Avamere Rehabilitation at Ridgemont

In the surveyor’s words

From the most serious findings on record at Avamere Rehabilitation at Ridgemont, in the surveyor’s own words.

• Actual harm, isolatedF684Oct 23, 2024

  Based on interview and record review, the facility failed to obtain clarification for treatment and assess timely for prompt intervention, a surgical incision under the dressing for 1 of 3 residents (Resident 1) reviewed for wound care. Resident 1 experienced harm when their surgical incision dehisced (opened back up), became necrotic (dead/devitalized tissue) and showed signs of infection after 19 days without observation of the incision below the dressing assessment. This failure placed residents at risk for medical complications and a decreased quality of life. Findings included . Resident 1 was admitted on [DATE] with diagnoses including diabetes, heart and kidney disease. […]

• Actual harm, isolatedF686Apr 4, 2022

  Based on observation, interview and record review, the facility failed to provide assessment, care planning and interventions to prevent a pressure injury (bed sore) from developing for one of three sampled residents (1) reviewed for pressure injuries. This failure caused harm to Resident 1 when the resident had a change of condition and developed an avoidable, advance stage wound on the sacrum (tail bone). Findings included . National Pressure Injury Advisory Panel (NPIAP) Quick Reference Guidelines, dated 2019, documented strong positive evidence that individuals with limited mobility and limited activity had high potential for pressure injury. […]

• No harm, potential for more than minimal, widespreadF925Nov 8, 2023

  Based on observation, interview and record review, the facility failed to ensure an effective pest control program was maintained to keep the facility free of phorid flies (a type of fly that breed in moist, decaying organic matter) in 3 of 4 resident care units (Hallway 100, 200 and 300), kitchen, dining room and common areas of the facility. This failure placed residents at risk for infection, distress and a decreased quality of life. Findings included . <RESIDENTS> On 11/08/2023 at 12:48 PM, Resident 1 said they were used to the flies and observed them frequently at mealtime or when food was present. Resident 1 said the flies would not land on their food because the resident would constantly move their fork to keep the flies from landing. […]

• No harm, potential for more than minimal, patternF605Sep 12, 2025

  .Based on interview and record review the facility failed to ensure psychotropic medications (drugs that affect behavior, mood, thoughts and perception) had an adequate indication for use, the specific target behaviors (TB) the medication was implemented to treat were identified and monitored, gradual dose reductions (GDRs) were performed and resident responses accurately assessed and documented, non-drug interventions were identified and attempted prior to administration of as needed (PRN) psychotropic medications, and staff monitoring for medication adverse side effects occurred for 3 of 5 residents (Residents 13, 44 & 26) reviewed for unnecessary medications. […]

• No harm, potential for more than minimal, patternF628Sep 12, 2025

  .Based on interview and record review, the facility failed to provide a transfer notice and written bed hold notice at the time of transfer to the hospital, for 3 of 3 sampled residents (Resident 24, 73 & 2) reviewed for hospitalization. This failure placed residents at risk for not knowing their rights to transfers or of bed holds while in the hospital and a diminished quality of life.Findings included .RESIDENT 24Resident 24 was admitted to the facility on [DATE]. The 5 Day Minimum Data Set (MDS, an assessment tool) dated 09/05/2025, documented Resident 24 was cognitively intact.Resident 24 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. […]