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 Givens Health Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, heart failure, and dementia had three documented unwitnessed falls in her room, each assessed by nursing staff as causing no injury. However, the annual MDS was coded to show no falls since the prior assessment. The MDS Coordinator, who reviewed the fall event history and completed the assessment, later acknowledged that the MDS should have been coded to indicate two or more falls without injury. The DON and Administrator both stated that MDS assessments are expected to be accurate and that this resident’s fall history should have been correctly reflected on the annual MDS.
The facility failed to maintain cleanliness and proper labeling in food service operations. Observations revealed dirty dishes on the tray line, unlabeled and undated food items in storage, and a dietary aide without a hair restraint. Staff interviews confirmed lapses in the dish cleanliness check process and uncertainty about food expiration dates.
Two residents in the facility did not have their Lidoderm pain patches removed at bedtime as ordered by their physicians. One resident with a spinal fracture and another with shoulder pain were found with patches still in place the following morning. The responsible nurse admitted to forgetting to remove the patches due to being busy. Both the physician and the DON emphasized the need for staff to follow physician orders.
A resident with acute respiratory failure and hypoxia was not provided supplemental oxygen per physician's orders due to a lack of monitoring of the portable oxygen tank. Observations showed the tank was almost empty or empty, and staff interviews revealed inconsistent monitoring practices. The Physician expected hourly checks, but there was confusion about the facility's protocol, and not all staff were trained to monitor the tanks.
Two residents in the facility had issues with inaccurate documentation regarding the removal of Lidoderm patches. A nurse documented the removal of the patches for both residents, but the patches were found still in place the following morning. The nurse admitted to documenting the task as completed but forgot to remove the patches due to being busy. The DON confirmed that documentation should only occur after task completion, and the Administrator emphasized the need for accurate documentation.
A facility failed to follow its Enhanced Barrier Precautions (EBP) policy when a Nursing Assistant (NA) was observed emptying a resident's urinary catheter bag without wearing a gown, despite signage and available PPE. Interviews revealed that the NA was aware of the EBP requirements but forgot to wear the necessary PPE. The physician and DON confirmed the expectation for staff to adhere to EBP protocols, and the Administrator noted that staff receive annual EBP education.
Inaccurate MDS Coding of Resident Fall History
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident by incorrectly coding the fall history section of the resident’s annual Minimum Data Set (MDS) assessment. The resident, admitted with diagnoses including Alzheimer’s disease, heart failure, and dementia, experienced three unwitnessed falls in her room during the assessment look-back period, as documented in nurse’s progress notes and a fall event record. Each time, the resident was found sitting on the floor and assessed by nursing staff, with documentation indicating no injury from any of the falls. Despite this documented fall history, the annual MDS assessment indicated that the resident had no falls since the prior assessment. During interviews, the MDS Coordinator confirmed she was responsible for completing the fall history on the annual MDS and that she reviewed the resident’s fall event history when coding the assessment. She acknowledged that, based on the documented falls occurring after the prior MDS, the annual MDS should have been coded to reflect two or more falls without injury. The DON and the Administrator both stated that MDS assessments are expected to be accurate and correctly coded, and that the annual MDS should have reflected that the resident had fallen since the prior assessment.
Deficiencies in Food Service Cleanliness and Labeling
Penalty
Summary
The facility failed to ensure cleanliness and proper labeling in their food service operations, as observed during a kitchen tour. Five out of thirty-six dishes ready for use on the tray line were found with dried crumb-like particles, indicating a lapse in the three-step dish cleanliness check process. This process involves checking dishes for cleanliness when removed from the dishwasher, when moved to storage, and when placed on the tray line. Interviews with dietary staff confirmed that these steps were not consistently followed, leading to the presence of dirty dishes on the tray line. Additionally, the facility did not provide expiration dates for several frozen pureed food items and failed to label and date a container of gravy and cookie sheets of bacon in a reach-in cooler. Dietary staff were uncertain about the shelf life of these items, with conflicting information provided regarding the duration for which frozen pureed foods remain usable. Furthermore, a dietary aide was observed without a hair restraint while checking food temperatures, despite having facial hair, which is against the facility's policy for food preparation. The administrator confirmed the expectation for staff to adhere to cleanliness and labeling procedures.
Failure to Remove Pain Patches at Bedtime
Penalty
Summary
The facility failed to ensure that pain patches were removed at bedtime as ordered for two residents. Resident #45, who was admitted with a wedge compression fracture and low back pain, was found with a Lidoderm patch still in place the morning after it was supposed to be removed. The Medication Aide observed the patch dated from the previous day, and Nurse #1 admitted to forgetting to remove it due to being busy. The physician and Director of Nursing both confirmed that the expectation was for staff to follow physician orders, which included removing the patch at bedtime. Similarly, Resident #31, who was admitted with shoulder pain, also had a Lidoderm patch left on overnight. The Medication Aide observed the patch still on the resident's shoulder the following morning. Nurse #1, who was responsible for the resident during the night, acknowledged forgetting to remove the patch. Both the physician and the Director of Nursing reiterated the importance of adhering to physician orders, which were not followed in these instances.
Failure to Monitor Resident's Supplemental Oxygen
Penalty
Summary
The facility failed to provide supplemental oxygen per physician's orders for a resident with acute respiratory failure and hypoxia. The resident was admitted with a requirement for supplemental oxygen at 2 to 3 liters per minute via nasal cannula. Observations on multiple occasions revealed that the resident's portable oxygen tank was either almost empty or completely empty, yet the resident was not in respiratory distress at those times. Staff interviews indicated a lack of consistent monitoring of the oxygen tank levels, with some staff members unaware of the need to check the tanks regularly. The Medication Aide and Nursing Assistant both acknowledged that they had not checked the resident's oxygen tank during the day, despite the expectation that portable oxygen tanks should be monitored periodically. The Physician expected hourly checks, but there was confusion about the facility's protocol for monitoring oxygen tanks. The Director of Nursing stated that various staff members were expected to check the tanks, but not all had been trained to do so. The Administrator deferred the issue to the clinical team, expecting all staff to ensure resident safety.
Inaccurate Documentation of Pain Patch Removal
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for two residents, leading to deficiencies in care. Resident #45 was admitted with a physician's order to apply a Lidoderm patch to the T12 spine area every morning and remove it at bedtime. However, on February 4, 2025, Nurse #1 documented the removal of the patch at 8:00 PM, but the patch was observed still in place the following morning. Nurse #1 admitted to documenting the task as completed but forgot to remove the patch due to being busy. The Director of Nursing confirmed that documentation should only occur after task completion. Similarly, Resident #31 had a physician's order to apply a Lidoderm patch to the right shoulder every morning and remove it at bedtime. On February 4, 2025, Nurse #1 documented the removal of the patch at 8:00 PM, but it was found still in place the next morning. Nurse #1 again admitted to documenting the task as completed but forgot to remove the patch. The Director of Nursing reiterated that documentation should reflect actual task completion. The Administrator deferred to the clinical team but emphasized the expectation for accurate documentation.
Failure to Follow Enhanced Barrier Precautions for Resident with Urinary Catheter
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a urinary catheter. Specifically, a Nursing Assistant (NA) was observed emptying a resident's urinary catheter bag without wearing a gown, which is a requirement under the facility's EBP policy. The policy, revised in June 2024, mandates the use of gowns and gloves during high contact resident care activities to reduce the transmission of multi-drug resistant organisms. Despite signage indicating the need for EBP and the availability of Personal Protective Equipment (PPE) outside the resident's room, the NA did not comply with the protocol. Interviews conducted with the NA, the physician, the Director of Nursing (DON), and the Administrator revealed gaps in adherence to and understanding of the EBP protocol. The NA acknowledged awareness of the EBP requirements but admitted to forgetting to wear the necessary PPE. The physician and DON both confirmed the expectation for staff to follow EBP protocols, particularly when providing direct care to residents with catheters. The Administrator stated that staff receive annual education on EBP, yet the incident indicates a lapse in protocol adherence during the observed care activity.
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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) |
|---|---|---|---|---|
| Deerfield Episcopal Retirement | 1 mi | ★★★★★ | 1 | 0 |
| Biltmore Haven Nursing And Rehabilitation | 2.5 mi | ★★★★★ | 2 | 2 |
| The Laurels Of Greentree Ridge | 4.3 mi | ★★★★★ | 0 | 0 |
| Fletcher Rehabilitation And Healthcare Center | 4.4 mi | ★★★★★ | 2 | 0 |
| Stonecreek Health And Rehabilitation | 5 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.