Mentor Ridge Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mentor Ridge Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 1, 2021

  Based on interview, record review, and facility policy review, the facility failed to ensure timely interventions were implemented to appropriately treat a deteriorating [CONDITION(S)] for Resident #64. Actual Harm occurred on 09/18/21 when Resident #64 had an MRI (Magnetic Resonance Imaging) exam of the right foot on 09/07/21, which revealed findings for [CONDITION(S)] (infection of bone or bone marrow). This was not reported to the resident's primary care physician (PCP) until 09/08/21 and was not addressed by a physician until 09/16/21. Resident #64 was subsequently admitted to the hospital with [CONDITION(S)] (infection in the blood). This affected one (Resident #64) of three (Resident's #1, #45 and #64) reviewed for wound care. […]

• No harm, potential for more than minimal, patternF880Mar 8, 2021

  Based on observations, staff interview, review of the facility's Coronavirus (COVID-19) policy, review of the Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) Memo QSO-20-14-NH (revised 3/13/20), review of the World Health Organization (WHO) hand hygiene brochure, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure proper hand hygiene was implemented after care for Resident #3, who was on droplet precautions, to potentially prevent the spread of COVID-19 infections. This had the potential to affect all 46 residents residing on the West Unit. […]

• No harm, potential for more than minimal, isolatedF580Feb 19, 2026

  Based on record review, interview, and facility policy review, the facility failed to notify the physician of a significant weight gain for a resident with a diagnosis of fluid overload. This affected one resident (#22) of three residents reviewed for nutrition. The facility census was 98.Findings include:Review of the medical record for Resident #22 revealed an admission date of 01/05/26 with a primary diagnosis of fluid overload and other diagnoses including unspecified fracture of the right tibia shaft, effusion of the right knee, type two diabetes, morbid (severe) obesity, hypertension (high blood pressure), and hyperlipidemia (high levels of fat in the blood).Review of Resident #22's Medication Administration Record (MAR) for January 2026 revealed an order dated 01/06/26 for a low… […]

• No harm, potential for more than minimal, isolatedF684Feb 19, 2026

  Based on record review, resident interview, staff interviews, review of the Self-Reported Incident (SRI) and facility policy review, the facility failed to timely and adequately respond after identification of an incident with injury including assessing on the day of the incident, timely notification of the physician, notification to hospice, completing a skin assessment and logging the incident on the facility's incident log. This affected one resident (#86) of one resident reviewed for incidents. […]

• No harm, potential for more than minimal, isolatedF880Feb 19, 2026

  Based on record review, observation, interview, review of the facility policy and Centers for Disease Control and Prevention (CDC) informational sheet, the facility failed to ensure appropriate testing was completed to rule out multi-drug resistant organisms (MDROs) and use appropriate enhanced barrier precautions (EBP) for MDROs. This affected one Resident (#11) of four residents reviewed for urinary tract infections (UTIs). The facility census was 98.Findings include:Review of the medical record for Resident #11 revealed an admission date of 08/15/23 with diagnoses including dementia with behavioral disturbance, chronic obstructive pulmonary disease, diabetes mellitus, and anemia. […]