Bear Mountain Health And Rehabilitation
Bear Mountain Health and Rehabilitation in Asheville, NC — inspection on December 30, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/30/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Bear Mountain Health and Rehabilitation
500 Beaverdam Road Asheville, NC 28804
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: