Mission Ridge Rehab & Nursing Center

In the surveyor’s words

From the most serious findings on record at Mission Ridge Rehab & Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 2 residents reviewed for accidents and hazards.The facility failed to ensure CNA A provided adequate supervision and used a 2-person assist while providing incontinent care to Resident #1. CNA A left Resident #1's bedside, while she lay on her right side. Due to her positioning, Resident #1 fell off the bed. Resident #1 sustained a rib fracture and contusions (bruising) to her right cheekbone, forehead, and back on 06/02/25.A PNC (Past Non-Compliance) Immediate Jeopardy (IJ) situation was identified on 06/02/25. The PNC IJ was removed on 06/30/25. […]

• Immediate jeopardy, isolatedF689Oct 10, 2024

  Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of 10 residents reviewed for supervision. The facility failed to ensure Resident #1 received adequate supervision while Resident #1 was unaccounted for approximately 36 minutes from 5:40 PM to 6:16 PM on 09/04/24 travelling approximately 500 feet while she eloped from the 200 hall exit door. Resident #1 was found approximately 100 feet from the front entrance along the side of the facility. The Immediate Jeopardy (IJ) template was provided to the facility on [DATE] at 4:10 PM. […]

• Actual harm, isolatedF684Nov 23, 2024

  Based on interview, and record review, the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, for 1 of 3 residents (Resident #48) reviewed for quality of care. 1. The facility staff failed to ensure blood sugar checks were completed per physician's orders. Resident #48's blood sugar level dropped below normal causing him to become unresponsive then subsequently coded while he was in EMS care at the facility. 2. The facility failed to ensure that LVN G documented Resident #48's blood sugar result on the morning of [DATE]. 3. […]

• No harm, potential for more than minimal, patternF760Feb 26, 2026

  Based on interview and record review, the facility failed to ensure residents were free from any significant medication errors for 4 of 10 residents (Resident #2, Resident #5, Resident #8, and Resident #16) reviewed for medication errors in that:1. The facility failed to ensure Resident #2's blood pressure altering medications were administered and/or documented as ordered on 02/04/26 and 02/25/26. 2. The facility failed to ensure Resident #5's blood pressure altering medication was administered and/or documented as ordered on 22 of 76 opportunities from 02/01/26 to 02/26/26.3. The facility failed to ensure Resident #8's blood pressure altering medications were administered, and/or documented as ordered on 02/08/26.4. […]

• No harm, potential for more than minimal, patternF812Feb 26, 2026

  Based on observation, interviews and record review, the facility failed to distribute and serve food with proper accordance with professional standards for food service safety. The kitchen staff member failed to wear the beard restraint properly to prevent hair from contacting food.The facility staff member failed to wear gloves during lunch and handled Resident #4's food bare handed. These failures could place residents who receive meals and/or snacks from the kitchen at risk for food contamination and food borne illness.Findings Include: Observations during the lunch hour in the dining room revealed on 02/25/26 at 12:30 PM revealed the MR who was helping to serve residents was in line to receive a tray from the kitchen to give to the residents proceeded to touch Resident #4's biscuit and… […]