Mountain Ridge Center, Genesis HealthCare

In the surveyor’s words

From the most serious findings on record at Mountain Ridge Center, Genesis HealthCare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880May 29, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were free from potential exposure to bloodborne pathogens when staff used a resident's insulin pen on two residents (Resident identifiers are #62 and #70). The facility also failed to implement infection control policies for hand hygiene and disinfection of equipment for 2 of 7 residents observed during medication administration (Resident identifiers are #41 and #48). Findings include: Resident #62 and Resident #70 Interview on 5/28/26 at approximately 8:30 a.m. with Resident #62 revealed he/she received someone else's insulin yesterday afternoon. Interview on 5/28/26 at approximately 9:30 a.m. […]

• No harm, potential for more than minimal, widespreadF725Jun 20, 2025

  Based on record review and interview, it was determined that the facility failed to provide sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in a census of 68 residents. Findings include: Review on 6/19/25 of Mountain Ridge Facility Assessment 2025 revealed staff/personnel required listed staff by shift for the entire facility and did not list staff/personnel required per resident unit. Review on 6/19/25 of personnel files revealed the following staff with light duty restrictions: Staff F (LNA with a 10 pound lifting restriction) and Staff R (LNA with a 10 pound lifting restriction). Interview on 6/19/25 at approximately 1:00 p.m. […]

• No harm, potential for more than minimal, patternF565May 29, 2026

  Based on interview and medical record review, the facility failed to act promptly upon the grievances and recommendations of issues of resident care raised at Resident Council Meeting for 2 of 2 months of resident council minutes reviewed. Findings include:Interview on 5/27/26 at approximately 10:00 a.m. during Resident Council Meeting revealed that the group had complained about long call bell wait times over the last 2 months. Residents at this meeting stated they do not feel this concern was addressed and that no one had followed up to inform them of what if any actions had been taken since the initiation of the concerns.Review on 5/27/26 of the facility's Resident Council Meeting minutes revealed the following documented concerns under Nursing:March 19, 2026, minutes: Residents are… […]

• No harm, potential for more than minimal, isolatedF658May 29, 2026

  Based on observation, interview, and record review, the facility failed to ensure that insulin was administered per manufacturer's instructions for 1 of 7 residents observed for medication administration (Resident identifier is #55).Findings include: Resident #55 Review on 5/26/26 of Resident #55's physician orders revealed an order for Novolog Insulin (Aspart Insulin) per sliding scale before meals for Diabetes Mellitus. Observation on 5/26/26 at 11:45 a.m. of Resident #55's insulin administration with Staff A (Licensed Practical Nurse (LPN)) revealed when injecting the insulin, with the insulin pen, Staff A held the plunger of the insulin pen for approximately 4 seconds. Interview on 5/26/26 at approximately 11:45 a.m. […]

• No harm, potential for more than minimal, isolatedF760May 29, 2026

  Based on interview and record review, the facility failed to ensure residents remained free of insulin medication errors for 2 of 2 residents reviewed for significant medication error in a final sample of 19 residents. (Resident identifier are #62 and #70.) Findings include:Resident #62Interview on 5/28/26 at approximately 8:30 a.m. with Resident #62 revealed he/she received someone else's insulin yesterday afternoon. Resident #62 stated that a male staff member approached her in the dining room and asked, Are you [first name omitted]?Review on 5/28/26 of Resident #62's provider note dated 5/27/26 revealed that .Nursing discovered that this pt likely received another pt's insulin (with the same first name). […]