Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Bear Mountain Health And Rehabilitation during CMS and state inspections, most recent first.
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 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 | ★★★★★ | 11 | 1 |
| River Bend Health And Rehabilitation | 3.7 mi | ★★★★★ | 4 | 0 |
| The Laurels Of Summit Ridge | 4.3 mi | ★★★★★ | 0 | 0 |
| Elevate Health And Rehabilitation | 4.7 mi | ★★★★★ | 4 | 1 |
| The Greens At Weaverville | 4.8 mi | ★★★★★ | 0 | 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.