Bear Mountain Health And Rehabilitation
Inspection Findings
F-Tag F0658
F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
was conducted with the Director of Nursing (DON) on 12/30/25 at 12:17 PM the DON stated Janumet XR was ordered for Resident #1 on her hospital discharge summary. She said Nurse #1 entered the wrong medication for Resident #1 in the electronic computer system. She reported one nurse was supposed to enter the admission orders into the electronic computer system and then a second nurse was supposed to
review and confirm the orders to make the orders active. The DON explained Nurse #1 had entered and confirmed the admission orders for Resident #1 and the orders had not been checked by a second nurse.
The DON stated she thought the error would have been caught if the orders had been checked by a second nurse.An interview was conducted with the Administrator on 12/30/25 at 4:19 PM. The Administrator said orders should be put in according to the hospital discharge summary and entered accurately into the electronic computer system. She stated from her knowledge there was a two-step process for putting in and checking admission orders. The Administrator explained Nurse #1 was a new nurse and thought she may not have known the facility process.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/30/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bear Mountain Health and Rehabilitation
500 Beaverdam Road Asheville, NC 28804
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0773
F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
provider was notified of Resident #1's lab results. The DON reviewed Resident #1's labs that were drawn on 9/5/25 and confirmed they were not reviewed by the PA until 9/9/25. After reviewing the lab report results,
the DON said Resident #1's sodium was high, chloride was high, glucose was high, and white blood cells were high. The DON stated yes the labs should have been called to the provider. The DON explained she normally checked all the labs but had been on vacation that week. She said the Unit Managers were supposed to cover for her and make sure everything was done while she was on vacation but there had only been one Unit Manager at the time.An interview was conducted with the Administrator on 12/30/25 at 4:19 PM. The Administrator stated that abnormal lab results should be called immediately to the provider when they were received from the lab. She stated she was not sure where the breakdown in communication was or what happened with Resident #1's labs that were reported to the facility on 9/6/25.
The Administrator explained there were different nurses working in the building that week who were not the facility's typical staff and who had not worked in the building for a while. She explained she thought the facility had more agency nurses working in the building that week who were not the facility's routine agency nurses. She stated the DON had been on vacation that week and when the DON was not there, the oversight of the labs and ensuring the provider was contacted was different. The Administrator stated the unit managers were supposed to follow up on things like labs when the DON was gone but said there was a transition in unit managers during that time and there had been only one unit manager.
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Bear Mountain Health and Rehabilitation in Asheville, NC inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Asheville, NC, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Bear Mountain Health and Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.