Mountain Ridge Rehabilitation And Healthcare Cente
Mountain Ridge Rehabilitation and Healthcare Cente 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.
Inspection Findings
utilize agency staff. On [DATE] all Nurse Aides that were working were educated by the Interim DON
jeopardy to resident health or resident.
They are to immediately notify the licensed nurse and wait for instructions on when and if it safety is safe to move the resident.
Starting [DATE] all Nurse Aides not previously educated were called by the Interim DON, Wound Care Nurse, and the MDS Nurse and educated that when a resident is found
immediately notify the licensed nurse and wait for instructions on when and if it is safe to move the resident.
All newly hired Nurse Aides will be educated by the Interim DON or designee during orientation.
The facility does not utilize agency staff.
The Interim DON or designee is maintaining the list of staff to confirm education.
Starting on [DATE] the Licensed Nurses will review with each Nurse Aide on their unit that they cannot move a resident that has fallen or found down until the Licensed Nurse assess the resident.
This will be done at the beginning of each shift for the next 2 weeks by the licensed nurse to the nurse aides during shift change.
Starting on [DATE] the Administrative staff, Activities staff, Therapy, Housekeeping, Laundry, Maintenance and Dietary Departments will be educated by the Administrator, the Director of Maintenance or the Certified Dietary Manager that no resident can be moved if they are found on 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]
345048 10/21/2025
Mountain Ridge Rehabilitation and Healthcare Cente 611 Old US Highway 70 East Black Mountain, NC 28711
complete: The Staff Development Coordinator has educated all Nurse Aides on the safe process based
jeopardy to resident health or always having a partner is required and they must be actively assisting, appropriate lift sling safety 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,
confirm sling straps are secure before moving lift.
This education was confirmed to be accepted and understood via successful completion of the lift competency.
This education and competency was started on 10/4/25 and completed on 10/7/25.
Any Nurse Aide not receiving this information and successfully completing an in-person lift competency by this date will complete before their next scheduled shift.
This information will be presented in new Nurse Aide orientation by the Staff Development Orientation and will include successful completion of an in-person lift competency prior to first day of floor orientation.
The facility does not utilize agency staff.
Subsequently, the Staff Development Coordinator educated Licensed Nurses on the proper process (based on manufacturer instructions and facility guidelines) for transferring a resident via mechanical lift and that their observations conducted of Nurse Aides transfers requiring a 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]
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.