Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Nc State Veterans Home - Black Mountain during CMS and state inspections, most recent first.
The facility did not submit required Level II PASRR evaluation requests for four residents with serious mental health disorders, despite documented diagnoses such as PTSD, major depressive disorder, and bipolar disorder, and ongoing use of psychotropic medications. Medical records and care plans reflected active psychiatric conditions, but no evidence of Level II PASRR referrals was found. Interviews with the SW and Administrator revealed a lack of training and understanding of the PASRR process, resulting in no evaluations being requested for affected residents.
A Nurse Aide failed to follow droplet-contact isolation precautions for a resident with influenza, entering the room without cleaning hands or wearing a gown and gloves as required by posted instructions. The NA acknowledged the oversight, and facility leadership confirmed staff are expected to adhere to these infection control measures.
A facility failed to follow its abuse policy when a Nurse Aide observed a bed sheet used as a restraint on a resident's feet and wheelchair. The incident was not immediately reported to the Administrator, delaying investigation and reporting to the State Agency. Both nurses involved did not escalate the issue, despite discussing the inappropriateness of using a bed sheet as a restraint.
Two residents with severe cognitive impairments were involved in physical altercations, leading to one resident sustaining a hip fracture. The incidents occurred in a memory support unit, where staff were not present to intervene. The first altercation involved one resident intentionally bumping his walker into the other's chair, leading to a fall. In the second incident, the same resident fell after the other tripped over his walker, causing a serious injury. The lack of supervision and staff presence contributed to the deficiency.
The facility failed to effectively address and communicate resolutions to concerns raised by residents during Resident Council meetings over several months. Issues such as speeding vehicles, medication delivery times, and maintenance problems were not adequately followed up on, leading to resident dissatisfaction. Despite attempts to reassure residents, the facility lacked a structured plan for ensuring residents were informed about the status of their concerns.
The facility failed to secure medications and adhere to storage guidelines, resulting in deficiencies. A resident's zinc oxide ointment was left unattended by a nurse, and expired medications, including Latanoprost eye drops and Mucinex tablets, were found in medication carts. Nurses acknowledged the errors, citing distractions and unclear responsibilities.
The facility failed to discard spoiled and expired food items in the walk-in refrigerator and freezer, including lettuce with browning leaves, celery with a white fuzzy substance, and expired cinnamon rolls. The Dietary Manager acknowledged that these items should have been discarded during routine checks, but they were overlooked. The Interim Administrator expected adherence to regulatory standards for food storage.
The facility failed to provide SNF ABN notices to two residents before the end of their Medicare Part A skilled services. NOMNCs were discussed with the responsible parties, but SNF ABNs were not issued due to a lack of awareness and process oversight by the Business Office Manager and MDS Coordinators.
A nurse aide in an LTC facility took an unauthorized video of a resident with severe cognitive impairment interacting with a Santa Claus mannequin and sent it to a nurse via a cellphone messenger app. Both staff members acknowledged the violation of privacy policy, stating there was no intent to harm or share the video beyond their communication. The facility's investigation confirmed the breach of privacy, and the incident was reported to the State Agency and Ethics Committee.
A facility failed to obtain an x-ray for a resident with non-pressure skin conditions as ordered by the Wound Care NP. The resident had increased tenderness and redness in the right foot, and the NP instructed the Wound Care Nurse to order an x-ray, but it was not entered into the system. The NP did not know how to enter the order, and the Wound Care Nurse did not verify its placement. The x-ray was performed later, showing no fracture or osteomyelitis.
The facility did not provide ongoing communication about resident rights, as revealed by a review of Resident Council meeting minutes and interviews. Residents confirmed that rights were not discussed during meetings, and the Activities Director, unaware of her responsibility, had not reviewed them since taking over. The Interim Administrator noted that reviewing rights was standard practice in her previous roles.
Failure to Submit Level II PASRR Evaluations for Residents with Serious Mental Health Disorders
Penalty
Summary
The facility failed to submit requests for Level II Preadmission Screening and Resident Review (PASRR) evaluations for four residents who had serious mental health disorders. Each of these residents had a Level I PASRR determination with no expiration date and were admitted with diagnoses such as PTSD, major depressive disorder, bipolar disorder, delusional disorder, and anxiety. Despite having active psychiatric diagnoses and receiving psychotropic medications, there was no documentation in their medical records that a Level II PASRR evaluation had been requested or completed for any of these residents. For each resident, medical records and care plans indicated ongoing mental health concerns and the use of medications such as antidepressants, anticonvulsants, and antianxiety agents. Psychiatric and physician progress notes documented the presence and management of these mental health conditions, including follow-up visits and medication adjustments. However, the facility was unable to provide evidence that the required Level II PASRR evaluations had been initiated, even when new or ongoing mental health diagnoses were identified after admission. Interviews with the Social Worker (SW) and Administrator revealed a lack of knowledge and training regarding the PASRR process. The SW, who took over the PASRR responsibilities in April, stated she had not been shown what to do or what to look for regarding Level II PASRR referrals and had not submitted any requests for evaluations. The Administrator, who also started in April, confirmed uncertainty about whether any Level II PASRR requests had been made and was unable to locate any documentation to that effect. Both indicated an expectation that referrals should be made when residents are admitted with mental health diagnoses or when new diagnoses are identified, but this was not occurring in practice.
Failure to Follow Droplet-Contact Isolation Precautions for Resident with Influenza
Penalty
Summary
A deficiency occurred when a Nurse Aide (NA) failed to follow the facility's infection control policy and procedures regarding droplet-contact isolation precautions for a resident who had tested positive for influenza A. The facility's policy required that residents with influenza be placed on droplet-contact precautions for seven days, with specific instructions posted on the resident's door. These instructions included cleaning hands before entering and when leaving, and wearing a gown, face mask, and gloves upon entry, with removal of PPE before exiting. During a meal tray service observation, the NA entered the resident's room wearing only a face mask, without cleaning her hands or donning a gown and gloves as required by the posted instructions. The NA acknowledged awareness of the infection control training and the posted precaution sign but stated she had forgotten to follow the instructions before entering the room. Interviews with the Infection Preventionist, DON, and Administrator confirmed that the expectation was for staff to read and adhere to the posted droplet-contact precaution instructions before entering the room of a resident on isolation. The failure to follow these procedures was directly observed and confirmed through staff interviews.
Failure to Report Alleged Restraint Use
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding the immediate reporting of an alleged use of physical restraint on a resident. A Nurse Aide observed a bed sheet wrapped around a resident's feet and wheelchair, which restricted the resident's movement. The Nurse Aide removed the sheet and informed a nurse, but did not immediately report the incident to the Administrator as required by the facility's policy. The incident was not promptly communicated to the Director of Nursing (DON) or the Administrator, resulting in a delay in the investigation and reporting to the State Agency. Nurse #1, who was informed of the incident by Nurse #2, did not report it to the Administrator or DON. Nurse #2, who discussed the incident with the staff, also failed to report it to the higher authorities, despite acknowledging that the use of a bed sheet as a restraint was unacceptable. The Director of Nursing and the Interim Administrator were unaware of the incident until it was brought to their attention by the surveyor. The facility's policy mandates that any concerns of abuse, even if uncertain, should be reported immediately to the Administrator or DON for investigation. The delay in reporting and investigating the incident highlights a breakdown in communication and adherence to the facility's abuse prevention policies.
Failure to Prevent Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when two residents were involved in physical altercations, resulting in one resident sustaining a serious injury. Resident #33, who had severe cognitive impairment and used a walker for mobility, was involved in two incidents with Resident #324, who also had severe cognitive impairment and a history of behavioral issues. During the first altercation, Resident #33 intentionally bumped his walker into Resident #324's chair, prompting Resident #324 to pull Resident #33 to the floor. Resident #33 was able to get up and walk away after this incident. In the second altercation, Resident #33 was banging his walker into a door when Resident #324 approached him again. As Resident #324 attempted to engage with Resident #33, he tripped over the wheel of the walker, causing Resident #33 to fall and sustain a left hip fracture. The fall was unwitnessed, and staff were not present in the area to intervene or prevent the altercation. The incident was captured on video footage, which was later reviewed by the facility's former Administrator and Director of Nursing. The facility's staff, including nurses and nurse aides, were not adequately monitoring the residents, particularly in the memory support unit where the altercations occurred. The lack of staff presence and supervision in the area where the incidents took place contributed to the deficiency, as staff were unable to prevent or deescalate the situation between the two residents. The facility's failure to ensure proper supervision and intervention led to the serious injury of Resident #33.
Deficiency in Addressing Resident Council Concerns
Penalty
Summary
The facility failed to effectively address and communicate resolutions to concerns raised by residents during Resident Council meetings over a period of several months. The Resident Council minutes from August 2023 to June 2024 revealed that residents consistently expressed doubts about the facility's responsiveness to their concerns, such as speeding vehicles around the facility, medication delivery times, and maintenance issues like the stabilization of a birdhouse. Despite the facility's attempts to reassure residents and propose resolutions, there was a lack of follow-up communication to confirm whether these issues were resolved, as indicated by the incomplete sections on the Resident Council Response Forms. Interviews with residents and staff highlighted the ongoing dissatisfaction with the facility's communication process. Residents expressed that they often received vague responses such as "we are working on it" or "we can't do that," without any satisfactory resolution or feedback on the actions taken. The Resident Council President acknowledged that while some issues might take time to resolve, clear communication about the steps being taken would be appreciated. The Activity Director, responsible for recording meeting minutes, confirmed that resolutions were typically reported back at the next meeting, but the documentation of these follow-ups was lacking. The Interim Administrator, who had previously served in the facility, noted that during her tenure, Town Hall meetings were used to discuss concerns and communicate the facility's responses. However, the current process seemed to lack a structured plan for ensuring residents were informed about the status of their concerns. This deficiency in communication and follow-up contributed to the residents' perception that their issues were not being adequately addressed.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to secure medications properly and adhere to storage guidelines, leading to several deficiencies. In one instance, zinc oxide ointment was left unattended in a resident's room. The resident, who had dermatitis and was not approved for self-administration of medication, found the ointment left by a nurse who was distracted by another resident's call for help. The nurse acknowledged leaving the ointment unattended, which was against the facility's protocol. Additionally, the facility did not remove expired medications from the medication carts. An opened bottle of Latanoprost eye drops was found in a medication cart, stored at room temperature beyond the manufacturer's recommended period. A nurse admitted to not knowing the specific storage guidelines for the eye drops. Furthermore, expired Mucinex tablets were found in another medication cart, with the nurse attributing the oversight to the night shift's responsibility and the consultant pharmacist's monthly checks. Both nurses acknowledged the expired medications should have been discarded.
Failure to Discard Spoiled and Expired Food
Penalty
Summary
The facility failed to properly manage food storage in both the walk-in refrigerator and freezer, leading to the presence of potentially hazardous and expired food items. During an observation of the walk-in refrigerator, surveyors found two unopened bags of green leaf lettuce with browning leaves and brown liquid, as well as a box of celery with a white fuzzy substance, indicating spoilage. Additionally, an open box of cinnamon rolls with an expired date was found in the walk-in freezer. Interviews with the Dietary Manager revealed that a dietary staff member was responsible for checking expiration dates and spoiled food weekly, but these items were overlooked. The Interim Administrator expressed that her expectation was for kitchen food storage to adhere to regulatory standards, ensuring expired or moldy foods are removed and disposed of.
Failure to Issue SNF ABN Notices
Penalty
Summary
The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) to two residents prior to the termination of their Medicare Part A skilled services. For Resident #12, the Notice of Medicare Non-Coverage (NOMNC) was discussed with the responsible party on April 2, 2024, indicating that Medicare Part A coverage would end on April 4, 2024. However, there was no evidence in the medical record that a SNF ABN was reviewed with or provided to Resident #12 or their responsible party. The Business Office Manager confirmed that a SNF ABN was not issued because the Minimum Data Set (MDS) Coordinators did not forward it along with the NOMNC, and she was unaware that both notices were required. Similarly, for Resident #70, the NOMNC was discussed with the responsible party on May 16, 2024, indicating that Medicare Part A coverage would end on May 20, 2024. Again, there was no evidence that a SNF ABN was reviewed with or provided to Resident #70 or their responsible party. The Business Office Manager confirmed that a SNF ABN was not issued due to the same oversight. The Interim Administrator acknowledged that the process for issuing the required notices had changed, which led to the SNF ABN not being issued, as the MDS Coordinators were responsible for forwarding both the NOMNC and SNF ABN to the Business Office Manager for review with the resident or their responsible party.
Unauthorized Video Recording of Resident
Penalty
Summary
The facility failed to protect a resident's right to privacy when a nurse aide used her cellphone to take an unauthorized video of a resident displaying behaviors and sent the video to a nurse via a cellphone messenger application. The resident involved, who had severe cognitive impairment due to Alzheimer's disease and dementia, was observed by the nurse aide engaging with a Santa Claus mannequin in a tender manner. The nurse aide, who was aware of the facility's policy against using cellphones to record residents, took the video to show the nurse the resident's behavior, which she had not seen before. The incident was reported to the facility on the same day it occurred, and an investigation was initiated. Both the nurse aide and the nurse confirmed the video was taken and shared, but they stated there was no intent to harm or share the video beyond their communication. The video was not posted on social media and was deleted from their devices. The facility's investigation found no malicious intent, but it was acknowledged that the action violated the resident's privacy rights. The former Director of Nursing confirmed the facility's policy prohibits staff from taking photographs or videos of residents. The incident was reported to the State Agency and the facility's Ethics Committee. The interim administrator emphasized that communication about residents should be verbal and that taking videos of residents is unacceptable.
Failure to Obtain Timely X-ray for Resident
Penalty
Summary
The facility failed to obtain an x-ray as ordered by the Wound Care Nurse Practitioner (NP) for a resident with non-pressure skin conditions, specifically to rule out a possible fracture and osteomyelitis. The resident, who had diagnoses including peripheral vascular disease and cellulitis of the right toe, was noted to have increased tenderness and redness in the right foot. The Wound Care NP had instructed the Wound Care Nurse to order an x-ray, but the order was not entered into the system, and the x-ray was not performed until several days later. Interviews revealed that the Wound Care NP did not know how to enter orders for diagnostic x-rays into the electronic medical record, and assumed the x-ray had been refused by the resident. The Wound Care Nurse uploaded the NP's progress note but did not verify that the x-ray order was in place. The Director of Nursing (DON) and the Interim Administrator expected the NP to enter the order, but it was not done until the deficiency was identified. The x-ray was eventually performed, showing no fracture or osteomyelitis.
Failure to Communicate Resident Rights
Penalty
Summary
The facility failed to provide ongoing communication to residents regarding their rights in a nursing home setting. This deficiency was identified through a review of Resident Council meeting minutes and interviews with residents and staff. The review of meeting minutes from May 11, 2023, through August 15, 2024, showed no evidence that resident rights were discussed. During a group interview, several residents confirmed that resident rights were not discussed during or outside of the Resident Council meetings. One resident mentioned that while he could access the posted resident rights, not all residents had the same ability. The Activities Director, who took over the position in May 2024, admitted to not reviewing resident rights during the meetings, as she was unaware it was part of her responsibilities. The Interim Administrator noted that in her previous experience, resident rights were typically reviewed during these meetings.
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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 Black Mountain
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Farms | 1.2 mi | ★★★★★ | 3 | 0 |
| Mountain Ridge Rehabilitation And Healthcare Cente | 3.4 mi | ★★★★★ | 2 | 2 |
| Black Mountain Neuro-medical Treatment Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Swannanoa Valley Health And Rehabilitation | 4.3 mi | ★★★★★ | 4 | 0 |
| The Laurels Of Summit Ridge | 6.7 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.