Mountain Ridge Rehabilitation And Healthcare Cente

Penalty

Inspection fine: $15,185

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was positioned upright before being given a hot beverage. Resident #62 had diagnoses including non-Alzheimer’s dementia and was documented as having severe cognitive impairment, with assistance needs for eating and significant assistance with bed mobility and positioning. Her care plan included a coffee cart activity, and she was observed lying flat in bed when the beverage was delivered. On the morning of the incident, an Activity Assistant gave the resident coffee and placed it on the bedside table without verifying that the resident was upright or otherwise safely positioned to drink it. The assistant later heard the resident say the coffee was hot. A Nursing Assistant who entered the room also observed the resident lying flat in bed. The resident had spilled the coffee onto herself, and staff found spilled coffee on her right side with redness to the skin. Nursing documentation stated the resident screamed in pain, complained of burning pain to the chest and upper back, and had red areas after the spill. The nurse removed the gown, applied cold towels, changed the bedding, and notified the physician and family. Subsequent records described partial-thickness burns to the chest and upper back, with measurements documented for the affected areas. The physician later confirmed the burns were second-degree and the wound care provider documented partial-thickness burns that later resolved.

Penalty

Inspection fine: $15,185

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to remove thickened liquids that were stored past their use-by date in the walk-in refrigerator. During an observation with the District Dietary Manager, 6 unopened cartons of thickened liquid were found on a shelf with a use-by date of 6/22/26. The District Dietary Manager stated that food dates in the walk-in refrigerator were checked weekly on food delivery days, but the food order had been delivered earlier that morning and stock had not yet been put away or checked. The District Dietary Manager also stated that a fill-in Dietary Manager had worked the previous week and had overlooked the expired cartons of thickened liquid. The Administrator later stated that the kitchen overlooked the expired items in the walk-in refrigerator.

Penalty

Inspection fine: $15,185

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to assess a resident's ability to self-administer a medicated anti-itch lotion for 1 of 1 resident observed for self-administration of medication. The resident was admitted with diagnoses including postherpetic polyneuropathy and had a quarterly MDS assessment showing he was cognitively intact. His medical record contained a physician order for triamcinolone acetonide 0.1% every 12 hours as needed, but there was no order for 1% pramoxine hydrochloride, the anti-itch lotion found in his room. The record also had no assessment or care plan for self-administration of medications. An observation and interview found a 6-ounce bottle of anti-itch lotion containing 1% pramoxine hydrochloride on the resident's bedside table, and the resident stated he had used it for the past year for itching from prior shingles areas and that his family had brought it to him. A later room observation with a nurse again found the lotion on the bedside table, and the nurse removed it. The nurse stated she had not noticed the lotion earlier and did not know whether the resident had been assessed as safe to self-administer medications. The DON stated residents requesting self-administration were assessed by the nurse and DON, but she did not recall whether this resident had been assessed or seeing the lotion in the room. The Administrator stated the lotion should not have been left in the room without a physician order and a completed self-administration assessment.

Penalty

Inspection fine: $15,185

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain accurate advance directives in the medical record for one resident reviewed. Resident #4, who was admitted with dementia, had a Medical Orders for Scope of Treatment (MOST) form dated with full code status and a care plan dated with full code. Later in the record, a MOST form was found indicating Do Not Resuscitate (DNR) with limited interventions, antibiotics as needed, IV fluids, and no feeding tube, along with a physician order for CPR, limited interventions, antibiotics if indicated, IV fluids, and no feeding tube. The Social Worker stated she was not aware the resident's MOST form had changed from full code to DNR and said the physician-signed MOST form had been uploaded to the chart without her knowledge. She stated the resident's MOST form and physician order should have matched. The Social Worker described the usual process as the physician signing the MOST after speaking with the resident or resident representative, then a nurse notifying her of the change so she could review the form, place it in her mailbox, and upload it after checking the physician order. The Administrator stated the signed MOST form did not make it to the Social Worker for review and upload, and that medical records uploaded it after it was placed in her mailbox.

Penalty

Inspection fine: $15,185

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its infection control policy for Enhanced Barrier Precautions (EBP) when two nurse aides transferred a resident with a dialysis port without sanitizing their hands before putting on gloves and without donning gowns. The facility policy stated that residents with a hemodialysis catheter or other indwelling medical device should be placed on EBP, and that gowns and gloves were required for high-contact resident care activities, including transferring a resident. The policy also required hand sanitizing when entering a resident room and before putting on gloves. On observation, two nurse aides entered the resident’s room, put on gloves without sanitizing their hands, and did not wear gowns. No EBP signage or PPE was observed outside or inside the room, although a hand sanitizer dispenser was located in the hall opposite the room. The resident was sitting in a wheelchair and was transferred to a recliner using a lift, then rolled to both sides so the sling could be removed. Interviews with the nurse aides, the assigned nurse, the DON, and the Administrator confirmed the resident had a dialysis port, that transferring the resident was high-contact care, and that the resident had not been placed on EBP because the facility misunderstood that the dialysis device required EBP.

Penalty

Inspection fine: $16,607

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of cerebral infarction, normal pressure hydrocephalus, aphasia, hemiplegia, contractures, osteoarthritis, osteoporosis, and prior vertebral fractures was dependent on staff for transfers and was prescribed antiplatelet medications increasing her risk of bleeding. During a mechanical lift transfer performed by two nurse aides, the resident slipped out of the sling, fell headfirst to the floor, and struck her head. Immediately after the fall, the resident was found lying supine on the floor, alert but complaining of head and neck pain, as well as left shoulder pain. The nurse on scene assessed the resident, noting her complaints and visible injuries, including a bruise and a skin tear. Despite the resident's complaints of head and neck pain and the mechanism of injury, staff proceeded to move her from the floor back to her bed using the mechanical lift before Emergency Medical Services (EMS) arrived. The staff, including two nurses and two nurse aides, rolled the resident onto the lift pad and transferred her to bed, with one nurse attempting to stabilize her head during the process. The facility did not have a cervical collar available at the time. EMS was called after the transfer, and upon arrival, EMS was informed of the headfirst fall and the resident's complaints. EMS placed a cervical collar and transported the resident to the emergency room. At the hospital, the resident was diagnosed with a C1 cervical vertebra fracture with moderate displacement and associated ligament disruption. She was not a surgical candidate and was transitioned to hospice care, where she later died. The immediate cause of death was listed as complications of blunt force trauma to the neck. Interviews with staff and medical personnel confirmed that the resident was moved prior to EMS assessment, despite her complaints of head and neck pain following a witnessed headfirst fall from a mechanical lift.

Removal Plan

• Reviewed risk management (incident/accident) reports to identify any other incidents involving mechanical lift transfer or falls with major injury, focusing on head or neck injury and inappropriate movement.
• Reviewed all resident transfers to acute care hospital to identify transfers involving serious injury from a fall on the head.
• Reviewed all Facility Reported Incidents to the state agency to identify any incidents involving serious injury from a fall on the head or neck.
• Reviewed the grievance log to identify any complaints of serious injury from a fall on the head or neck.
• Collaborated with the Medical Director to develop education content for Licensed Nurses on appropriate post-fall response actions, including recognizing severity and potential injury.
• Developed education from facility policy and Medical Director direction, emphasizing not moving residents with signs/symptoms of unconsciousness, head/neck pain, tenderness, or deformities, and maintaining alignment while awaiting EMS.
• Educated all Licensed Nurses working on the training developed by the Medical Director for assessing residents, when not to move them, and potential additional injury from moving after a head or neck injury.
• Ensured all newly hired staff will receive this education during orientation.
• Called all nurses not previously educated prior to their next shift to provide education and confirm understanding.
• Maintained a list of staff to confirm education completion.
• Provided written information at each nurses' station.
• In-person education for all nurses on assessing residents, when not to move them, and potential additional injury, to be completed on or before their next shift.
• Educated all Nurse Aides working that when a resident is found down or has a fall/accident, they are not to move the resident and must notify the licensed nurse and wait for instructions.
• Called all Nurse Aides not previously educated to provide education and confirm understanding.
• Ensured all newly hired Nurse Aides will be educated during orientation.
• Licensed Nurses to review with each Nurse Aide at the beginning of each shift for two weeks that they cannot move a resident who has fallen or is found down until the Licensed Nurse assesses the resident.
• Educated Administrative staff, Activities staff, Therapy, Housekeeping, Laundry, Maintenance, and Dietary Departments that no resident can be moved if found on the ground or after a fall/accident, and to notify the licensed nurse immediately.
• Ensured all staff will be educated on or before their next shift; newly hired staff will be educated during orientation.
• Interim DON, Administrator, and Minimum Data Set Nurses to review, five days a week, incident/accident reports, 24-hour report, order listing report for medication changes, discharge report, and grievance log to ensure all falls and injuries from a fall on the head are handled according to the plan.

Penalty

Inspection fine: $16,607

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to provide a safe transfer for a resident with significant physical impairments, including left foot drop, hemiplegia, and hemiparesis, who was also on antiplatelet medications. During a mechanical lift transfer, two nurse aides did not ensure that the resident's feet, which had shoes on, cleared the bed while being lifted. As the lift was moved, the resident's feet became caught on the mattress, and when they came loose, the resident swung and fell headfirst out of the sling from a height of approximately four feet, resulting in a C1 cervical vertebra fracture. The resident was subsequently transferred to the emergency department, placed in a cervical collar, and later transitioned to hospice care, where she died from complications of blunt force trauma to the neck. The incident was witnessed and documented by staff, with both nurse aides involved providing statements and interviews. One aide turned away from the resident to prepare the wheelchair, leaving the resident unsupervised and without physical support during the lift. The other aide continued to move the lift even after noticing the resident's foot was caught, failing to stop or seek assistance to guide the resident's legs. Neither aide maintained hands-on contact with the resident during the transfer, contrary to manufacturer instructions and facility policy, which require two staff to actively assist and ensure the resident is elevated high enough to clear the bed before moving the lift. Observations and interviews confirmed that the mechanical lift and sling were used, but the process deviated from both manufacturer guidelines and facility policy. The resident's care plan specified total assist by two staff for transfers using a mechanical lift, and the facility's policy required staff to follow manufacturer recommendations. Despite these requirements, the staff did not ensure the resident's safety during the transfer, directly leading to the fall and subsequent fatal injury.

Removal Plan

• Assess Resident #1's post-fall condition and transfer to the emergency department for evaluation and treatment.
• Update Resident #1's care plan to reflect the fall, interventions, and injuries.
• Notify the Interim Director of Nursing, Administrator, Corporate Director of Clinical Services, and Corporate Director of Operations of the incident.
• Initiate investigation, including suspension of both Nurse Aides involved in the transfer.
• Reenact the incident with both Nurse Aides to establish consistency in the description of events.
• Remove and review the lift and sling used during the incident by the Maintenance Director for function and quality.
• Examine all facility lifts and slings for function and quality per manufacturer guidelines.
• Review current residents and care plans to identify those requiring lift transfers and update as needed.
• Review risk management reports to confirm no other incidents involving mechanical lift transfers occurred.
• Review personnel files and facility grievance logs for both Nurse Aides to identify any prior disciplinary action or similar events.
• Educate all Nurse Aides on safe transfer processes based on manufacturer instructions and facility guidelines, including always having an actively assisting partner, appropriate sling selection, correct positioning, secure placement, confirmation of lift base legs spread, and confirmation of sling straps before moving the lift.
• Validate competency for Nurse Aides on lift transfers.
• Include lift transfer education and competency in new Nurse Aide orientation.
• Educate Licensed Nurses on proper transfer processes and observation requirements for Nurse Aide transfers.
• Provide training for Licensed Nurses.
• Include lift transfer education in new Licensed Nurse orientation.
• Provide lift competency training for all Licensed Nurses, including demonstration of safe transfer process using a manikin.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to post cautionary and safety signage outside the rooms of residents receiving supplemental oxygen. This deficiency was identified for five residents who had physician orders for continuous or as-needed oxygen therapy due to conditions such as chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, pneumonia, heart failure, and emphysema. Observations on multiple occasions confirmed that these residents were receiving oxygen via nasal cannula connected to either oxygen concentrators or portable tanks, yet no signage was present outside their rooms to indicate oxygen was in use. Interviews with nursing staff, including nurses and the Director of Nursing (DON), revealed that staff were either unaware of any requirement or policy to post oxygen signage on individual resident room doors. The DON confirmed that the facility's practice had been to only place oxygen signage at major entry points, based on the facility's smoke-free campus policy, and that this had been the standard for several years. Staff interviews further indicated a lack of knowledge or clarity regarding the need for room-specific oxygen signage, even when new oxygen orders were initiated for residents. The deficiency was consistently observed across all five residents reviewed for respiratory care, with each resident actively receiving oxygen therapy during the surveyors' visits. Despite the presence of oxygen equipment and active therapy, there was no cautionary or safety signage posted on or near the doors of these residents' rooms. The absence of such signage was confirmed through direct observation and staff interviews, and the facility's policy was cited as the reason for this omission.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to discard food items showing signs of spoilage and did not date open food items in the walk-in cooler. Specifically, an opened container of sour cream and an egg flat containing 17 eggs were found without open dates, and two of the eggs were cracked with visible shiny clear material around the cracks. The Dietary Manager confirmed that facility policy requires dating all opened food items and immediate disposal of spoiled food, and acknowledged that these items should have been dated and the cracked eggs discarded. Both the Dietary Manager and cook were identified as responsible for checking and labeling food items daily, but these procedures were not followed as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that an as-needed (PRN) psychotropic medication, Lorazepam, prescribed for a resident with anxiety and depression, included a required 14-day stop date. The medication order was entered by a nurse upon the resident's readmission, but no stop date was specified. Review of the resident's medication administration record showed that the order for Lorazepam remained active throughout the month, although no doses were administered. The resident was cognitively intact, displayed no behaviors or rejection of care, and did not receive any antianxiety medication during this period. Interviews with facility staff revealed that providers had recently begun entering their own orders and often omitted stop dates for medications when indicated. The DON acknowledged that the order should have included a 14-day stop date and that the admitting nurse had an opportunity to clarify this with the provider during order verification. The facility had a standing policy to discontinue unused medications after 60 days, but this did not align with the specific requirement for a 14-day stop date for PRN psychotropic medications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately code Minimum Data Set (MDS) assessments for three residents in the areas of hospice care and PASRR (Preadmission Screening and Resident Review) status. For one resident with diabetes mellitus who was certified for hospice care, the quarterly MDS assessment did not indicate that the resident was receiving hospice services, despite documentation and staff confirmation that hospice care was being provided. The MDS Coordinator acknowledged the oversight and stated that hospice care should have been reflected in the assessment. For two other residents with diagnoses including schizoaffective disorder, bipolar disorder, delusional disorder, anxiety disorder, and major depressive disorder, both had valid Level II PASRR determinations indicating serious mental illness. However, their respective MDS assessments failed to indicate their Level II PASRR status. The MDS Coordinator confirmed these omissions and noted that the assessments were completed by a previous coordinator who was no longer employed. The Administrator confirmed that MDS assessments are expected to be coded correctly.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent urinary catheter bags from touching the floor for two residents, increasing the risk of infection. Resident #69, who was moderately cognitively impaired and had an indwelling catheter, was observed multiple times with his catheter bag touching the floor. Staff, including the ADON and NAs, struggled to find a suitable position for the catheter bag on his wheelchair, leading to repeated instances where the bag was in contact with the floor. The DON acknowledged that catheter bags should not touch the floor but did not provide a solution to the issue at the time of the observations. Resident #51, who had a suprapubic catheter and was severely cognitively impaired, was also observed with his catheter bag touching the floor on multiple occasions. Staff, including Nurse #1 and NA #1, had difficulty positioning the catheter bag due to the long tubing and the design of the wheelchair. Despite attempts to reposition the bag, it continued to touch the floor. The DON and ADON recognized the problem but did not implement an effective solution. Additionally, the facility failed to obtain physician orders to flush Resident #51's suprapubic catheter as recommended by the Urology PA. The Urology PA had advised flushing the catheter to prevent blockages, but this recommendation was not communicated effectively to the facility staff. The NP and DON were aware of the recommendation but did not ensure that an order was placed. This oversight led to Resident #51 experiencing issues with catheter leakage and obstruction, resulting in an ER visit where he was diagnosed with a urinary tract infection and required catheter replacement.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to remove expired produce from the walk-in refrigerator and to store boxes of food in the walk-in freezer off the floor. Observations with the Dietary Manager (DM) revealed two plastic bags of bell peppers with splotchy brown/black spots and a fuzzy appearance, a bag of whole lettuce that was brown and contained off-colored liquid, and two boxes of grapes that were brown and mushy. The DM acknowledged that the expired produce should have been removed earlier. Additionally, two boxes of frozen food were found stored on the floor of the walk-in freezer, which the DM stated were overlooked during the last delivery day. The Administrator confirmed that the expired produce should have been disposed of and the food boxes should not have been left on the floor.