VA watchdog finds Asheville leaders responded properly to Black Mountain falls concerns

The VA Office of Inspector General found that leaders at the Western North Carolina VA Health Care System responded properly to serious fall concerns tied to the North Carolina State Veterans Home in Black Mountain, and the watchdog issued no recommendations.

That finding matters for families in Buncombe County because the review was triggered by patient-safety concerns first raised in October 2025 by an OIG healthcare inspection team. The inspector general opened the case on Jan. 5, 2026, held a virtual site visit Jan. 20-22, and kept working through early February before issuing the report June 2.

The watchdog reviewed 13 issue briefs completed by Black Mountain State Veterans Home staff from August 2024 through December 2025. Eleven of those briefs involved resident falls, and two involved resident injuries that were not fall-related. The home determined that two of the 13 events were sentinel events, meaning fall-related incidents that led to injury and subsequent death. The OIG said those events were reported on time to the VA medical facility representative.

In its review, the OIG concluded that leaders at the facility, Veterans Integrated Service Network 6 and Geriatrics and Extended Care knew about the safety events, including the sentinel events that occurred in the fall of 2024, and took the actions required by the Veterans Health Administration. The report also said the sentinel-event issue briefs and updates were sent through the VISN liaison for review, approval and submission to the GEC SVH National Program Manager.

The finding is not a blanket all-clear. It means the watchdog did not find a breakdown in the VA chain of oversight for these events, not that the falls themselves were minor or that future harm is impossible. The Black Mountain home is a 100-bed skilled nursing facility, and the Western North Carolina VA Health Care System, centered at Charles George VA Medical Center in Asheville, serves about 49,000 veterans across 23 counties. State veterans homes are state-owned facilities recognized and certified by VA, and they are overseen through surveys, audits and record reviews. If a home fails to meet standards or federal law, it can lose certification, recognition and per diem payments.