Mountain Ridge Rehabilitation and Healthcare Cente

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Oct 21, 2025

  Based 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). […]

• Immediate jeopardy, isolatedF689Oct 21, 2025

  Based 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. […]

• Actual harm, isolatedF689Jul 9, 2026

  Based 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. Findings included: Resident #62 was admitted to the facility on [DATE] with diagnoses which included non-Alzheimer's dementia. Resident #62's care plan revised 9/26/25 had an activity needs focus which included coffee cart. […]

• No harm, potential for more than minimal, patternF812Jul 9, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF695May 30, 2025

  Based on record review, observations, resident and staff interviews, the facility failed to post cautionary and safety signage outside residents' rooms that indicated the use of oxygen for 5 of 5 residents reviewed for respiratory care (Resident #14, Resident #74, Resident #28, Resident #7 and Resident #51). The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, and acute respiratory failure with hypoxia (a condition in which there is an inadequate supply of oxygen to the body's tissues). A review of Resident #14's physician orders indicated an order dated 4/25/25 for oxygen to be administered continuously via nasal cannula at 3 liters per minute every shift. […]