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 The Laurels Of Summit Ridge during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
Surveyors found undated bags of shredded cheese and unsanitary conditions in a walk-in refrigerator, including a dripping cooling unit pipe and a white, fuzzy substance on the pipe and walls. Staff interviews revealed a lack of awareness regarding the issues and uncertainty about the cleaning schedule.
Two residents who previously used assist bars or side rails to assist with bed mobility and transfers had these devices removed following a corporate directive, without individualized assessments or therapy input. Both residents experienced increased difficulty and required more staff assistance after device removal, despite prior independence and therapy recommendations supporting the use of these devices.
Surveyors found that a shower room floor with missing and broken tiles was used for resident showers, despite the damaged area being present for several weeks. Staff and management were aware of the issue, but repairs had not been made, and the area continued to be used for resident care.
A Floor Technician entered a resident's room on enhanced droplet precautions for COVID-19 without wearing the required N95 mask, gown, or eye protection, as mandated by facility policy and posted signage. The technician, who was filling in for a housekeeper, wore only a surgical mask and gloves and later acknowledged not following the PPE protocol despite recent infection control training.
A resident with multiple chronic conditions, including diabetes, was not provided with necessary fingernail care, resulting in overgrown and dirty nails. Despite being care planned for assistance with activities of daily living and having a history of refusing showers, staff failed to notice or report the need for nail care, and the resident's nails remained untrimmed and uncleaned for an extended period.
A nurse failed to administer a prescribed Vitamin B12 tablet and gave the wrong dose of Guaifenesin to a resident with COPD and anemia, resulting in a medication error rate of 6.45%. The errors occurred when the nurse omitted the Vitamin B12 and administered a 400 mg Guaifenesin tablet instead of the ordered 600 mg, using what was available from stock. The DON confirmed that the correct strength could have been ordered from the pharmacy.
A resident continued to receive trazadone daily despite a physician's order to change it to PRN and then discontinue it. The DON failed to update the MAR, leading to the medication being administered daily for several months.
The facility failed to remove expired thickened liquids from two nourishment room refrigerators. The Dietary Manager admitted to overlooking the expired items, which were found during an observation. The Administrator confirmed that expired items should be discarded.
The facility failed to ensure all trash was disposed of inside the dumpster. Two full and tied trash bags were found lying on the ground beside the dumpster. The Dietary Manager was unaware of how long the trash bags had been there and stated that kitchen, housekeeping, and nursing staff were responsible for disposing of trash into the dumpsters. The Administrator confirmed that trash should be disposed of in the dumpsters and not left on the ground.
The facility's QAA Committee failed to maintain infection control procedures, resulting in a repeat deficiency. Staff did not follow standard precautions during laundry services, and similar issues were observed in a previous survey. This indicates a pattern of non-compliance with infection control protocols.
The facility failed to implement infection control policies for laundry services when a staff member did not follow standard precautions. The Laundry Staff transported a soiled linen bin, allowing clean resident shirts to rub against it, and did not wash her hands after removing gloves or handling contaminated items. The Housekeeping/Laundry Supervisor and Infection Preventionist confirmed the need for proper hand hygiene, and the Director of Nursing planned to follow up on the issue.
A resident with minimal cognitive impairment and limited mobility was unable to reach the call bell, which was improperly placed on the right side of the bed despite the care plan indicating it should be within reach. Multiple observations and interviews confirmed the resident's difficulty in accessing the call bell, leading to reliance on the roommate for assistance.
The facility failed to maintain accurate advanced directive information for a resident, leading to discrepancies in the resident's code status documentation. Despite the resident's preference against a feeding tube, the EHR and progress notes reflected outdated information, causing confusion among staff during emergencies. The process for updating and verifying code status information was inconsistent, with no interim checks to ensure the most current directives were followed.
The facility failed to complete a Level II PASRR for a resident with a new mental health diagnosis. Despite the resident being prescribed medication for mood disorder and having a new primary diagnosis of bipolar disorder, no new PASRR Level II was completed due to lack of training and coordination among staff.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Undated Food and Unsanitary Conditions in Walk-In Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to date leftover food stored in the walk-in refrigerator, specifically noting two opened and undated bags of shredded cheese on a storage rack. Additionally, the walk-in refrigerator's cooling unit pipe was found to be dripping water onto the floor and wall, and both the pipe and the refrigerator walls had a white, fuzzy substance present. Staff interviews confirmed that the cheese should have been dated for use within seven days and that the walk-in refrigerator's cleaning schedule was unclear, with no one able to state when it was last deep cleaned. Further interviews revealed that neither the dietary staff nor the Maintenance Director were aware of the dripping pipe or the presence of the substance on the pipe and walls. The temporary Dietary Manager acknowledged that the refrigerators should be deep cleaned quarterly but was unaware of the last cleaning. The Administrator confirmed that food should be dated when stored and that the refrigerator should be routinely cleaned and maintained to prevent such issues.
Failure to Accommodate Resident Needs for Bed Mobility and Transfers
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents by not providing assist bars or side rails, which were previously used to maximize their independence with transfers and bed mobility. For one resident with chronic obstructive pulmonary disease, spinal issues, and generalized muscle weakness, assist bars had been assessed as beneficial and low risk for entrapment. Despite this, the assist bars were removed following a corporate directive to reduce device use, without consulting therapy or conducting a new individualized assessment. The resident reported increased difficulty with bed mobility and transfers after the removal, and staff interviews confirmed that the resident had previously been independent with these activities when assist bars were in place. Another resident with chronic kidney disease and cervical disc degeneration also had side rails removed, which she had used to reposition herself in bed. The removal was carried out by staff without a documented risk assessment or observation, and the resident was not consistently able to follow directions according to the unit manager. The resident reported that she now required staff assistance to roll in bed, whereas she had previously been mostly independent. Therapy staff indicated that the resident would benefit from side rails to improve her bed mobility, and nurse aides confirmed the resident's increased dependence on staff since the removal of the side rails. The decision to remove assistive devices was based on a corporate directive to use the least restrictive interventions and reduce device use for safety reasons. However, the process did not consistently involve therapy input or individualized assessments prior to device removal. Residents and therapy staff were not always consulted, and documentation of risk assessments was lacking. As a result, residents who had previously demonstrated independence with the use of assistive devices experienced a decline in their ability to perform bed mobility and transfers independently.
Damaged Shower Room Floor Not Repaired, Used for Resident Showers
Penalty
Summary
Surveyors observed that the facility failed to maintain the shower room floor in good repair, resulting in a damaged area with 22 missing and broken tiles at the front of the shower area. The damaged section measured approximately one foot by one foot, with several tiles loose, unattached, or broken into pieces, creating an irregular and potentially hazardous surface. The observation was made while the shower area was still wet from recent use, and it was noted that a resident's feet could come into contact with the damaged area while in a shower chair. Staff interviews revealed that the damaged tiles had been present for about six weeks to a couple of months, and the area continued to be used for resident showers despite the condition. The Unit Manager and Maintenance Director were aware of the issue, with the Maintenance Director stating that repairs were delayed until other flooring projects were completed. The Administrator was also aware of the damage but believed the shower room was not in use, although staff and observations confirmed otherwise.
Failure to Follow Enhanced Droplet Precaution PPE Requirements
Penalty
Summary
A deficiency occurred when a Floor Technician entered the room of a resident who was on enhanced droplet precautions for a recent COVID-19 diagnosis. The facility's policy and posted signage required staff to wear an N95 mask, gown, gloves, and eye protection before entering rooms under these precautions. Despite this, the Floor Technician entered the resident's room wearing only a surgical mask and gloves, and did not don the required N95 mask, gown, or eye protection. The technician was in the room for approximately 10 seconds to check the trash can, which was located about four feet from the resident's bed. The Floor Technician later confirmed in an interview that he was aware of the enhanced droplet precaution signage but did not realize he needed to wear the full set of PPE before entering. He stated that he typically did not enter resident rooms and was filling in for a housekeeper on that day. Both the Infection Preventionist and the Director of Nursing confirmed that all staff, regardless of their usual assignments, were expected to follow the posted PPE requirements for rooms under enhanced droplet precautions.
Failure to Provide Fingernail Care for Dependent Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate fingernail care for a resident with multiple diagnoses, including dementia, Parkinson's Disease, type 2 diabetes, and osteoarthritis. The resident was care planned for functional ability deficits and required assistance with self-care and mobility, as well as frequent re-approach for care refusals. Observations revealed that the resident's fingernails were approximately 1/2 inch past the fingertips and contained a black substance underneath. The resident reported that it had been a couple of months since his fingernails were last cut or cleaned by staff, and that he had not attempted to care for his own nails. He also stated he was told by a nurse aide that only a nurse could trim his nails due to his diabetes, but no action was taken to address his nail care needs. Interviews with the assigned nurse aide and nurse confirmed that while nail care was part of the shower routine, the aide did not notice the condition of the resident's nails and did not report the need for nail care to the nurse. The nurse was unaware of the resident's nail condition and had not attempted to trim the nails prior to being informed. The resident also reported not being offered nail care during refusals of showers or baths, and the nurse aide did not communicate the need for nail care to the nurse. Facility policy required that long nails of diabetic residents be reported to a nurse for appropriate care, but this was not followed, resulting in the resident's fingernails remaining untrimmed and uncleaned for an extended period.
Medication Error Rate Exceeds 5% Due to Omission and Wrong Dosage
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 31 opportunities during a medication pass for one resident. The first error involved the omission of a prescribed Cyanocobalamin (Vitamin B12) tablet, which was not administered to a resident with chronic obstructive pulmonary disease (COPD) and anemia, despite an active physician's order. Nurse #1, who was responsible for the medication pass, confirmed during an interview that she missed giving the Cyanocobalamin tablet and it was not included among the medications administered. The second error occurred when Nurse #1 administered the wrong dosage of Guaifenesin, giving a 400 mg tablet instead of the ordered 600 mg extended-release tablet for COPD. Nurse #1 stated that she used what was available from the stock bottle, which only contained 400 mg tablets, and did not realize the discrepancy at the time of administration. The Director of Nursing confirmed that Guaifenesin is typically available in different strengths and that the correct dosage could have been ordered from the pharmacy if not in stock. Nurse #1 was newly assigned to the medication cart after several weeks of orientation.
Failure to Discontinue Psychotropic Medication as Ordered
Penalty
Summary
The facility failed to follow a physician's order to discontinue a psychotropic medication for a resident diagnosed with insomnia and anxiety. The resident was admitted with these diagnoses and had been receiving trazadone 25 mg daily since the order was placed. Despite a pharmacy recommendation to attempt a gradual dose reduction (GDR) and a subsequent physician's order to change the medication to PRN for two weeks before discontinuing it, the medication continued to be administered daily. This oversight was due to the Director of Nursing (DON) failing to update the medication administration record (MAR) with the new physician's order. The deficiency was identified during a review of the resident's records, which showed that the trazadone was administered daily from December 2023 through March 2024, contrary to the physician's order. Interviews with the DON and the Medical Director (MD) confirmed that the order was overlooked and not implemented. The MD stated that his orders should be followed, and the missed GDR order did not cause harm to the resident.
Expired Thickened Liquids Found in Nourishment Room Refrigerators
Penalty
Summary
The facility failed to remove expired thickened liquids from two of three nourishment room refrigerators, specifically in the 100 Unit and 300 Unit nourishment rooms. During an observation with the Dietary Manager (DM), it was found that the 100-unit nourishment room refrigerator contained three unopened 4 oz thickened liquid containers with an expiration date that had passed. Similarly, the 300-unit nourishment room refrigerator contained three unopened 4 oz thickened liquid containers with another past expiration date and one unopened 4 oz thickened liquid container with a different past expiration date. The DM admitted responsibility for checking the refrigerators daily for expired items and replenishing them as needed but acknowledged that he had overlooked the expired thickened liquids. The Administrator confirmed that expired thickened liquids should be removed and discarded, and no expired items should be present in the nourishment room refrigerators.
Improper Disposal of Trash
Penalty
Summary
The facility failed to ensure all trash was disposed of inside the dumpster, as observed on 3/20/24 at 10:41 AM. Two full and tied trash bags were found lying on the ground beside the dumpster. The Dietary Manager (DM) was unaware of how long the trash bags had been there and stated that kitchen, housekeeping, and nursing staff were responsible for disposing of trash into the dumpsters. The DM also mentioned that the dumpsters were emptied on Monday and Friday and were not full at the time of observation. The Administrator confirmed on 3/21/24 at 12:46 PM that trash should be disposed of in the dumpsters and not left on the ground, emphasizing that it was everyone's responsibility to ensure proper disposal.
Repeat Deficiency in Infection Control
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions following a complaint survey conducted on 10/1/21. This resulted in a repeat deficiency for infection control, which was also cited during the recertification and complaint investigation survey completed on 3/21/24. Specifically, the facility failed to implement their infection control policies for laundry services when a staff member did not follow standard precautions during an infection control observation. During the initial complaint survey, a staff member failed to sanitize her hands after handling soiled linen and before assisting a resident, and another staff member failed to properly bag a resident's urinals before placing them in the bathroom. These actions were observed again during the follow-up survey, indicating a pattern of non-compliance with infection control protocols.
Failure to Follow Infection Control Policies in Laundry Services
Penalty
Summary
The facility failed to implement their infection control policies for laundry services when a staff member did not follow standard precautions during an infection control observation. The Laundry Staff was observed transporting a soiled linen bin while wearing short gloves, which allowed clean resident shirts to rub against the soiled bin. After removing her gloves, she did not wash her hands and proceeded to touch clean items, including a stack of washcloths. Additionally, she handled a bag of soiled laundry without washing her hands afterward and then touched clean mop heads. The Laundry Staff admitted to being trained to wear gloves when handling soiled linens but did not follow proper hand hygiene protocols due to limited workspace in the laundry room. The Housekeeping/Laundry Supervisor confirmed that the Laundry Staff should have washed her hands with soap and water after removing gloves and when handling contaminated items. The Infection Preventionist stated that all staff were trained in infection control practices during orientation and were expected to follow standard precautions, including hand hygiene. The Director of Nursing indicated that she would follow up with the Infection Preventionist to discuss a plan of action. The deficiency was observed during a survey, highlighting a failure to adhere to infection control policies in the laundry services area.
Failure to Maintain Call Bell Within Reach
Penalty
Summary
The facility failed to maintain the call bell within reach for a resident with minimal cognitive impairment and limited mobility. The resident, who has a contracted neck and leans to the left side, was unable to reach the call bell that was hanging off the right side of the bed. Despite the care plan indicating that the call bell should be within reach and the resident encouraged to use it for assistance, multiple observations over two days showed the call bell remained out of reach. Interviews with the resident, the resident's roommate, and a nurse aide confirmed that the resident was unable to access the call bell and had requested it be placed on the left side of the bed. The resident's inability to reach the call bell led to situations where the resident had to rely on the roommate to call for assistance. The nurse aide acknowledged the improper placement of the call bell but did not rectify the situation. The facility administrator was unaware that the resident could use the call bell and believed the resident would either yell for help or rely on the roommate. This misunderstanding and failure to follow the care plan resulted in the resident's needs not being promptly addressed.
Failure to Maintain Accurate Advanced Directive Information
Penalty
Summary
The facility failed to maintain accurate advanced directive information for a resident, leading to discrepancies in the resident's code status documentation. Resident #18, who was cognitively intact, had conflicting Medical Orders for Scope of Treatment (MOST) forms in his electronic health record (EHR) and the nurses' station book. The MOST form dated 11/14/23 indicated the resident wanted a feeding tube for a defined trial period, while the form dated 12/27/23 indicated he did not want a feeding tube. Despite the updated form, the EHR and subsequent progress notes continued to reflect the older code status information, causing confusion among the staff about the resident's current wishes regarding a feeding tube. Interviews with the resident confirmed he did not want a feeding tube, but this preference was not accurately documented in the facility's records. The staff, including the charge nurse and unit manager, relied on outdated information during emergencies, which could have led to inappropriate medical interventions. The process for updating and verifying code status information was inconsistent, with no checks in place to ensure the most current directives were followed. The facility's Director of Nursing acknowledged the lack of interim checks and the reliance on care plan meetings to review code status forms, highlighting a gap in the facility's procedures for maintaining accurate and up-to-date advanced directive information.
Failure to Complete Level II PASRR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with a new mental health diagnosis. Resident #36, who was admitted with diagnoses including adjustment disorder, unspecified mood disorder, generalized anxiety, and major depressive disorder, had a halted Level II PASRR. Despite a new primary diagnosis of bipolar disorder and being prescribed Valproic Acid for mood disorder, no new PASRR Level II was completed. The resident's annual Minimum Data Set (MDS) did not consider her to have a serious mental illness according to the state Level II PASRR. Interviews with staff revealed a lack of training and coordination in handling PASRR referrals. The Social Worker (SW) and Admission Coordinator were not adequately trained, and the Business Office Manager, who was responsible for compliance, was not notified of the resident's new diagnosis. The facility's process involved checking PASRR on admission and submitting necessary information through the North Carolina web portal, but this was not effectively communicated or executed in the case of Resident #36. The Administrator acknowledged the oversight and indicated that the facility would develop a plan of correction.
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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) |
|---|---|---|---|---|
| Swannanoa Valley Health And Rehabilitation | 2.5 mi | ★★★★★ | 4 | 0 |
| The Laurels Of Greentree Ridge | 3.2 mi | ★★★★★ | 0 | 0 |
| Elevate Health And Rehabilitation | 3.8 mi | ★★★★★ | 4 | 1 |
| Stonecreek Health And Rehabilitation | 4.3 mi | ★★★★★ | 0 | 0 |
| Bear Mountain Health And Rehabilitation | 4.3 mi | ★★★★★ | 2 | 0 |
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