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Complaint Investigation

Mountain Ridge Health And Rehab

October 21, 2025 · Black Mountain, NC · 611 Old Us Highway 70 East
Citations 2
CMS Rating 1/5
Beds 97
Provider ID 345048
Healthcare Facility
Mountain Ridge Health And Rehab
Black Mountain, NC  ·  View full profile →
Inspection Summary

Mountain Ridge Health and Rehab in Black Mountain, NC — inspection on October 21, 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.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

the ground or have a fall or accident.

They are to immediately notify the licensed nurse.

All staff will be educated on or before their next shift by the Administrator or designee.

Newly hired staff will be educated by the Interim DON during orientation.

Starting on [DATE] the Interim DON, Administrator, Minimum Data Set Nurses will review 5 days a week, the incident/accident reports, 24-hour report, the order listing report for medication changes, the Discharge report, and grievance log to ensure that all falls and injuries, resulting from a fall on their head, have been handled according to this plan.

Completion Date: [DATE]On [DATE] the facility's credible allegation of immediate jeopardy removal was validated by the following:Review of facility audits revealed the facility completed audits of all incidents, hospital transfers, grievance logs, and facility reportable incidents from [DATE] to [DATE].

Incident reports were audited by the facility for falls with injury, head/ neck injury, and reviewed for if residents with injury was moved inappropriately.

The facility did not identify any issues from the incident report audit.

The facility completed an audit of resident hospital transfers to identify any hospital transfers related to a fall with injury or head/ neck injury; there were no issues identified.

Facility reportable incidents were reviewed and did not contain any reportable incidents related to falls with injury.

Grievance log audits were completed to identify any grievance related to physical injury; there were no issues identified.Grievance logs, facility reportable incident logs, incident logs, and hospital transfer logs were reviewed.

There were no issues related to falls with injury, head/ neck injury, or residents being moved in appropriately.

All facility audits were reviewed and verified as completed.Review of education revealed specific post fall education was developed by the Medical Director and included assessment steps to take after a resident has a fall, when to not move a resident, and when to call emergency medical services (EMS).

The education included additional injury and/or adverse outcomes if a resident was moved after a head or neck injury.Review of in-service education logs revealed the education material developed by the Medical Director was used to educate licensed nurses on assessing a resident after a fall, when not to move a resident after a fall, and additional injury that could incur if a resident was moved. It was verified the Staff Development Nurse and involved floor nurse received the education.In-service logs revealed all staff were educated to notify the nurse and to not move a resident after a fall.Addit[TRUNCATED]

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Mountain Ridge Health and Rehab

611 Old US Highway 70 East Black Mountain, NC 28711

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

mechanical lift should include validation of; two qualified staff members' active participation, appropriate lift sling selection, correct positioning in sling, secure placement of sling to attachment points, confirmation lift base legs spread, resident is raised above bed, chair or applicable surface and again, confirm sling straps are secure.

This education was initiated on 10/4/25 and completed by 10/7/25. On 10/14/25 The Staff Development Coordinator started a second round of training for the Licensed Nurses.

This training will be completed by 10/16/25.

Any Licensed Nurse not receiving this education by this date will receive education via phone call by the Staff Development Coordinator prior to their next scheduled shift.

This information will be presented in new Licensed Nurse orientation by the Staff Development Coordinator.

The facility does not utilize agency staff.

All Licensed Nurses will receive lift competency training, which is, the safe process based on manufacturer instructions and facility guidelines for transferring a resident via lift, to include; always having a partner is required and they must be actively assisting, appropriate lift sling selection (when the resident is placed in the center of the sling, it should extend 3 to 6 inches past their body on each side), correct positioning in sling, secure placement of sling to attachment points, confirmation lift base legs spread, resident is raised above bed, chair or applicable surface and again, confirm sling straps are secure before moving lift demonstrating they are qualified to perform lift transfers.

This was done by the Staff Development Coordinator.

The competency training includes the use of a lift, 2 nurse aides and/or the Staff Development Coordinator as the second person (if needed), sling, and Manikin brand medical model.

This was initiated on 10/17/25 and all Licensed Nurses will complete the training on or before their next scheduled shift.

All Nurse Aides have been train[TRUNCATED]

Facility ID:

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 Black Mountain, 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 Mountain Ridge Health and Rehab or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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