Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountain Ridge Health And Rehabilitation during CMS and state inspections, most recent first.
A male resident with cognitive impairments was found naked on top of a female resident with severe cognitive impairment, attempting to remove her brief. Despite the incident being witnessed by staff and the female resident showing signs of distress, the facility's administrative staff failed to recognize it as abuse and did not report it to state agencies or law enforcement.
The facility failed to report an alleged sexual abuse incident involving two residents, where one resident was found on top of another in bed, attempting to remove the other's brief. Despite staff recognizing it as abuse, the DON and Administrator did not report it to authorities, citing the absence of physical harm and the confusion of the involved resident. This inaction violated the facility's policy and state regulations.
A facility failed to report an incident where a resident was found naked from the waist down on top of another resident. Despite staff identifying it as an abuse allegation, the Administrator and DON did not report it, believing it was not abuse due to the resident's dementia and lack of prior inappropriate behavior. The decision not to report was confirmed through interviews with facility staff.
The facility's Governing Body failed to oversee the Administrator, leading to a failure to report an allegation of sexual abuse. Staff observed a resident, naked from the waist down, on top of another resident, attempting to remove their brief. Despite staff reporting the incident as abuse, the Administrator and DON did not report it to authorities. The Governing Body members, including the RDO and RDCS, did not provide guidance, citing it was the Administrator's responsibility.
The facility failed to investigate injuries of unknown origin for three residents, leading to a deficiency in handling potential abuse cases. A resident with cognitive impairment sustained skin tears after a male CNA provided care against her wishes, with no documented investigation. Another resident was diagnosed with a fractured hip of unknown origin, and a third resident had a large bruise with no investigation. Interviews revealed a lack of awareness and documentation of these incidents.
The facility failed to report injuries of unknown origin for three residents to the State Survey Agency within the required timeframe. A resident with cognitive impairment sustained skin tears from a male CNA, another was diagnosed with a fractured hip of unknown origin, and a third had a large bruise on the arm. None of these incidents were reported as required.
The facility did not ensure RN coverage for at least eight consecutive hours a day, seven days a week, missing coverage on 12 days over a four-month period. The DON admitted there was no policy to ensure consistent RN scheduling, and the Administrator, who occasionally worked as an RN, was unsure if her hours counted towards the requirement. The facility was adjusting to new ownership during this period.
The facility did not comply with food service safety standards, as uncovered and undated food items were found in the refrigerator, potentially affecting 25 residents. Despite existing policies requiring food to be covered and labeled, staff failed to follow these guidelines, as confirmed by interviews with the Dietary Manager and Regional Director of Operations.
A resident with cognitive impairment was injured during care by a male CNA, despite having expressed a preference for female caregivers. The facility failed to document this preference in the care plan until after the incident, leading to a violation of the resident's rights. Interviews revealed that the facility was aware of the preference but did not initially include it in the care plan, resulting in the incident.
A resident with right-sided paralysis was left struggling to feed himself during a meal service, resulting in distress and spillage. Staff referred to residents needing assistance as 'feeders,' compromising their dignity. Despite awareness of the issue, the term was used by multiple staff members, including the Administrator, indicating a systemic problem.
Failure to Report and Address Sexual Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, as evidenced by an incident involving two residents. On the evening of November 21, 2024, two CNAs discovered a male resident, who was naked from the waist down, on top of a female resident in her bed. The male resident was observed attempting to remove the female resident's brief and made inappropriate comments. Despite the clear signs of a non-consensual encounter, the facility's administrative staff did not recognize the incident as an allegation of abuse and failed to report it to the appropriate state agencies or law enforcement. The female resident involved in the incident had severe cognitive impairment, as indicated by a BIMS score of zero, and was unable to communicate verbally due to a previous stroke. The male resident also had cognitive impairments and a history of wandering into other residents' rooms. Despite these factors, the facility did not take immediate action to protect the female resident or to investigate the incident as a potential case of sexual abuse. The facility's policy on abuse, neglect, and exploitation clearly defined such incidents as reportable, yet the administrative staff did not adhere to these guidelines. Interviews with staff members revealed that the Director of Nursing and the Administrator were informed of the incident but did not consider it to be abuse or a reportable event. The facility's failure to recognize and report the incident as abuse, despite the presence of multiple witnesses and the distress of the female resident, highlights a significant deficiency in the facility's handling of resident safety and abuse prevention protocols.
Failure to Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to immediately report an allegation of sexual abuse involving two residents, R2 and R3, as required by their policy and state regulations. On the evening of the incident, two CNAs discovered R3, who was naked from the waist down, on top of R2 in R2's bed, attempting to remove R2's brief. R3 stated they were engaging in sexual activity. R2, who was moderately cognitively impaired and lacked the capacity to consent to sexual contact, was not physically harmed but was involved in a situation that met the definition of sexual abuse according to the facility's policy. Despite the CNAs and an LPN recognizing the situation as an allegation of abuse and reporting it to the Director of Nursing (DON) and the Administrator, the facility did not report the incident to the State Survey Agency or law enforcement within the required two-hour timeframe. The DON and Administrator, who was also the facility's abuse coordinator, decided that the incident did not constitute abuse and therefore did not require reporting. They based their decision on the absence of physical harm to R2 and their assessment that R3, who had dementia, was confused and did not intend harm. The facility's failure to report the incident was confirmed through interviews with the DON, Administrator, and other staff members. The Medical Director was informed of the incident but was not aware that it had not been reported to the appropriate authorities. The Regional Director of Operations was also informed but did not provide guidance on reporting. The facility's inaction in reporting the incident as required by their policy and state regulations constitutes a deficiency in their handling of abuse allegations.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an incident involving two residents, where one resident was found naked from the waist down on top of another resident, to the State Survey Agency or law enforcement. The incident was witnessed by two CNAs who immediately reported it to the nursing staff, including the DON and Administrator. Despite the direct care staff identifying the situation as an allegation of abuse, the administrative staff did not report it as required by the facility's policy. The Administrator and DON, after reviewing witness statements and assessing the situation, concluded that the incident did not constitute abuse and therefore did not require reporting. They based their decision on the belief that the resident found on top of the other was confused due to dementia and had no prior history of inappropriate sexual behavior. The Administrator, who was the facility's abuse coordinator, and the DON both decided that the incident was not a reportable event, despite the facility's policy requiring immediate reporting of such allegations. The failure to report the incident was confirmed through interviews with the Administrator, DON, and Regional Director of Operations. The Administrator acknowledged awareness of the reporting requirements but chose not to report the incident, believing it was not abuse. The Regional Director of Operations stated that the responsibility to report lay with the Administrator, whose name was on the facility's license. The decision not to report was maintained even after further discussions with the resident's family and additional staff interviews.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility's Governing Body failed to provide effective oversight to the Administrator, resulting in a failure to implement policies for identifying and reporting an allegation of sexual abuse. On the night of the incident, staff observed a resident, R3, naked from the waist down, on top of another resident, R2, in bed. R3 was attempting to remove R2's brief and made an inappropriate comment. This incident was reported to the Administrator and the Director of Nursing (DON), who are members of the Governing Body, but they did not report the incident to the State Survey Agency or law enforcement. Interviews with Certified Nursing Assistants (CNAs) and a Licensed Practical Nurse (LPN) revealed that they perceived the incident as abuse and reported it up their chain of command. Despite this, the Administrator and DON did not identify the situation as possible abuse and failed to report it. The Administrator informed other members of the Governing Body, including the Regional Director of Operations (RDO) and the Regional Director of Clinical Services (RDCS), but they did not provide guidance or direction to report the incident. The RDO and RDCS stated that it was the Administrator's responsibility to decide whether to report the incident, despite the facility's policy indicating that the Governing Body is responsible for ensuring compliance with federal regulations. Both the RDO and RDCS refused to comment on whether the incident should have been reported, citing their absence from the facility at the time. This lack of oversight and failure to ensure compliance with abuse reporting regulations placed residents at risk.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate injuries of unknown origin for three residents, leading to a deficiency in handling potential abuse cases. Resident 27, who had a history of moderate to severe cognitive impairment, sustained skin tears after a male CNA provided care against her wishes. Despite the resident's refusal for male caregivers, the facility did not document an investigation into the cause of the injuries, which were reported by the family as inconsistent with the explanation given by the facility. Resident 110, who was severely cognitively impaired, was diagnosed with a fractured hip of unknown origin. The family had expressed concerns about the resident's condition, prompting medical evaluations and eventual hospitalization. However, there was no documented investigation by the facility to determine the cause of the fracture, despite the presence of a bruise on the resident's spine and a previous fall. Resident 111, who was cognitively intact, was found with a large bruise on her right upper arm, which was also of unknown origin. The resident complained of pain, and an x-ray was ordered, but there was no documentation of an investigation into the bruise. Interviews with the prior and current administrators revealed a lack of awareness and documentation of these incidents, indicating a systemic failure to investigate and report injuries of unknown origin.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report injuries of unknown origin for three residents to the State Survey Agency within the required timeframe. Resident 27, who had a history of moderate to severe cognitive impairment, sustained skin tears while receiving care from a male CNA, despite having previously expressed a preference against male caregivers. The incident was not reported to the State Survey Agency, and there was no documented evidence of such a report. Resident 110, who was severely cognitively impaired, was diagnosed with a fractured hip of unknown origin. The resident's family had expressed concerns about the resident's condition, which led to a hospital transfer where the fracture was discovered. Despite the severity of the injury, there was no documented evidence that the incident was reported to the State Survey Agency. Resident 111, who was cognitively intact, was found to have a large bruise on the right upper arm, which was also of unknown origin. The resident complained of pain, and an x-ray was ordered, but there was no documented evidence of the x-ray report or that the injury was reported to the State Survey Agency. The prior Administrator did not recall these incidents, and the current Administrator noted that there was no process in place for reporting and investigating such incidents at the time.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) were utilized for at least eight consecutive hours a day, seven days a week, as required by regulation. This deficiency was identified through interviews and record reviews, revealing that the facility did not provide the required RN coverage for 12 days between May 1, 2024, and August 31, 2024. The Director of Nursing (DON) acknowledged the absence of a policy to ensure consistent RN coverage and admitted that the facility had not consistently scheduled an RN for the required hours. The Administrator, who is also an RN, was aware of the regulation but was uncertain if her hours worked on weekends counted towards the required coverage. The facility underwent a change in ownership as of August 1, 2024, and was still adjusting to the new management.
Failure to Adhere to Food Storage Policies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by observations of uncovered and undated food items in the refrigerator. On two separate occasions, surveyors observed pureed and sliced watermelon, as well as lemonade, stored in the refrigerator without proper covering or labeling. This oversight potentially affected 25 out of 55 residents in the facility. The facility's policy on Food Receiving and Storage mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated, which was not followed in this instance. Interviews with the Dietary Manager and the Regional Director of Operations revealed that the dietary staff had been previously educated on the importance of covering and dating stored food items. The Dietary Manager acknowledged that the Dietary Aide was aware of the policy but failed to comply due to being in a hurry. Both the Dietary Manager and the Regional Director of Operations emphasized the importance of following the storage policy to protect food from harmful bacteria, objects, and chemicals. The Administrator also expressed the expectation that all staff adhere to facility policies.
Failure to Honor Resident's Caregiver Preference
Penalty
Summary
The facility failed to uphold a resident's right to choose their caregiver, specifically in the case of a resident who did not want male staff to provide personal care. The resident, who had a history of moderate to severe cognitive impairment, expressed a preference for female caregivers, which was documented in the care plan only after an incident occurred. The incident involved the resident becoming combative during care provided by a male CNA, resulting in skin tears that required treatment. Despite the resident's prior communication of her preference, the care plan did not reflect this until after the incident. Interviews with family members and staff revealed that the facility was aware of the resident's preference before the incident. However, the facility's documentation and care planning did not initially include this preference, leading to the incident where the resident was injured. The current administrator confirmed awareness of the resident's preference and ensured compliance, but was not in position at the time of the incident. The previous administrator and other staff members were either unaware of the incident or did not recall it, indicating a lapse in communication and documentation regarding the resident's care preferences.
Resident Dignity Compromised During Meal Service
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents during meal service, as observed on 09/05/2024. Staff members used labels to identify residents requiring assistance with meals and referred to them as 'feeders,' which is considered unprofessional and a dignity issue according to facility policy. During the noon meal, a resident with a history of cerebral infarction and right-sided paralysis was left struggling to feed himself, resulting in food and drink being spilled on his clothing. The resident was visibly distressed and left unattended for two minutes before staff intervened. The resident, identified as R6, was admitted to the facility with multiple diagnoses, including type II diabetes mellitus, cerebral infarction, and hemiplegia affecting the right side. The resident's care plan indicated a need for feeding assistance due to his physical limitations. However, during the observed meal, staff failed to provide the necessary assistance, leading to the resident's difficulty in self-feeding and subsequent distress. The staff's use of the term 'feeder' was overheard by survey agents and other residents, further compromising the resident's dignity. Interviews with various staff members, including CNAs, the Activities Director, and the Administrator, revealed a general awareness of the inappropriate terminology and its impact on resident dignity. Despite this awareness, the term 'feeder' was used by multiple staff members, including the Administrator, indicating a systemic issue within the facility. The Director of Nursing acknowledged the problem and initiated re-education for staff on resident rights and dignity, but the deficiency had already occurred, affecting the resident's quality of life.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Monticello
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clinton County Care And Rehabilitation Center | 15.1 mi | ★★★★★ | 0 | 0 |
| Fair Oaks Health And Rehabilitation | 15.5 mi | ★★★★★ | 0 | 0 |
| Pickett Care And Rehabilitation Center | 20.8 mi | ★★★★★ | 0 | 0 |
| Somerset Nursing And Rehabilitation Facility | 24.2 mi | ★★★★★ | 2 | 0 |
| Lake Cumberland Regional Hospital Scu | 24.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.