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Deficiency Records for Avamere Rehabilitation at Ridgemont

A list of the most recent deficiencies for Avamere Rehabilitation at Ridgemont. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Avamere Rehabilitation at Ridgemont. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-01-11 2024-01-30 Y
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-11-08 2023-11-24 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2023-09-21 2023-11-05 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-09-21 2023-11-05 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2023-09-21 2023-11-05 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-09-21 2023-11-05 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-09-21 2023-11-05 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2023-09-21 2023-11-05 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-09-21 2023-11-05 N
Provide enough food/fluids to maintain a resident's health. Health 2023-09-21 2023-11-05 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-09-21 2023-11-05 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2023-09-21 2023-11-05 N
Ensure that residents are free from significant medication errors. Health 2023-09-21 2023-11-05 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2023-09-21 2023-11-05 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-09-21 2023-11-05 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-09-19 2023-10-20 N
Have properly installed electrical wiring and gas equipment. Fire Safety 2023-09-19 2023-10-20 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-09-19 2023-10-20 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2023-09-19 2023-10-20 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-09-19 2023-10-20 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2023-09-19 2023-10-06 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-09-19 2023-10-06 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-09-19 2023-10-06 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2023-08-17 2023-09-01 Y
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2022-08-25 2022-10-12 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2022-08-29 2022-10-11 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2022-08-29 2022-10-11 N
Ensure each resident receives an accurate assessment. Health 2022-08-29 2022-10-11 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-08-29 2022-10-11 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2022-08-29 2022-10-11 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-08-29 2022-10-11 N
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Health 2022-08-29 2022-10-11 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-08-29 2022-10-11 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-08-29 2022-10-11 N
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2022-08-29 2022-10-11 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-08-29 2022-10-11 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2022-08-29 2022-10-11 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2022-08-29 2022-10-11 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2022-08-29 2022-10-11 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-08-29 2022-10-11 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2022-08-29 2022-10-11 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2022-08-29 2022-10-11 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2022-08-29 2022-10-11 Y
Respond appropriately to all alleged violations. Health 2022-08-29 2022-10-11 Y
Have simulated fire drills held at unexpected times. Fire Safety 2022-08-25 2022-09-30 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-08-25 2022-09-29 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-08-25 2022-09-29 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2022-07-13 2022-08-10 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-04-04 2022-05-24 Y
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2022-04-04 2022-05-24 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2019-08-16 2019-09-30 N
Ensure each resident receives an accurate assessment. Health 2019-08-16 2019-09-30 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2019-08-16 2019-09-30 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2019-08-16 2019-09-30 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2019-08-16 2019-09-30 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2019-08-16 2019-09-30 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2019-08-16 2019-09-30 N
Observe each nurse aide's job performance and give regular training. Health 2019-08-16 2019-09-30 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2019-08-16 2019-09-30 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2019-08-16 2019-09-30 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2019-08-16 2019-09-30 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2019-08-16 2019-09-30 N
Implement a program that monitors antibiotic use. Health 2019-08-16 2019-09-30 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2019-08-16 2019-09-30 N
Install an approved automatic sprinkler system. Fire Safety 2019-08-21 2019-09-15 N
Have properly installed hallway dispensers for alcohol-based hand rub. Fire Safety 2019-08-21 2019-08-26 N
Ensure proper usage of power strips and extension cords. Fire Safety 2019-08-21 2019-08-22 N

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