Fleshers Fairview Health Care: Pressure Ulcer Risk Failures - NC
The assessment in question is called a Braden scale, a standardized tool nursing homes use to measure how likely a resident is to develop a pressure ulcer. Pressure ulcers, sometimes called bedsores, can begin as surface redness and progress to deep wounds that expose bone. They are painful, slow to heal in elderly patients, and in serious cases can become life-threatening. The Braden scale is supposed to be completed quarterly, at minimum, so that care plans can be updated and preventive measures put in place before skin breaks down.
For Resident 16, that hadn't happened since February.
When inspectors arrived in late September, the gap had stretched to roughly seven months. The administrator confirmed it directly: Resident 16 should have had a Braden assessment completed since February. Nobody had done one.
The Director of Nursing told inspectors that nurses on the floor had said they couldn't get to the assessments and that the MDS nurse should be handling them. The MDS nurse, whose role centers on the federally required assessments that drive care planning and Medicare billing, was the logical person to own that responsibility. But when inspectors pressed, the administrator said she had spoken with the MDS nurse earlier that same day. The MDS nurse had not known she was supposed to be checking that the Braden assessments were being completed, and had not known she was supposed to do them herself when they weren't.
The administrator said she had spoken with the MDS nurse earlier today.
That sentence, buried in the inspection record, carries its weight. The inspection was already underway. The conversation happened after investigators arrived, not before. It was a complaint inspection, meaning someone had already raised concerns serious enough to trigger a federal review. And still, as of that morning, the nurse whose job it was to catch this gap didn't know the gap existed, or that catching it was her responsibility.
The deficiency was cited at the "actual harm" level, meaning inspectors determined the lapse wasn't a paperwork problem. Something measurable and real had happened, or failed to happen, for a resident because the assessments weren't done. CMS reserves the actual harm designation for situations where the deficiency caused more than minimal discomfort or put a resident at more than theoretical risk.
Fleshers Fairview Health Care sits on Cane Creek Road in Fairview, a small community in Buncombe County outside Asheville. The facility is certified under CMS provider number 345413.
What the inspection record captures is a breakdown in the most basic layer of oversight: the person assigned to audit a safety process didn't know she had that assignment, the floor nurses assumed someone else was handling it, and the administrator learned the full picture only after a complaint brought inspectors through the door. The Director of Nursing described a system where accountability had simply fallen between roles, each pointing toward the other, and no one checking to see whether the work was actually getting done.
For Resident 16, the result was seven months without anyone formally evaluating whether their skin was at risk, whether their care plan needed adjustment, whether warning signs were being tracked. Whatever was or wasn't happening at the bedside, the clinical record carried no evidence that the question was being asked.
The inspection report does not describe what, if anything, happened to Resident 16's skin during those seven months. It does not say whether they developed a wound. What it says is that the harm was real, that the assessment gap was confirmed by the facility's own leadership, and that the nurse responsible for catching it learned of her responsibility the same morning inspectors came to ask why it hadn't been done.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fleshers Fairview Health Care from 2025-09-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 16, 2026 · Our methodology
Fleshers Fairview Health Care in Fairview, NC was cited for violations during a health inspection on September 22, 2025.
The assessment in question is called a Braden scale, a standardized tool nursing homes use to measure how likely a resident is to develop a pressure ulcer.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.