Ryze at Homewood

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient staff to provide nursing and related services as determined by assessments, individual plan of care, number of residents, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. This failure has the potential to affect all 131 residents currently at the facility. The 1/12/26 facility census includes 73 (2nd floor) residents. 1. R1 resides on the 2nd floor. On 1/12/26 at 10:17 AM, R1 was lying atop of a LALM (Low Air Loss Mattress), however, the setting was on static (firm) mode (the setting should be on alternate mode - while lying in bed). Several large white clumps of food were observed on R1's chest. R1 affirmed he was served Grits for breakfast. R1 also affirmed he was unable to move the right upper extremity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items in the walk-in cooler were labeled and dated; failed to ensure sanitizing compartment sink and sanitizing bucket had the correct concentration of sanitizer to wipe food preparation surfaces; failed to ensure food carts were free of dried food spills; and failed to ensure the floor of the kitchen and dry storage room were kept clean and free of visible dirt. These failures have the potential to affect all 127 residents that receive oral foods from the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 2 of 3 outside dumpsters garbage disposal were covered with the lids, and failed to ensure that the floor around the dumpsters were free of spilled trash, thus creating an unsanitary environment. These failures have the potential to cause harboring of rodents which can affect all 131 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store/transport clean clothing in a manner that prevents potential contamination. This failure has the potential to affect all 131 residents that reside within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five residents (R5, R16, R58, R74, and R76), out of a sample of 54 residents reviewed for resident rights, were treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident call lights were within reach, failed to ensure resident equipment was clean, failed to ensure equipment (in use) was in good condition, failed to ensure sheets covered the mattress while in use, failed to ensure soiled bed linens were changed, failed to ensure requested condiments were provided, and failed to ensure staff provided assistance when resident socks were wet and needed to be changed for six of 54 residents (R2, R13, R27, R32, R88, R94) in the sample.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to ensure esident curtains were hung properly, failed to ensure dining room tables/resident rooms are cleaned timely for four (R11, R56, R69, R88) residents, failed to ensure the 700 unit shower room was clean, failed to discard soiled toilet paper, failed to replace the shower head, failed to repair broken floor tiles in the shower, and failed to ensure soiled linen was placed in the laundry for 23 residents residing on the 700 unit in a total sample of 54 reviewed for homelike environment.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to ensure that ADL (Activities of Daily Living) care was provided to 10 of 54 dependent residents (R1, R2, R3, R13, R27, R29, R54, R78, R79, R121) in the sample reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left at bedside and failed to date opened multidose medications for four of 54 residents (R27, R112, R122, R127) in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the multi-use vial of blood glucose test strips was labeled with the date opened and remained closed when not in use. These failures have the potential to affect six residents (R5, R27, R74, R91, R123, and R127) who receive blood glucose monitoring tests residing on units 300 and 400, reviewed for laboratory storage in the sample of 54 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure cold foods were stored properly and failed to ensure food was maintained within the required temperature range to prevent food borne illness. These failures have the potential to affect 73 (2nd floor) residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure corridors have firmly secured handrails. This failure has the potential to affect all 32 residents that reside on the 300 and 400 units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the LALM (Low Air Loss Mattress) was on the correct setting while in use and failed to ensure all nursing staff were aware of required LALM settings for one of 54 residents (R1) in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the restorative needs and failed to provide restorative services for residents with mild hand contractures to prevent further decline. These failures affected two residents (R6 and R12) of three residents, reviewed for restorative care, in a total sample of 54 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall prevention interventions and failed to provide supervision to one of 54 residents (R140); failed to ensure the 300 unit emergency exit door (egress) was able to be opened; and failed to ensure the 300 unit emergency exit door alarmed when opened affecting twelve 300 unit residents.

Inspectors wroteBased on observation, interview, and record review, failed to implement care plan interventions, failed to follow physician orders, failed to notify the physician of abnormal urine, failed to document abnormal urine, failed to obtain orders for urinalysis/culture, failed to ensure urinary catheter bags remain below the bladder level to prevent backflow and potential UTI (Urinary Tract Infection), and failed to ensure a nephrostomy tube drainage bag was placed below the kidney level to prevent backflow of urine into the kidney and the potential for kidney infection. These failures affected three residents (R1, R4, R13) in the sample of 54 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to execute physician orders and failed to implement care plan interventions for one resident (R3) in a sample of 54 residents reviewed for nutrition. These failures resulted in R3 sustaining a significant weight loss of -15.06% in less than 3 months (2 months and 13 days) and -7.04% in less than 1 month (17 days).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that posted nursing staffing information was complete and accurate. This failure has the potential to affect all 131 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to monitor and investigate how a resident with a history of drug usage was able to obtain illicit drugs in the facility. This failure affected one (R3) of three residents reviewed for supervision. As a result of this failure, R3, who did not have an independent outside pass privilege, tested positive for illicit drugs on 9/19/25, 9/25/25, and 10/3/25, requiring transfer to local hospital. The Immediate Jeopardy began on 9/19/25 when R3 was sent to the hospital and tested positive for illicit drugs while in the facility. V1 (Administrator) was notified on 12/23/25 at 1:38 PM of the Immediate Jeopardy. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of an unwitnessed fall with potential head injury affecting one resident (R1) and failed to properly in-service staff on the Fall Risk Assessments. These failures affected one resident (R1) reviewed for falls and has the potential to affect all the residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete Fall Assessments for four residents (R1, R6, R7 and R8), who have a history of falling. This failure has the potential to affect four residents (R1, R6, R7 and R8) in a sample of six residents (R1, R4, R5 R6, R7 and R8) reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to keep two residents (R3 and R5) free from resident-to-resident physical abuse after R3 was punched in the right eye by another resident (R4), and R5 was slapped on the head by another resident (R1) for two out of five residents reviewed for abuse in a total sample of nine. This failure resulted in R3 sustaining blunt head trauma and a swollen, black eye. Findings Include:1. R3 is a [AGE] year-old female resident admitted in the facility on 5/1/2024. R3 is assessed to be alert, able to make needs known, forgetful at times. R4 is a [AGE] year-old male resident admitted in the facility on 7/8/2025. On 9/16/2025 at 12:07 PM, R3 observed in her room lying in bed. R3 was able to answer questions appropriately, but noted forgetful at times. There was slight purplish discoloration around the right eye observed. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect a resident from staff to resident misappropriation of resident property. This failure affected one resident (R1) out of three residents reviewed for abuse. As a result of this failure, R1 felt awful, targeted, afraid, trapped, and unsafe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a Dietary Manager available to ensure daily Dietary services were performed appropriately and efficiently resulting in residents not receiving meals according to their preferences, requests, needs, or the facility's menu; residents not being served in a timely and consistent manner; residents not receiving food at an appetizing temperature; and dry food not being stored under sanitary conditions. These failures applies to all 131 residents receiving food from the facility.

Inspectors wroteBased on interview and record review, the facility failed to monitor and document a dependent resident's fluid intake for all meals that required one to one supervision during meals and failed to assess for signs and symptoms of dehydration. This affected one of four residents (R1) reviewed improper nursing care and dehydration. This failure resulted in R1 being emergently transferred to the hospital and diagnosed with severe hypernatremia (excessively high sodium level in the blood) and AKI (Acute Kidney Injury). R1 was hospitalized for 5 days requiring intravenous fluids and antibiotic treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders for daily wound care treatments were completed as ordered; failed to ensure daily monitoring of a wound for presence of possible complications such as signs of increasing area of ulceration or signs of soft tissue infection; and failed to ensure care plan interventions for alteration in skin integrity were implemented for one (R1) of four residents reviewed for wound care. These failures resulted in R1 developing a worsening coccyx pressure ulcer and require transfer to a local hospital with a diagnosis of septic shock due to pressure wound infection requiring admittance to the intensive care unit for five days.

Inspectors wroteBased on interview and record review, the facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program effectively identified quality deficiencies and described how the facility would evaluate the effectiveness of corrective actions and performance improvement activities to address repeated deficiencies regarding infection control. This deficient practice had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for the administration of medication, oxygen and enhance barrier precautions. This deficiency affects all five (R14, R41, R56, R108, and R177) residents in the sample of 26 reviewed for Professional Standards of Practice.

Inspectors wroteBased on observation, interview, and record review, the facility failed to determine self-administration of medication was appropriate for a resident whose medication was left at the bedside for the resident to self-administer for one of one resident (R20) reviewed for self-administration of medications in sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident call light was within reach. This deficiency affects two (R46, R72) of three residents in the sample for 26 reviewed for accommodation of needs.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibits prevention of resident abuse. This deficient practice 3 of 5 residents (R29, R41, R123) reviewed for abuse prevention program in a sample of 26.

Inspectors wroteBased on record review and interview, the facility failed to submit information for preadmission screening and resident review for level l Preadmission screening and Resident Review (Preadmission screening resident review PASRR) and for a level ll evaluation for 1 of 4 resident's (R20) reviewed for PASRR in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow manufacturer's recommendation in using low air loss mattress to resident who has stage 4 pressure ulcer. This deficiency affects one (R6) of three resident in the sample of 26 reviewed for Pressure ulcer Management.

Inspectors wroteBased on observation, interview, and record review ,the facility failed to implement fall preventive measures for a resident who has history of falls. This deficiency affects two (R21 and R56) of three residents in the sample of 26 reviewed for Fall prevention management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to followa a physician's order for oxygen administration. This deficiency affects one (R96) of three residents in the sample of 26 reviewed for oxygen management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to act upon and implement medication recommendations in a timely manner. This deficiency affects two (R56 and R114) in the sample of three residents in the sample of 26 reviewed for Pharmacy medication review.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have appropriate diagnosis for resident receiving anti-psychotic medications. This deficiency affects one (R110) of three residents reviewed for Psychotropic medication management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hospice coordinated communication and plan of care are available and accessible to facility staff. This deficiency affects one (R177) of three residents in the sample of 26 reviewed for Hospice care services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices, such as hand hygiene and used of personal protective equipment (PPE), were performed during enteral feeding assessment, and failed to ensure the urinary catheter tubing and drainage bag was not touching the floor for infection control. This deficient practice has the potential to affect 1 of 3 residents reviewed for enteral feeding procedure (R51) and 1 of 2 residents reviewed for urinary catheter management (R177) in a sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the physician and obtain an order to transport a resident with an acute change in mental status and respiratory status to the hospital. This affected one of three residents (R1) reviewed for acute change in condition. This failure resulted in R1 experiencing an acute change in condition at on 10.13.24 at approximately 7:00am, and the facility staff not notifying the physician or calling EMS until 10:44am. R1 was admitted to the hospital with a diagnosis of aspiration pneumonia and sepsis secondary to pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to prevent an incident of resident-to-resident physical assault. This affected two of three residents (R9, R10) reviewed for physical abuse. This failure resulted in R10 pushing R9 to the ground unprovoked, and R9 sustaining an extensive intraparenchymal and subarachnoid hemorrhages from hemorrhagic contusions and extensive skull fractures extending from the vertex anteriorly and posteriorly.

Inspectors wroteBased on interview and record review, the facility failed to ensure safety measures were in place to prevent avoidable resident accidents. This affected two of three (R7, R8) reviewed for safety. This failure resulted in R7 wheelchair not being secured in a medivan, R7 sliding out of the wheelchair sutaining a comminuted transversely impacted fracture of the right tibial (shin bone) and fibula (long slender bone in the lower leg that run alongside the tibia) requiring surgical intervention and the application of a long leg cast and a left proximal tibia fracture with hemarthrosis (bleed into joint space) requiring aspiration and application of long-leg splint; and facility staff not applying foot/leg support to R8's wheelchair resulting in R8 feet hitting the ground abruptly stopping and falling forward while being pushed by staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the supervision of one cognitively impaired resident while in the dining room, failed to follow their policy and determine the cause of what triggered a door alarm on the memory care unit, and lacked an effective plan to ensure the outside gate was locked after landscapers/vendors exits. These failures affected one of three residents (R1) reviewed for supervision and elopement. These failures resulted in R1 exiting the locked memory unit and being found nearly one-half mile, after dark, from the facility by local police. The Immediate Jeopardy began on 08/01/2024 when R1 exited the facility unauthorized thru the locked memory care door. V8 (Administrator) was notified of the Immediate Jeopardy on 09/04/2024 at 1035am. [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately supervise a resident in the locked unit who was assessed as high fall risk (R1) and failed to ensure two staff were used when providing care for a resident (R7) per the resident's plan of care. These failures affected two (R1, R7) of four residents reviewed for falls and resulted in R1 sustaining a laceration to her head that required treatment for scalp laceration and R7 sustaining a head laceration.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative of a resident discharge from the facility, including the reasons for the move in writing, and failed to have a record that the local Ombudsman was notified of the discharge. This failure affected one (R3) of three residents reviewed for discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the environment in good repair and failed to maintain a clean and sanitary environment. These failures have the potential to affect all thirty residents residing on the fifth floor of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an avoidable fall for high fall risk resident with poor sitting balance by not providing 2 persons assist during a shower. This affected one of three residents (R1) reviewed for safety and falls. This failure resulted in R1 falling out of the shower chair on 1/24/24, being transported to the local hospital for treatment, and recieving 7 sutures to the left eyebrow area.

Inspectors wroteBased on interview and record review, the facility failed to provide two staff assistance while providing incontinence care. This failure applied to one (R1) of three residents reviewed for falls, and resulted in R1 having a fall while being provided care from one staff member, and subsequently had to be transferred to the local hospital for evaluation and treatment of laceration; R1 required sutures with a skin closure device. The past noncompliance occurred from 10/24/23 to 10/25/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and regularly assess a resident for arterial ulcers, who then developed necrosis to the right heel and right great toe. This failure applied to one (R3) of three residents reviewed for nursing care.

Inspectors wroteBased on interview and record review, the facility failed to prevent or determine how an injury of unknown origin occurred for one (R1) of three residents reviewed for resident injuries in a total sample of three. This failure resulted in R1 suffering a right hip fracture after being sent to the hospital for right thigh swelling and not being able to stand. Findings Include: R1 is a [AGE] year old with the following diagnosis: fractured neck of the right femur, urinary tract infection, myocardial infarction, dementia, and history of falling. R1's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score is a six (severe cognitive impairment). A Nursing note, dated 9/19/23, documents it was brought to the nurse's attention by other staff, R1 could not stand or sit on the edge of the bed. Upon assessment, R1's right thigh was swollen. [...]

Inspectors wroteDeficienices at this level require 2 Deficient Practice Statements. A. Based on observation, interview, and record review, the facility failed to adequately supervise a resident (R43) with elopement behaviors for residents reviewed for elopement. This failure resulted in R43 eloping and being found unresponsive in the community, sustaining a traumatic muscle injury, and being hospitalized . B. Based on observation, interview, and record review, the facility failed to follow their policy and procedures for accident prevention by not providing adequate staff assistance for a resident who requires two-person assist for bed mobility and transfers, and not providing a cognitively impaired and agitated resident who was refusing care with adequate time to perform activities of daily living, for 2 residents (R20 and R71) reviewed for supervision and accidents

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was provided personal privacy during a physical assessment by a medical provider, and failed to ensure residents were provided privacy during blood glucose monitoring and insulin administration. These failures applied to six (R49, R71, R84, R94, R101, and R112) of six residents reviewed for nursing care in the sample of 33 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for infection control related to glucometer cleaning after resident use; failed to ensure that reusable equipment (wrist blood pressure cuff) was cleaned between use of residents; failed to perform hand hygiene prior to putting on PPE (Personal Protective Equipment) and after performing blood glucose monitoring; and failed to ensure infection control was maintained during tracheostomy care for a resident. These failures applied to four (R38, R101, R110, and R135) of four residents reviewed for nursing care in a sample of 29 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly address a resident's urinary catheter care needs by allowing the resident to continue the use of the same catheter that was leaking, while the resident was experiencing adverse symptoms, for a resident with a history of urinary tract infection (UTI). This failure applied to one (R78) of five residents reviewed for catheter care/UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for pain management by not regularly assessing and monitoring a resident's complaints of pain and by not communicating resident pain to a provider in a timely manner following a fracture. This failure applied to one (R7) of one resident reviewed for pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were available during medication administration per physician orders for one (R135) of five residents reviewed during medication administration observation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were three medication errors out of 25 medication opportunities resulting in a 12% medication error rate. This failure applied to two (R110, R135) residents reviewed during the medication administration task.

Inspectors wroteBased on interview and record review, the facility failed to notify a physician about residents not receiving their ordered medications for four (R3, R4, R5, R6) of six reviewed for physician notification. Findings Include: 1. R3 is a [AGE] year old with the following diagnosis: type 2 diabetes, hypertension, and transient ischemic attacks. The Medication Administration Record, dated 08/2023, documents on 8/20/23, R3 did not receive the following ordered medications: Aspirin 81 milligrams (mg) - 1 tablet at 9AM; Insulin glargine 100 units/milliliter (mL) - 32 units at 9PM; Metformin 500 mg - 2 tablets at 9PM; Metoprolol 25 mg - 1 tablet at 9AM; Insulin NPH 100 unit/mL - 2 units at 4PM and 11PM; and Xarelto 2.5mg - 1 tablet at 9AM. Aspirin and Xarelto prevent blood clot formation, Insulin and Metformin help control blood sugar levels, and Metoprolol helps control high blood pressure. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to replace two open nursing shifts on day shift (7AM - 7 PM), and three open nursing shifts on night shift (7PM - 7AM) on 8/20/23, leaving two units during the day and three units during the night without a scheduled nurse, affecting 69 residents. Findings Include: R3 is a [AGE] year old with the following diagnosis: type 2 diabetes, hypertension, and transient ischemic attacks. R4 is a [AGE] year old with the following diagnosis: quadriplegia, adult failure to thrive, hypertension, chronic embolism/thrombosis of the veins, and idiopathic epilepsy. R5 is a [AGE] year old with the following diagnosis: congestive heart failure, type 2 diabetes and hypertension. R6 is a [AGE] year old with the following diagnosis: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the administration of medication as ordered by the physician. This affected four of four residents (R3-R6) reviewed for medication error, omission and medication administration. findings Include: 1. R3 is a [AGE] year old with the following diagnosis: type 2 diabetes, hypertension, and transient ischemic attacks. The Medication Administration Record. dated 08/2023. documents on 8/20/23. R3 did not receive the following ordered medications: Aspirin 81 milligrams (mg) - 1 tablet at 9AM; Insulin glargine 100 units/milliliter (mL) - 32 units at 9PM; Metformin 500 mg - 2 tablets at 9PM; Metoprolol 25 mg - 1 tablet at 9AM; Insulin NPH 100 unit/mL - 2 units at 4PM and 11PM; and Xarelto 2.5mg - 1 tablet at 9AM. [...]