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Bear Mountain Health and Rehabilitation

500 Beaverdam Road, Asheville, NC 28804 · For profit - Limited Liability company · 77 certified beds · (828) 254-8833 Medicare & Medicaid certified

Call the home — (828) 254-8833 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 16 lower-level deficiencies on record (see below)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • nursing-staff turnover (60%) runs well above the national median (45%)
  • about 27% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
201 NC Highway 9 · (828) 820-8266 · Call to confirm hours
Pharmacy
841 Merrimon Ave · (828) 225-5113 · Call to confirm hours
Grocery
Asheville1.5 mi
915 Merrimon Ave.
Park
415 Beaverdam Rd · (828) 903-8678 · Typically dawn to dusk
Place of worship
399 Beaverdam Rd · (828) 220-0039

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 3 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased10.3%15.6%15.4%better
Long-stay residents who lose too much weight12.3%7.2%5.4%worse
Long-stay residents with a catheter left in their bladder1.9%0.7%0.9%worse
Long-stay residents with a urinary tract infection4.0%2.3%2.0%worse
Long-stay residents with depressive symptoms0.0%5.9%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury4.0%3.5%3.3%worse
Long-stay residents whose ability to walk worsened7.7%18.3%16.1%better
Long-stay residents on antianxiety or hypnotic medication32.2%21.3%18.9%worse
Long-stay residents given the seasonal flu vaccine97.0%94.1%95.3%typical
Long-stay residents with pressure ulcers7.7%5.5%4.7%worse
Long-stay residents with worsening bladder/bowel control17.8%20.7%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table15.9%14.0%17.1%typical
Short-stay residents who newly got an antipsychotic medication3.8%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine89.2%78.1%79.4%better
Short-stay residents rehospitalized after admission22.7%22.9%22.6%typical
Short-stay residents with an outpatient ER visit9.0%12.9%12.0%better
Long-stay hospitalizations per 1,000 resident days2.131.781.67worse
Long-stay outpatient ER visits per 1,000 resident days1.251.801.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

9.4%U.S. median 10.7%
Went back to hospital
0.41U.S. median 0.30
Therapy hours / resident / day
0.19hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.41 therapist hours per resident per day in 2025Q4 — more than 72% of the 13,714 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 14% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.0–13.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.—
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.131.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.49
RN hours/ resident / day
0.58
LPN hours/ resident / day
2.21
Aide hours/ resident / day
3.28
Total nurse hours/ resident / day
0.35
RN hoursweekends
60.5%
Total nursing turnover
55.6%
RN turnover

How full it usually is: this home is certified for 77 beds and averages 65.3 residents a day — about 85% occupied, or roughly 12 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.49 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.21 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.60 hrs/resident/day on weekends vs 3.25 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 0.48 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 60% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3 ↓
deficiencies at the latest standard inspection (2026-07-15)
6
at the previous standard inspection (2025-05-09)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.

  • Potential for harm · E2026-07-15 · tag F0679 — failed to provide activities — pattern
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 7 of 9 residents reviewed for activities (Residents #10, #41, #11, #57, #8, #56, #9). The residents expressed not being able to leave the facility made them feel sad and sometimes depressed and angry. The findings included: A review of the activity calendars from May 10, 2025 to July 2026 revealed activities were scheduled inside of the facility during the week and on the weekends. There was one outside of the facility activity scheduled on 2/5/26. Observation of the facility location on 7/13/26 at 8:00 AM revealed it was located in a rural area that was within an 8-to-10-minute driving distance to numerous local and commercial shops, grocery stores, fast food, and sit-down restaurants. a. Resident #10 was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-07-15 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, Responsible Party, resident and staff interviews, the facility failed to obtain consent and inform the resident or resident representative in advance of the risks and benefits of psychotropic medications prior to starting them for 2 of 5 residents reviewed for unnecessary medications (Resident #12 and Resident #3). The findings included: 1. Resident #12 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder. A review of the physician's orders in Resident #12's medical record indicated an active order which started on 7/15/25 for Buspirone (an anti-anxiety medication) oral tablet 10 milligrams – give 1 tablet by mouth two times a day for agitation/restlessness. This order was entered into Resident #12's medical record by Unit Manager #1. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 was rarely/never understood and had severely impaired cognitive skills for daily decision making. Resident #12 had no behavioral symptoms, and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-07-15 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and staff interviews, the facility failed to discard an expired medication from 1 of 2 medication carts (West-Front Hall) reviewed for medication labeling and storage.The findings included: On 07/14/26 at 8:54 AM, an observation was made of the West-Front hall medication cart with Unit Manager #1. The third drawer on the right side, which was a locked drawer, held a plastic bag that contained an unopened package of two naloxone nasal spray bottles (medication used in emergencies to reverse the effects of a life-threatening opioid emergency). The bag had a pharmacy label with the name of a resident no longer at the facility with a date dispensed of 5/7/22 and a manufacturer's expiration date of 6/30/24. In an interview with the Unit Manager #1 on 7/14/26 at 8:55 AM she stated she had worked on that cart many times but never saw the naloxone package before. She explained that the controlled medications were kept in the second drawer on the right side which was also a locked drawer, and the third drawer was an extra locked drawer in case they had an overflow of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-30 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, Pharmacist, and Medical Director interview, the facility failed to transcribe and implement orders for diabetes care according to the hospital discharge summary for a resident with diabetes. The hospital discharge summary ordered sitagliptin/metformin (Janumet extended release). The facility instead entered and administered metformin, omitting the sitagliptin component and the extended-release formulation. This deficient practice occurred for 1 of 3 residents reviewed for providing care according to professional standards (Resident #1).Findings included:A hospital Discharge summary dated [DATE] included the following medication order: metformin-sitagliptin (Janumet extended release (XR) 100 milligram (mg)-1000 mg oral tablet, 1 tablet by mouth daily for diabetes. According to manufacturer's information, metformin-sitagliptin is a combination of two medications and is marketed under the brand name of Janumet extended release XR.Resident #1 was admitted to the facility on [DATE]. Her…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-30 · tag F0773 — isolated
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff, Clinical Practice Manager, and Physician Assistant (PA) interviews, the facility failed to notify the medical provider of abnormal laboratory results for 1 of 1 resident reviewed for notification of laboratory results (Resident #1).Findings included:Resident #1 was admitted to the facility on [DATE]. Her diagnoses included Type-2 diabetes mellitus, hypertension (high blood pressure), long-term use of anticoagulants (blood thinning medication), metabolic encephalopathy (confusion caused by chemical imbalances in the body), malignant neoplasm of the pancreas (pancreatic cancer), hypo-osmolality (excess water relative to solutes such as electrolytes) and hyponatremia (low sodium level), anemia (low red blood cells), hypothyroidism (thyroid disorder), and a disorder of urea cycle metabolism (body cannot properly remove ammonia from the body).An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severe cognitive impairment.A physician order dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and staff interviews, the facility failed to promote care in a dignified manner for 1 of 2 residents who were assisted with meals (Resident #2). Staff were observed standing beside the resident's bed while feeding assistance was provided. The finding included: Resident #2 was admitted to the facility on [DATE] with diagnoses including dysphagia and malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #2 with intact cognition. The assessment indicated Resident #2 was dependent on staff for eating and receiving a mechanically altered diet. During a continuous breakfast observation on 05/07/25 from 9:01 AM to 9:10 AM, Resident #2 was observed seated at approximately 45-degree angle in her bed. Her breakfast tray was brought into the room by Nurse Aide (NA) #1 and placed on top of the overbed table in front of Resident #2. NA #1 stood on the left side of the bed. She set up the tray and started feeding Resident #2 while she was standing and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASARR) and high-risk drug classes usage that involved anticoagulant, antipsychotic, and opioid medications for 3 of the 7 sampled residents (Residents #11, #24, and #52). Findings included: a. Resident #11 was admitted to the facility on [DATE] with diagnoses that included high blood pressure and peripheral vascular disease. A review of the Medication Administration Records (MAR) for January 2025 revealed Resident #11 did not receive any anticoagulant throughout the month. Instead, the MAR indicated that he received 1 tablet of enteric-coated aspirin 81 milligrams (mg) by mouth once daily since 01/20/25. The quarterly MDS assessment dated [DATE] coded Resident #11 with intact cognition. The Medication section of the MDS indicated Resident #11 had received anticoagulant during the 7-day assessment periods. b. Resident #24 was admitted…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-09 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and medical record review, the facility failed to refer a resident with newly diagnosed serious mental illnesses for Pre-admission Screening and Annual Resident Review (PASARR) Level II screening for 1 of 2 residents reviewed for PASARR (Resident #36). The findings included: A review of Resident #36's medical records revealed he had a PASRR Level I evaluation completed in 2023. Resident #36 was admitted to the facility on [DATE] with diagnoses including bipolar disorder. A review of Resident #36's list of cumulative diagnoses revealed a new diagnosis of bipolar disorder with an onset date of 03/13/24 was documented in his medical record. A review of physician's order dated 03/14/24 revealed Resident #36 had an order to receive 1 tablet of Depakote 500 milligrams (mg) delayed release by mouth 2 times daily for mood symptoms related to bipolar disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #36 with intact cognition. The Section A1500 indicated he was not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-05-09 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and Medical Director (MD), resident and staff interviews, the facility failed to readjust medication orders after those orders had been updated which resulted in the resident missing one dose of five medications for 1 of 1 resident reviewed for pharmacy services (Resident #36). The finding included: Resident #36 was admitted to the facility on [DATE] with diagnoses including stroke, insomnia, and bipolar disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #36 with intact cognition. The assessment indicated Resident #36 had adequate hearing and vision with clear speech. During the initial interview conducted with Resident #36 on 05/05/25 at 1:13 PM, he stated he disliked nursing staff waking him up around midnight at times to administer his medications. A review of medication administration records (MAR) on 05/05/25 revealed Resident #36 had the following 5 active physician's orders to receive medications once daily at either 8:00 PM or 10:00…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-05-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and staff interviews, the facility failed to intervene effectively when two residents became agitated and were yelling at each other in a common area. Resident #44 was cognitively impaired and had a history of violent behaviors caused Resident #229 to sustain a skin tear by hitting her on the hand with a cellphone. This deficient practice occurred for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #229). The findings included: Resident #44 was admitted to the facility on [DATE] with diagnoses that included: hemiplegia (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting right dominant side, schizophrenia (psychiatric disorder), vascular dementia with mood disturbance, aphasia (brain disorder that affects the ability to communicate) following cerebral infarction, bipolar disorder (mood disorder), anxiety disorder, violent behaviors. Resident #44 was a current resident at the facility. The…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 6 citations
  • Potential for harm · D2025-05-09 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to keep a urinary catheter bag and drainage spout from touching the floor to reduce the risk of infection for 1 of 1 resident (Resident #62). This deficient practice occurred for 1 of 1 resident reviewed with a urinary catheter. Findings included: Resident #62 was admitted to the facility on [DATE] and had been re-admitted to the facility on [DATE]. His diagnoses included chronic obstructive uropathy. A significant change Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #62 was never/rarely understood and his cognitive skills for daily decisions making were severely impaired. He was documented on the MDS as having an indwelling catheter. Resident #62 had a care plan dated 6/14/24 for long term indwelling catheter. The care plan interventions included positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door. An order dated 4/3/25 read, indwelling urinary catheter…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-03-07 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, resident, and staff interview the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident reviewed for medications at bedside (Resident #67). The findings included: Resident # 67 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes mellitus with hyperglycemia and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #67 was cognitively intact. Review of Resident #67's medical record revealed no documentation that Resident #67 had been assessed to self-administer medications at bedside. An in-room observation and interview with Resident #67 on 3/4/24 at 11:17 AM revealed a medication cup sitting on Resident #67's overbed table containing 11 pills. Resident #67 stated the nurse had brought her medication to her about 30 minutes prior for her to take. Resident #67 said she told the nurse she would take the pills after she used the bathroom,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-07 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for a resident with new mental health diagnoses for 1 of 2 residents reviewed for PASRR (Resident #23). The findings included: Review of Resident #23's medical record revealed the resident had a PASRR level I completed prior to his admission dated 8/3/17. He was admitted to the facility on [DATE] with diagnoses of bipolar disorder and anxiety disorder. A diagnosis of major depressive disorder was added on 8/29/23. Review of Resident #23's medical records revealed no PASRR level II had been completed. Review of Resident #23's annual Minimum Data Set (MDS) dated [DATE] revealed he had not been evaluated by Level II PASRR. During an interview on 3/6/24 at 2:25 pm, the Interim Administrator and the Social Worker (SW) explained the facility's PASRR process. The SW stated all residents had PASRR when they got to the facility. Their diagnoses determined what kind of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-03-07 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and resident and staff interviews the facility administered a medicated powder without a physician's order for 1 of 1 resident reviewed for professional standards of practice (Resident #21). The findings included: Resident #21 was admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #21 was cognitively intact. A review of Resident #21's active physician orders for March 2024 revealed that there was not an order for nystatin powder. An in-room observation and interview with Resident #21 occurred on 3/04/24 at 11:08 AM. A bottle labeled nystatin topical powder was observed on Resident #21's overbed table. She stated it was brought to her the previous night and left on the table and the bottle was left in her room often. Resident # 21 stated the nursing assistants applied the powder on to her. Resident # 21's Unit Manager who was Resident #21's assigned nurse was interviewed on 3/04/24 at 11:11 AM and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2024-03-07 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to complete quarterly assessments within the regulated time frames for 3 of 3 residents reviewed for completion of quarterly Minimum Data Set (MDS) assessments (Residents # 34, #15, #69). The findings included: 1. Resident #34 was admitted to the facility 8/29/18. The quarterly MDS assessment with an assessment reference date (the last day of the assessment period) of 2/8/24 was reviewed and revealed the assessment was still in progress on 3/6/24. The MDS Coordinator was interviewed on 3/6/24 at 9:25 AM and stated she had been working at the facility for one month and was aware of the late quarterly MDS assessment. The MDS Coordinator stated the facility had been without a MDS Coordinator and had a plan to complete late assessments. The Interim Administrator stated on 3/7/24 at 11:32 AM the MDS quarterly assessments should have been completed on time. The facility was working on a plan to catch up on the late MDS assessments. 2. Resident #15 was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has plan of correction
  • No harm found · B2024-03-07 · tag F0867 — failed to act on quality-improvement findings — pattern
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record review and staff interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification surveys conducted on 1/28/22 and 12/16/22. This was for a repeat deficiency in the area of quarterly assessments that was originally cited on 1/28/22 during the recertification survey, and subsequently recited during the recertification survey on 12/16/22 and the recertification survey completed on 3/7/24. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross-referenced to: F638 - Based on record review and staff interviews, the facility failed to complete quarterly assessments within the regulated time frames for 3 of 3 residents reviewed for completion of quarterly Minimum Data Set (MDS) assessments (Residents # 34, #15, #69). During the recertification survey on 1/28/22, the facility failed to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has plan of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to ASCENT HEALTHCARE MANAGEMENT — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 3 of 52.2+0.8 vs chain
Health inspection 3 of 52.5+0.5 vs chain
Staffing 3 of 52.0+1.0 vs chain
Quality measures 3 of 52.8+0.2 vs chain
The other 5 homes this chain runs (chain average 2.2★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
NEBO HOLDCO LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/01/2024
BADIMU, KAMUINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF—since 01/01/2025
CRUM, KATHERINEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF—since 01/01/2025
FRIEDMAN, YISROELIndividualOPERATIONAL/MANAGERIAL CONTROL—since 05/01/2024

CMS files one row per role, so the 6 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.5M
Net patient revenuemost recent cost report
-12.1%
Operating marginrevenue minus expenses
$2.2M
Related-party expense27% of expenses
Who pays — share of resident-days
Medicaid 83%Medicare 4%Other / private 13%

About 83% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $2.2M paid to related parties — landlords or management companies under common ownership — equal to about 27% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$363per resident / day
operating cost
$11,044per month
≈ monthly operating cost
$324per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the North Carolina Medicaid page.

Typical monthly cost in North Carolina
$9,733/mo
Nursing home (semi-private)
$10,798/mo
Nursing home (private)
$6,496/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-09-01 — CMS provider number 345010. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-07-15, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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