Review of VA's Oversight of a State Veterans Home at the Western North Carolina VA Health Care System in Asheville

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Western North Carolina VA Health Care System (system) to assess concerns brought forward in October 2025 by an OIG Healthcare Facility Inspection team regarding issue briefs related to sentinel events and falls at the North Carolina State Veterans Home (SVH) in Black Mountain, North Carolina (Black Mountain SVH). The OIG initiated the inspection on January 5, 2026, conducted a virtual site visit from January 20 through 22, 2026, and continued inspection activities through early February 2026.

The OIG determined facility, Veterans Integrated Service Network (VISN), and Veterans Health Administration (VHA) leaders were aware of patient safety events, including sentinel events, at the Black Mountain SVH as reported by SVH staff. From August 2024 through December 2025, facility staff completed 13 issue briefs in response to the reported patient safety events to alert VISN and VHA Geriatrics and Extended Care (GEC) leaders. Eleven of the issue briefs were related to resident falls, while two involved resident injuries unrelated to falls. The Black Mountain SVH determined 2 of the 13 events were sentinel events—resident falls resulting in injury and subsequent death—and were reported timely to the VA medical facility representative. Further, the OIG determined facility, VISN, and GEC leaders responded to SVH sentinel events as required by VHA—both sentinel event issue briefs, and associated updates, were provided to the VISN liaison for review, approval, and submission to the GEC SVH National Program Manager.

The OIG made no recommendations.