevate Health And Rehabilitation | 4.7 mi | ★★★★★ | 1 | 0 |
| The Greens At Weaverville | 4.8 mi | ★★★★★ | 7 | 0 |
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