Mountain Ridge Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 13, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF609Dec 13, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF835Dec 13, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF837Dec 13, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF812Jan 15, 2026

  Based 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. […]