Mountain Ridge Rehabilitation and Healthcare Cente

Inspectors wroteBased on observation, record review, staff interviews, Wound Care Consultant Physician Assistant interview, and Physician interview, the facility failed to position Resident #62 in an upright position to safely drink a hot beverage for 1 of 3 residents reviewed for accidents (Resident #62). This failure caused the resident to spill hot liquid onto her chest and upper back and resulted in actual harm in the form of partial thickness burns.

Inspectors wroteBased on observations and interviews with staff, the facility failed to remove thickened liquids stored for use past the use by date in the facility's walk-in refrigerator. This was for 1 of 3 refrigerators (walk-in) observed in the kitchen. The deficient practice had the potential to affect thickened liquids served to residents. Findings Included: On 7/6/26 at 9:59 AM an observation was conducted with the District Dietary Manager in the walk-in refrigerator. The observation found 6 unopened cartons of thickened liquid with use by date of 6/22/26 located on a shelf. On 7/2/26 at 10:02 AM, the District Dietary Manager stated the dates of items stored in the walk-in refrigerator were checked weekly on food delivery days. She stated the food order had been delivered earlier in the morning and she had not yet put up stock or checked the dates. [...]

Inspectors wroteBased on observations, record review and staff and resident interviews, the facility failed to assess a resident's ability to self-administer a medicated anti-itch lotion for 1 of 1 resident observed for self-administration of medication (Resident #36).

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain accurate advanced directives throughout the medical record for 1 of 1 resident reviewed for advanced directives (Resident #4).

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to follow their infection control policy for Enhanced Barrier Precautions (EPB) when two nurse aides (NAs) transferred Resident #92 who had a dialysis port without sanitizing their hands before putting on gloves and not donning a gown for 2 of 6 staff members observed for infection control practices (NA #1, NA #2).

Inspectors wroteBased on record review, and interviews with staff, Medical Director, Emergency Medical Services (EMS) Supervisor, Physician Assistant and emergency room Physician, the facility failed to leave Resident #1 in place on the floor after a headfirst fall from a mechanical lift while being transferred by Nurse Aide (NA) #1 and NA #2 on [DATE]. The resident was prescribed two medications that increased the risk of bleeding. Resident #1 reported head and neck pain to Nurse #1 when she was assessed immediately after the fall. Resident #1 was lying on her back and was turned onto the mechanical lift pad and returned to her bed using the mechanical lift prior to an evaluation by Emergency Medical Services (EMS). Emergency Medical Services (EMS) was called and when they arrived, they were told Resident #1 fell from the mechanical lift, struck her head and complained of neck pain. [...]

Inspectors wroteBased on record review, observation, and interviews with staff and the Medical Director, the facility failed to provide a safe transfer of Resident #1 using a mechanical lift. Resident #1 had left foot drop, hemiplegia (paralysis) and hemiparesis (weakness) on both sides and was prescribed an anti-platelet medication. Resident #1 was transferred with a mechanical lift by Nurse Aide (NA) #1 and NA #2 on 10/4/25 and they failed to ensure that Resident #1's feet (with shoes on) cleared the bed while in the mechanical lift. Resident #1's feet got caught on the mattress and as the lift was moved, the force of Resident #1's feet coming loose caused Resident #1 to swing and fall headfirst out of the sling that was approximately 4 feet in the air. Resident #1 landed on the floor and complained of pain in her head/neck area and was transferred to the Emergency Department (ED) for evaluation. [...]

Inspectors wrote4. Resident #7 was readmitted to the facility on [DATE] with diagnoses that included respiratory failure and chronic obstructive pulmonary disease (COPD, difficulty breathing). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had intact cognition and received oxygen therapy while a resident at the facility. A physician's order dated 05/12/25 for Resident #7 revealed she was to receive continuous oxygen administered via nasal canula at 2 liters per minute (LPM) every shift. An observation on 05/27/25 at 2:08 PM revealed Resident #7 lying in bed receiving supplemental oxygen via nasal cannula with the flow rate on the oxygen concentrator set at 2 LPM. There was no cautionary signage posted on the door, doorframe or in Resident #7's room to indicate oxygen was in use. [...]

Inspectors wroteBased on observation and staff interviews the facility failed to discard food with signs of spoilage in 1 of 1 walk-in cooler and date open food items and food ready for use in 1 of 1 walk-in cooler. This practice had the potential to affect food served to residents.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure an as needed (PRN) psychotropic medication, Lorazepam (medication used to relieve anxiety), had a stop date of 14 days for 1 or 5 residents (Resident #7) reviewed for unnecessary medications.

Inspectors wrote2. Resident #31 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder-depressive type, bipolar disorder and Post-Traumatic Stress Disorder (PTSD). A PASRR Level II determination notification letter dated 01/02/25 revealed Resident #31 had a Level II PASRR with no expiration date. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 05/29/25 at 8:38 AM, the MDS Coordinator confirmed Resident #31 had a Level II PASRR and the MDS assessment dated [DATE] was completed by another MDS Coordinator who was no longer employed. [...]

Inspectors wroteBased on record review, observations and interviews with resident representative, staff, Nurse Practitioner, and Urology Physician Assistant (PA), the facility failed to prevent urinary catheter bags from touching the floor to reduce the risk of infection for 2 of 3 residents (Resident #69 and Resident #51) reviewed for urinary catheters. In addition, the facility failed to obtain physician orders to flush a suprapubic catheter as recommended by the Urology PA for Resident #51.

Inspectors wroteBased on observations and staff interviews the facility failed to remove expired produce from the walk-in refrigerator. The facility also failed to store boxes of food in the walk-in freezer off the floor. This practice had the potential to affect food served to residents.