Avantara Park Ridge

In the surveyor’s words

From the most serious findings on record at Avantara Park Ridge, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 16, 2026

  Based on observation, interviews, and record review, the facility failed to ensure a resident received appropriate incontinence care and repositioning that led to the development of a pressure ulcer for 1 (R85) of 3 residents reviewed for pressure ulcers in total sample of 48. This failure resulted in R85 developing stage 3 pressure ulcer to the right buttock.Findings include:R85 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Multiple Sclerosis; Major Depressive Disorder; Hemiplegia and Hemiparesis Following Nontraumatic Intracerebral Hemorrhage Affecting Left Dominant Side; and Essential (Primary) Hypertension.MDS (Minimum Data Set) assessment dated [DATE], shows R 85 is at risk of developing pressure ulcer/injuries and does not… […]

• Actual harm, isolatedF689Sep 16, 2024

  Based on observation, interview and record review, the facility failed to a.) ensure (R3's) fall risk assessment was accurate b.) failed to implement fall prevention interventions and failed to provide supervision for two ( R2, R3) of four residents reviewed for falls. These failures resulted in the following: R2 fell on [DATE] and on 7/06/24. R3 fell on [DATE] (fall without injury) and R3 also fell on [DATE] (7 days later) and sustained a subdural hemorrhage (bleeding inside the head). […]

• Actual harm, isolatedF689Nov 2, 2023

  Based on observations, interviews and records reviewed the facility failed to follow fall prevention interventions to include supervision/monitoring and use of assistive/safety devices to prevent the risk of falling. This affected three of three residents (R1-R3) reviewed for falls and fall prevention interventions. This failure resulted in R1 being involved in a fall incident sustaining a fracture of the L4 and L5, Lumbar Spine, and R3 being involved in a fall incident resulting in an Oblique Fracture of the Left Fifth Metatarsal and of the Neck of the Right Radius. […]

• Actual harm, isolatedF686Jun 18, 2023

  Based on interview and record review the facility failed to prevent a facility acquired pressure ulcer from developing, failed to develop and implement a care plan with pressure relieving interventions to prevent a pressure ulcer from developing, failed to develop and implement a care plan with interventions to address a pressure ulcer once developed, and failed to do skin checks for one of three residents (R4) reviewed for pressure ulcers in the sample of five. These failures resulted in R4, who was admitted to the facility without pressure ulcers, developing a stage two pressure ulcer to the right heel that progressed to an unstageable infected pressure ulcer that required R4 to be hospitalized and treated with intravenous antibiotics. […]

• Actual harm, isolatedF689Jun 18, 2023

  Based on interview, observation, and record review the facility failed to use an appropriate mechanical lift sling per manufacturer's instructions during a transfer and failed to transfer a resident safely, as directed by the facility's policy, using a mechanical lift for one of three residents (R3) reviewed for falls in the sample of five. These failures resulted in a mechanical lift tipping over with R3 during a transfer from the bed to the wheelchair, resulting in the mechanical lift falling on R3's left arm, fracturing the left radial head (knobby area of the radius where it meets the elbow) of R3's left arm. Findings include: The facility's Mechanical Lift Transfers policy dated 1-14-13 documents, Procedures: 1. Follow manufacturer's guidelines on how to operate machine. 4. […]