Mountain Ridge Health and Rehabilitation

Inspectors wroteBased on observation, interview, and facility policy the facility failed to prepare, store, and serve food under sanitary conditions. Observations on 01/13/2026 during initial kitchen tour, foods were not labeled or dated, and steam table pan removed from the dish rack and stacked onto another steamtable pan still wet. Continued observation in the kitchen on 01/13/2026, lunch service, staff changed gloves without preforming hand hygiene, touching clothing with gloved hand and food placed onto the steamtable over 30 minutes before service. Observation of the resident refrigerator at the nurses' station resident food items not labeled or dated and the refrigerator needed cleaning.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to provide housekeeping services to ensure a clean and sanitary environment for six (Resident (R) R1, R4, R7, R37, R41 and R54) of 58 sampled residentsThe

Inspectors wroteBased on observation, interview, record review, review of the facility's policy and review of the facility's investigation documentation, the facility failed to protect the resident's right to be free from sexual abuse. On 11/21/2024 at 6:20 PM Certified Nursing Assistant 1 (CNA1) and CNA 2 heard noises coming from Resident 2's (R2) room. Upon entering the room, they observed Resident 3 (R3) naked from the waist down in the bed on top of Resident 2 (R2). R3 was observed pulling at R2's brief and stated, We are fucking. R2 and R3 were immediately separated and R3 was placed on 1:1 staff observation. The facility's administrative staff failed to identify the incident as an allegation of abuse. The facility did not report the incident to the appropriate state agencies or law enforcement. Refer to F609, F835 and F837.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to immediately report an allegation of sexual abuse (defined as non-consensual contact of any type with a resident) involving two (Resident (R) 2 and R3) of nine sampled residents reviewed for abuse. On 11/21/2024 at 6:20 PM, Certified Nursing Assistant (CNA) 1 and CNA 4 heard noises coming from R2's room. Upon entering the room, they observed R3, who was naked from the waist down, in the bed on top of R2. R3 was observed pulling at R2's brief and stated, We are fucking. The facility failed to report the incident of sexual abuse of R2, who did not have the capacity to consent to sexual contact, to either the State Survey Agency or to law enforcement for investigation. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy and documents, the facility failed to ensure that it was administered in a manner to ensure the highest practicable physical, emotional, and psychosocial wellbeing for one (Resident (R) 2) of nine sampled residents reviewed for abuse. Administrative staff, including the Administrator and Director of Nursing (DON) were aware that on 11/21/2024, Certified Nursing Assistant (CNA) 1, and CNA 4 observed R3 naked from the waist down, while in bed on top of R2. R3 was observed pulling at R2's brief and stated, We are fucking. However, the administrative staff failed to make a report of an allegation of sexual abuse to either the State Survey Agency (SSA)/(Office of Inspector General - OIG) or to law enforcement. [...]

Inspectors wroteBased on interview, record review, and facility policy/document review, the facility's Governing Body failed to provide effective oversight to the Administrator to ensure the facility implemented policies, including identifying and reporting an allegation of sexual abuse of one (Resident (R) 2) of nine sampled residents reviewed for abuse. On 11/21/2024, staff observed R3, who was naked from the waist down, in bed on top of R2. R3 was observed pulling at R2's brief and stated, We are fucking. The Administrator and Director of Nursing (DON), who were both members of the Governing Body, reported this incident to additional members of the Governing Body, including the Regional Director of Operations (RDO) and Regional Director of Clinical Services (RDCS). on the same night it occurred. [...]

Inspectors wroteBased on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to ensure resident injuries of unknown origin were reported immediately (not later than two hours after the allegation) to the administrator and other officials (including the State Survey Agency), for three of three (Resident (R) 27, R110, and R111) sampled for abuse. The facility failed to report to the administrator and the State Survey Agency when R27 sustained skin tears while receiving care from a male CNA on [DATE], when R110 was diagnosed on [DATE] with a fractured hip which was of unknown origin, and when R111 was noted on [DATE], to have a large bruise to the right upper extremity which was of unknown origin.

Inspectors wroteBased on interviews, record reviews, and review of the facility's policies, it was determined the facility failed to ensure injuries of unknown origin were investigated thoroughly, after the injury was discovered for three of three residents (Residents (R) 27, R110, and R111) reviewed for abuse. The facility failed to investigate the injury of unknown origin when R27 sustained skin tears while receiving care from a male CNA on 06/16.2022, when R110 was diagnosed on [DATE] with a fractured hip which was of unknown origin, and when R111 was noted on [DATE], to have a large bruise to the right upper extremity which was of unknown origin. .

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure the services of a Registered Nurse (RN) was utilized for at least eight consecutive hours a day, seven days a week. The facility failed to provide eight consecutive hour RN coverage for 12 days between 05/01/2024 and 08/31/2024.

Inspectors wroteBased on observation, interview, and facility policy review, it was determined the facility failed to store, prepare, distribute and/or serve food in accordance with professional standards for food service safety. Observations revealed uncovered food and drink in the refrigerator on 09/03/2024 and 09/04/2024 potentially affecting 25 of 55 residents of the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of their quality of life, and to recognize each resident's individuality for one of two meals observed. Observations during the noon meal on 09/05/2024 revealed staff used labels to identify residents requiring assistance with meals and called the residents feeders during meal service. Additionally, staff initially set-up Resident (R) 6's lunch meal on 09/05/2024 instead of providing feeding assistance.

Inspectors wroteBased on observation, interview, record review and facility policy, the facility failed to promote and facilitate the resident 's right to choose not to have a male provide personal care for 1 of nineteen sampled residents (Residents (R) 27).

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, it was determined the facility failed to implement the person-centered care plan for one (1) of nineteen (19) sampled residents (Resident #17). The facility had assessed Resident #17 to be at risk for falls and care planned to have a fall mat to the left side of the bed as a fall prevention intervention. However, observations on 11/13/19 and 11/14/19 of Resident #17 while resting in bed revealed there was no fall mat to the left side of the bed.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy it was determined the facility failed to provide care consistent with professional standards of practice for pressure ulcers for one (1) of nineteen (19) sampled residents (Resident #14). Resident #14 developed a wound on 07/09/19 to the left thigh that the facility failed to identify as a pressure ulcer. On 11/04/19, the same wound was documented as an unstageable pressure ulcer and on 11/07/19 the pressure ulcer was documented as Stage 3. The resident was provided the same wound treatment from 07/09/19 until 10/31/19 without evidence in documentation of wound improvement or decline, as there were no measurements from 07/09/19 until 11/04/19.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure one (1) of nineteen (19) sampled residents (Resident #17) was provided the adequate supervision and assistance devices to prevent accidents. Observations of Resident #17 revealed there was no fall mat to the left side of the resident's bed on 11/13/19 and 11/14/19, as care planned for fall prevention.

Inspectors wroteBased on observation, interview, record review, and facility policy review, it was determined that the facility failed to notify the physician of the Registered Dietitian recommendations for two (2) of seven (7) residents with nutritional concerns out of twenty-one (21) sampled residents. Resident #36 had recommendations to add dietary supplements due to weight loss and there was no evidence that the physician was notified of the recommendations. Resident #14 was assessed to have a significant weight loss. The Registered Dietitian (RD) had written dietary recommendations dated 03/14/19 and 08/12/19 for the resident to have fortified foods and Mighty Shakes two (2) times a day. However, there was no documented evidence that the physician was contacted with the RD recommendations.

Inspectors wroteBased on observation, interview, and review of the facility policy, it was determined the facility failed to ensure proper storage of insulin in one (1) of two (2) medication carts. The facility failed to ensure an unopened vial of insulin was refrigerated. While auditing the medication storage on B Wing on 11/15/19, an unopened vial of Lantus insulin was discovered on the cart.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure a communication process was maintained between the facility and the hospice provider for one (1) of nineteen (19) sampled residents. The medical record for Resident #50 did not contain hospice documentation or a hospice care plan.

Inspectors wroteBased on observation, interview, and review of the facility policy, it was determined the facility failed to post the required daily staffing information. Observations on 11/12/19 and 11/13/19 revealed there was no daily staffing information, which included the number and disciplines of staff and the number of total hours worked as well as resident census, posted in the facility.