Cycle 1
Health 2025-05-30 · Fire 2024-05-02
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Black Mountain, NC
Mountain Ridge Health and Rehab
1-star overall rating with 1-star inspections with $24,850 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
611 Old US Highway 70 East, Black Mountain, NC
(828) 669-9991
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
97
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Care
Operator or chain grouping
Approved since
1978-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 3 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.21
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,075
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9995
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.83
Baseline 23.65% · Performance 18.80% · Measure score 6.83 · Achievement 5.69 · Improvement 6.83
Healthcare-associated infections
3.21
Baseline 7.75% · Performance 6.88% · Measure score 3.21 · Achievement 3.21 · Improvement 2.66
Total nurse turnover
5.79
Baseline 40.00% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 0
Adjusted total nurse staffing
2.62
Baseline 3.96 hours · Performance 3.82 hours · Measure score 2.62 · Achievement 2.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.2% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 6.77% · Lower 95% interval 6.46% |
| Discharge to community | 51.76% |
50.57%
1.2 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 47.48% · Lower 95% interval 45.21% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 101 · Denominator 101 |
| Falls with major injury | 2.97% |
0.77%
2.2 pts worse
|
Numerator 3 · Denominator 101 |
| Discharge self-care score | 36.99% |
53.69%
16.7 pts worse
|
Numerator 27 · Denominator 73 |
| Discharge mobility score | 27.4% |
50.94%
23.5 pts worse
|
Numerator 20 · Denominator 73 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 101 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 6% · Lower 95% interval 4.32% |
| Staff COVID-19 vaccination coverage | 12.17% |
8.2%
4 pts better
|
Numerator 14 · Denominator 115 |
| Staff flu vaccination coverage | 51.88% |
42%
9.9 pts better
|
Numerator 124 · Denominator 239 |
| Discharge function score | 31.51% |
56.45%
24.9 pts worse
|
Numerator 23 · Denominator 73 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 52 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 18.75% |
25.2%
6.4 pts worse
|
Numerator 9 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.8
1.3 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.5%
7.8 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 98.6% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.6%
0.2 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.5% · Q3 2.8% · Q4 1.4% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
7.2%
0.4 pts better
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.8% · Q3 10.9% · Q4 3.0% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.5% |
21.6%
2.1 pts better
|
19.6%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 19.1% · Q3 19.1% · Q4 17.9% · 4Q avg 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.7% |
15.0%
3.3 pts better
|
16.7%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 12.3% · Q3 12.3% · Q4 8.5% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 49.9% |
21.5%
28.4 pts worse
|
16.3%
33.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 49.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.6% |
16.8%
9.8 pts worse
|
14.9%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 33.3% · Q3 32.8% · Q4 24.2% · 4Q avg 26.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.6%
0.8 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.4% · Q3 1.5% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.5% |
21.2%
2.3 pts worse
|
19.8%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 24.2% · Q3 26.9% · Q4 17.3% · 4Q avg 23.5% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
6.0%
0.6 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.0% · Q3 6.5% · Q4 6.9% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
79.9%
19.2 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 96.6% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
13.2%
4.9 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 8.2% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 1.8% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.1%
21.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
22.9%
1.2 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 20.4% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-02 · Fire 2023-01-12
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-01-12 · Fire 2021-05-06
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-02
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-06-04
D · Potential for more than minimal harm
2024-05-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-04
F · Potential for more than minimal harm
2023-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-23
F · Potential for more than minimal harm
2023-01-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-23
F · Potential for more than minimal harm
2023-01-12
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-04-23
D · Potential for more than minimal harm
2023-01-12
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-04-23
D · Potential for more than minimal harm
2023-01-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-23
D · Potential for more than minimal harm
2023-01-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-23
D · Potential for more than minimal harm
2023-01-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-23
D · Potential for more than minimal harm
2023-01-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-23
D · Potential for more than minimal harm
2023-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-23
D · Potential for more than minimal harm
2021-05-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-18
D · Potential for more than minimal harm
2021-05-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-18
Inspection history
Recent health citations
J · Immediate jeopardy
2025-10-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-30
J · Immediate jeopardy
2025-10-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-30
E · Potential for more than minimal harm
2025-05-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-17
E · Potential for more than minimal harm
2025-05-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-30
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-05-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-17
E · Potential for more than minimal harm
2024-05-02
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-05-23
E · Potential for more than minimal harm
2024-05-02
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-23
E · Potential for more than minimal harm
2023-01-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-05
D · Potential for more than minimal harm
2023-01-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-02-05
D · Potential for more than minimal harm
2023-01-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-05
Penalties and ownership
What sits behind the stars
$12,425
2025-10-21
Fine
Fine · fine $12,425
Fine
$12,425
2025-10-21
Fine
Fine · fine $12,425
Fine
Ownership
Kothari, Zahid
Operational/Managerial Control · Individual
Womack, Steven
5% Or Greater Direct Ownership Interest · Individual
Womack, Steven
Operational/Managerial Control · Individual
Woodward, Melvin
5% Or Greater Direct Ownership Interest · Individual
Woodward, Melvin
Operational/Managerial Control · Individual
Ww Healthcare Consultants, LLC
Operational/Managerial Control · Organization
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#2
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#3
NC State Veterans Home - Black Mountain
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