Ryze at the Ridge

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents knew staff names and titles due to staff not wearing identification badges. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview and document review the facility failed to ensure the residents right to be free from physical abuse for 2 of 4 residents (R1, R2) reviewed for abuse. This resulted in R1 being grabbed by the throat by R2.

Inspectors wroteBased on interview , observation and document review the facility failed to ensure the facility maintains an effective pest control program on 1 of 3 resident floors.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to immediately assess a resident (post fall), failed to follow physician's orders, and failed to provide timely hospital transfer for one of three residents (R3) reviewed for falls. These failures resulted in R3's (5/2/25) delayed care of a fall with right impacted intertrochanteric fracture - with varus deformity [an excessive inward angulation of a joint or bone's distal segment] which required surgical intervention and likely experienced excruciating pain [for roughly 33 hours - prior to transfer] which was rated 3/10 - by facility staff.

Inspectors wroteBased upon observation, interview, and record review the facility failed to implement fall prevention interventions. These failures resulted in R3's (5/2/25) fall with sustained right hip impacted intertrochanteric fracture with varus deformity which required surgery.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician and obtain a treatment order, failed to monitor and document the status of a wound, and failed to develop an individualized care plan to address the wound of 1 resident (R1) out of 2 residents reviewed for wound care. Findings Include: On 5/6/25 at 10:56 AM, observed R1 in her room alert and able to verbalize needs. R1 stated when she was admitted in the facility, she had a healing surgical wound on her abdominal area. R1 stated she had a hernia repair six months ago and it takes a while for the wound to heal because she is Diabetic. R1 stated that the surgical site re-opened sometime last month, and she notified a nurse (could not remember nurse's name). R1 stated that staff are not doing anything to treat her re-opened surgical wound. [...]

Inspectors wroteBased on interview and record, the facility failed to ensure residents are free from resident-to-resident physical altercation. This failure affected 2 residents (R1,R2) reviewed for abuse in the total sample of 6 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Abuse final Reportable was sent to the Survey Agency within the mandated time frame. This failure affected 2 (R1 and R2) residents reviewed for timely submission of reportable in the total sample of 6 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the cook has appropriate competencies and skills resulting in recipes during food preparation not being followed. This failure has the potential to affect all 128 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were labeled and dated with an opened and use by date, failed to discard expired food based on use by guidelines and labeled use by date. The facility also failed to sanitize cooking equipment based on manufacturers' guidelines. These failures have the potential to affect all 128 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who smoke are re-evaluated on a quarterly basis for their ability to smoke safely and smoking care plan was followed. These failures affect 4 (R1, R18, R41, R62) of 7 residents reviewed for smoking in the sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: (a) properly date opened multi-dose medication solution, eye drops and inhalers; (b) properly store unopened multi-dose insulin vial and (c) properly discard expired house stock medication from 3 of 5 medication carts and 2 of 3 medication storage rooms inspected for medication storage and labeling. These failures affect 7 residents (R4, R16, R29, R34, R70, R75, R127) reviewed during medication storage observation.

Inspectors wroteBased on interview and record review, the facility failed to assess eligibility and offer pneumococcal vaccinations, and failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccinations to 4 (R1, R11, R128, R102) out of 6 residents reviewed for pneumococcal vaccinations in the sample of 26. Findings Include: On 8/20/24 at 10:54 AM, interviewed V14 (Infection Control Nurse) and stated that the facility sets up vaccination clinics for residents who need to receive the vaccines. V14 stated that the residents are educated about the vaccines. V14 stated that after the education is provided, consents are obtained from the resident or their representative. V14 stated that consents are uploaded right away in the resident's electronic health records (EHR) under the miscellaneous tab. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess eligibility and offer COVID-19 vaccination for 4 residents (R11, R110, R231, R128), failed to ensure the residents medical records includes documentation if COVID-19 vaccinations were received or did not receive for 5 residents (R1, R11, R110, R231, R128), and failed to ensure the residents medical records includes documentation that education was provided to residents and/or resident representatives regarding the benefits and potential side effects of COVID-19 vaccination for 6 residents (R1, R11, R110, R231, R128, R102) out of 6 residents reviewed for COVID-19 vaccination in the sample of 26. Findings Include: On 8/20/24 at 10:54 AM, interviewed V14 (Infection Control Nurse) and stated that the facility sets up vaccination clinics for residents who need to receive the vaccines. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to complete a significant change in status Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for one (R30) of seven residents reviewed for resident assessment in a sample of 26.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident receiving hospice services for end-of-life support. This failure affects one resident (R30) out of one reviewed for hospice and comprehensive care plan in a sample of 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures to appropriately store oxygen tubing when not in use for 1 (R70) resident in a sample of 26. Findings Include: R70's Minimum Data Set (MDS) dated [DATE] shows R70 is cognitively intact. R70's Physician Order Sheet (POS) shows active order as of 8/20/24, Oxygen at 2Liters per nasal cannula continuous every shift related to acute and chronic respiratory failure with hypoxia. On 08/20/24 at 11:14 AM, surveyor with V10 (Certified Nursing Assistant/CNA) observed R70's oxygen nasal cannula tubing on the floor when not in use. V10 picked R70's oxygen nasal cannula tubing from the floor and placed the nasal cannula tubing on the oxygen tank. On 08/20/24 at 11:20 AM, surveyor and V8 (Registered Nurse/RN)) both entered R70's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% for 2 (R27, R103) of 11 residents in the sample reviewed for medication administration. There were 31 opportunities and 4 errors resulting to 12.9% medication error rate.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect a resident's (R1) right to manage their financial affair and inform R1 of the charges the facility imposed against R1's personal funds. This affected one out of four residents reviewed for personal funds. This failure resulted in the facility, misusing R1's $10,000 check R1 received from family member without R1's consent.

Inspectors wroteBased on observations and interviews the facility [A] failed to ensure housekeeping services were provided to maintain a clean and sanitary environment related to offensive odors, unclean floors, and bathrooms [B] failed to ensure the facility's furniture, equipment, plumbing, and over bed light fixtures were functioning properly for 8 [R1, R2, R5, R6, R7, R8, R9, R10] out of 10 residents in the sample reviewed for a homelike environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain accurate and complete records of a resident's (R1) personal funds and provide R1's financial records quarterly and upon request for one out of four residents reviewed for trust fund.

Inspectors wroteBased on interview and record review the facility failed to make prompt efforts to resolve a grievance and keep a resident updated on the progress of the investigation for one (R1) out of three residents who had spoken to staff regarding their concerns.

Inspectors wroteBased on interview and record view the facility failed to report an allegation of misappropriation of a resident funds by failing to submit a report within the required time frame to the Illinois State agency for one (R1) of one resident reviewed for the abuse. Findings Include: R1 was admitted to the facility on [DATE] with diagnosis not limited to Paraplegia, Low Back Pain, Psychosis, Bipolar Disorder and Anemia. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Document titled Concern/Compliment Form date received: 05/09/24 document in part: Name of person voicing concern/compliment: R1. Concern/compliment reported to V4 (Psychiatric Rehabilitation Services Director): R1 had a check for $10,000 that was deposited at the end of February. R1 takes out money from her trust fund each week. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to keep R4 free from abuse for one out of five residents reviewed for abuse. This failure resulted in R4 sustaining abrasions to the face and right wrist. A reasonable person would feel terrified and scared to be attacked by being punched and kicked while on the floor.

Inspectors wroteBased on interviews and record review the facility failed to supervise (R3). A resident with criminal background history, with aggressive behaviors and non-compliant with smoking, from intentionally starting a fire to R3's roommate's bed (R4). This failure has the potential to cause serious harm or death to all 123 residents in the facility at the time of incident. The facility failed to have a system to ensure that contraband and/or hazardous devices are secured and not brought into the facility. The facility lacks a system to ensure that all residents are closely monitored. The facility lacks a system to ensure that the residents' environment is free of hazards. The facility failed to report incident to IDPH. The immediate Jeopardy began on 1/21/24 at 11:30PM when R3 set R4's bed on fire. [...]

Inspectors wroteBased on interview and review of document the facility failed to ensure the right to be free from abuse for one of three residents reviewed (R2) for allegations of abuse. This failure resulted in R2 being sent to the emergency room and returning to facility with a 1cm laceration to the right cheek.

Inspectors wroteBased on interview and record review, the facility failed to report a serious fire incident that had the potential of causing serious bodily injury within 24 hours for 2 (R3, R4) of 4 residents sampled. This failure has the potential to affect all 123 residents residing in the facility at time of incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly assess and supervise a newly admitted resident (R2) for risk of elopement for one (R2) out of 7 residents reviewed for hazards and accidents on the sample list of 11. This failure resulted in R2 eloping from the facility through a window. R2 was subsequently found at the lake and transported to the hospital where R2 was pronounced dead by neurological criteria by ICU (Intensive Care Unit) and Neurology attending physician. This failure resulted in an Immediate Jeopardy which began on 08/30/2023 when R2 went out of a window on the second floor of the facility, eloped and was later found in a lake. R2 was transported to the hospital and pronounced dead. On 09/29/2023 at 09:38 AM V1 (Administrator) was notified of immediate jeopardy via phone call. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents right to be free of abuse for two (R1, R3) of four residents (R1, R2, R3, R4) reviewed for abuse on the sample list of eight residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to a.) properly clean and sanitize tableware and cooking equipment, b.) ensure food items were properly label and dated, c.) properly store raw animal food separately from ready to eat foods, d.) follow hand washing and glove usage procedure. These deficient practices have the potential to affect all 126 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure call lights were within reach for four residents (R12, R21, R51, R56) and staff failed to respond in a timely manner to the call light for one resident (R51) of 7 residents reviewed for accommodation of needs in a total sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow smoking safety policy by not completing smoking safety assessment upon admission for one resident (R177) and on a quarterly basis for four residents (R20, R27, R47, R77) to determine the level of assistance and supervision needed during smoking, the ability to carry and store smoking materials, and if a smoking apron is indicated. The facility also failed to ensure that smoking care plan is initiated/ developed upon admission for one resident (R177). These failures can potentially affect five (R20, R27 R47, R77 and R177) of eight residents reviewed for smoking in the sample of 25.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy for psychotropic medication by failing to obtain or provide consent of psychotropic medication use for two (R20 and R53) residents, failed to monitor residents on antipsychotic drug therapy by not completing Abnormal Involuntary Movement Scale (AIMS) assessment timely for four (R20, R2, R35 and R53) residents, and failed to review drug regimen irregularities / recommendations for one (R53) five residents reviewed for unnecessary medications in a sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedures for medication storage and labeling by failing to discard expired house-stock medications, failing to ensure personal items and floor cleaner chemicals were stored separately. The facility also failed to ensure that medications are labeled with open date for four (R24, R39, R41, R50) residents and failed to ensure that medication is stored in the container in which they were originally received for one resident (R78). These failures affect five residents (R24, R39, R41, R50, R78) in the sample of 25 residents.

Inspectors wroteBased on interview and record review, the facility failed to complete the quarterly Minimum Data Set (MDS) assessment using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframe for one (R33) of four residents reviewed for quarterly resident assessment on the total sample list of 25. Findings Include: On 7/11/23 at 11:06 M, R33's electronic health record (EHR) reviewed. R33 was admitted on [DATE]. R33's Quarterly MDS assessment with assessment reference date (ARD) of 1/18/23 was completed on 2/6/23 past the 14 days regulatory timeframe. At 1:10 PM, interviewed V23 (MDS Coordinator/Care Plan Coordinator) and stated that Quarterly MDS assessments are signed and completed the day after the ARD. V23 stated that the facility follows the (Resident Assessment Instrument (RAI) manual to complete the MDS assessments. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive resident centered care plan with goals and interventions for two residents (R24, R56) reviewed for care plans on the total sample list of 25.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a current code status for one (R7) of one residents is correctly addressed in the comprehensive care plan in a sample of 25 reviewed for advance directives. Findings Include: On [DATE] at 11:24 AM, R7's face sheet and physician order sheet (POS) shows R7 is a Full Code. R7's Physician Orders for Life Sustaining Treatment (POLST) form shows R7 chose Cardiopulmonary Resuscitation (CPR) should be attempted in the event R7 is found with no pulse and is not breathing. R7's comprehensive care plan shows R7 selected Do Not Resuscitate (DNR) should R7 stops breathing and displays no pulse. At 12:34 PM, V18 (Social Service Director) stated that a resident's code status should be ordered in the POS and addressed in the care plan. V18 stated that care plan is updated right away when the code status is changed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow routine catheter and infusion site care policy by not changing a midline dressing weekly for one (R5) of one residents reviewed for intravenous therapy in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy for oxygen therapy for one (R53) of one residents reviewed for respiratory care in the sample of 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the meal ticket menu for 1 (R7) of 2 residents reviewed for nutrition in a total sample of 25 residents. Findings Include: On 07/09/23 at 12:30 PM, R7 was eating lunch in her room with V14 (Licensed Practical Nurse) supervising R7. R7's lunch tray consisted of pureed pork, pureed potatoes, pureed spinach, and a beverage. R7's meal ticket shows R7 was supposed to also receive pureed buttered dinner roll and pureed cinnamon diced pears, but these items were not on R7's lunch tray. At 12:45 PM, R7 ate 100% of R7's lunch and still did not receive the pureed cinnamon diced pears and pureed buttered dinner roll. On 7/11/23 at 11:29 AM, a phone interview conducted with V26 (Registered Dietitian). V26 stated that residents on mechanically altered diets can be at nutritional risks. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to a.) monitor the temperature of a resident's personal refrigerator, b.) label and date food items in a resident's personal refrigerator for 1 resident (R78) reviewed on the sample of 25 for safe personal food storage.

Inspectors wroteBased on observation and interview, the facility failed to display the [NAME] Class Members retaliation hotline number. This failure has the potential to affect all 45 [NAME] members. Findings Include: On 7/09/23 at approximately 12:52 PM, during the survey team's initial observations, there were no [NAME] Class Members Retaliation hotline numbers posted on the first, second, and third floors where the residents reside. At 1:00 PM V18 (Social Service Director) stated that the facility has [NAME] members and that the [NAME] Hotline signage should be on each floor in the hallways visible to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to discard food items stored in the refrigerator on time, failed to label food, failed to perform hand hygiene and change gloves appropriately, and failed to follow proper food storage practices to prevent food borne illnesses. These failures have the potential to affect all 107 residents residing in the facility who are getting nutrition orally.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure the dumpster is fully closed at all times and failed to maintain an effective pest control program to ensure that the facility is free of insects. These failures have the potential to affect all 108 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to enter a code status order in the electronic medical record (EMR) under the physician orders which affected two residents (R28 and R73); failed to ensure that a current and properly completed copy of the resident's IDPH (Illinois Department of Public Health) Uniform Practitioner Order Form for Life-Sustaining Treatment (POLST) was in the electronic medical record which affected three residents (R14, R36 and R95); and failed to ensure the care plan matched the current code status order for one resident (R14) in the sample of 51 residents reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review the facility failed to provide functional lights, and a clean wall and window. These failures affected 5 residents (R25, R26, R27, R43, R79) reviewed for safe, clean, comfortable, and homelike environment in the sample of 51 residents.

Inspectors wroteBased on observation and interview the facility failed to provide and maintain a temperature log for the refrigerator that stores the resident's insulin on the second floor. This failure has the potential to affect all residents that reside on the 2nd floor.

Inspectors wroteBased on interview and record review, the facility failed to develop a smoking care plan for 1 (R68) resident reviewed for comprehensive care plan in the sample of 51 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ADL (Activities of Daily Living) care related to nail care for one dependent resident (R42) in the sample of 51 residents when reviewed for ADL care.

Inspectors wroteBased on observation, interview and record review, the facility failed to be free of medication error rate of 5% or more. There were a total of 8 medication errors out of 25 opportunities. The medication error rate was 32% that affected R42 and R44.