Ryze on the Avenue

Inspectors wroteBased on interview and record review, the facility failed to protect residents' rights to be from physical abuse from another resident. This failure affects two (R4, R5) residents out of five residents reviewed for abuse in a total sample of 14. As a result of this failure, R5 hit R4 in the head on 02/27/2026 resulting in R4 sustaining a laceration to his head and being sent to the hospital. As a result of this failure, R4 hit R5 in the face on 02/27/2026 resulting in R5 sustaining a closed nasal bone fracture and being sent to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to provide one to one (1:1) feeding assistance for one resident (R1) in the sample of 3 residents reviewed for feeding assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a home-like environment for five (R1, R4, R6, R7) of eight residents residing in the facility reviewed for physical environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three (R1, R2, R5) of eight residents' accommodation of needs were provided for with working call lights.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that missing ceiling tiles were replaced in a hallway and residents' room. This failure has affected R3, R21, R22 and has the potential to affect 36 residents that reside in the first floor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff monitor a resident's blood glucose per physician's order and failed to ensure staff document the result of the blood glucose accordingly. These failures affected 1 (R67) resident reviewed for professional standard of care in the total sample of 66 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one resident's (R77) low air loss mattress was set at the correct settings. These failures affected one residents (R77) in a total sample size of 66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications are securely stored for one of one resident (R4) reviewed for medication storage in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights are answered in a timely manner for one resident (R4) in the sample of 8 residents reviewed for call lights.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that three residents (R2, R4 and R6) were free from physical abuse. This failure resulted in R2, R4 and R6 being attacked by their roommates. R4 stated she does not feel safe. R6 stated R6 was upset and felt helpless.

Inspectors wroteBased on interview and record review the facility failed to assure that a resident (R1) with pressure ulcers received the necessary treatment and services to promote wound healing. This failure caused one resident's (R1) wound to decline leading to wound infection and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess or evaluate a resident that are high risk for falls, failed to provide plan of care for falls. The facility failed to ensure fall preventive measures or interventions were implemented. The facility also failed to monitor and supervise a resident to prevent falls for 1 (R1) out of 3 residents reviewed for fall prevention program. These failures resulted in R1 falling twice. R1's first fall resulted in R1 being admitted to the hospital with an epidural brain bleed. R1's second fall resulted in R1 sustaining a laceration to the back of his head.

Inspectors wroteBased on interviews and review of records that facility failed to ensure personal belongings of 1 (R3) out of 3 residents were properly inventoried in accordance with facility's policy. These failures affected 1 resident (R3) resulting in not being able to unable to account personal belonging.

Inspectors wroteBased on interview and record review, the facility failed to prevent and protect two residents (R1, R5) from resident-to-resident abuse out of four residents reviewed for physical assault in a total sample of 14 residents. This failure resulted in R5 falling in the facility and sustaining a pneumothorax and several fractured ribs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and monitoring for residents in the dining room. The facility also failed to monitor and track residents who are on fall precautions. This failure affects one of three residents (R4) reviewed for falls. The facility also failed to monitor one resident (R1) with a known history of wandering in the facility. These failures have the potential to affect 73 residents residing on the second floor in the facility.

Inspectors wroteBased on interviews and records review, the facility failed to notify a representative for one (R7) of three residents reviewed of change in condition in a total sample of 14 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's call light device was functioning properly for resident use. This failure affected one resident (R10) out of three residents reviewed for call lights.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow generally accepted stand of professional practice when administering IV (Intravenous) fluids rate as ordered by physician for 5 of 5 residents (R8, R9, R10, R11, and R12) reviewed in the sample for IV therapy. This failure affected R8, R9, R10, R11, and R12 who were receiving IV fluid were observed not infusing at the right drip rate per minute to infuse 1000ml/hour as ordered. This has potential to affect all 73 residents listed as getting IV therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication cart was locked when not in visual proximity of the nurse and not in use to prevent tampering and accidental hazard. This failure has the potential to affect all the 73- residents residing on the 4th floor.

Inspectors wroteBased on interview and record review the facility failed to ensure that four of six residents (R2, R3, R5 and R6) were free from physical abuse. This failure affected R2, R3, R5 and R6 who had verbal altercation that resulted in physically hitting one another.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate assistance during ADL (activities of daily living) care and follow ADL care plan intervention for use of side rails. The facility also failed to complete fall risk evaluation/assessment in a timely manner. These failures affected 1 (R1) out of 3 residents reviewed for accidents and adequate supervision. R1 had a fall incident on 12/15/24 and sustained a left hip fracture while receiving care.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide individualized and person-centered care plan related to pressure ulcer and hospice care per their policies and hospice agreement for 1 out of 3 residents (R1) reviewed for plan of care. These failures affected 1 resident (R1) who acquired pressure ulcer and receiving hospice care in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide comfort measures and document that abnormal vital signs were addressed for a hospice resident. The facility failed to notify a change in the resident's physical status (abnormal vital signs) to Hospice Services per the hospice agreement and facility's hospice policy. These failures apply to 1 out of 3 residents (R1) reviewed for improper nursing care and affect 1 resident (R1) receiving hospice care in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician order for weekly skin assessment, monitoring, and documentation. The facility failed to follow plan of care intervention for daily skin check, failed to document daily monitoring of pressure ulcer prevention according to their policy. These failures apply to 1 out of 3 residents (R1) reviewed for skin. These failures affected 1 resident (R1) who acquired pressure ulcer on the sacral in the facility.

Inspectors wroteBased on observations, interviews and records review, the facility failed to provide a working call light to one (R9) of four residents reviewed in a sample of six.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their abuse prevention and residents' rights policies by failing to affirm the right of the resident to be free from abuse and to have a safe environment. This deficient practice affected one resident (R2) with severe cognitive impairment involved in an allegation of physical abuse by another resident (R1) out of three residents reviewed for resident-to-resident abuse. On [DATE], R1 placed a pillow and a blanket over R2's face. Findings Include: R1's clinical records show an admission date of [DATE] with included diagnoses not limited to Bipolar Disorder, Depression, and anxiety disorder. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is cognitively impaired and required partial/moderate assistance with activities of daily living (ADL) except for eating and oral hygiene required supervision assistance. [...]

Inspectors wroteBased on interview and record review, the facility failed to properly assess, monitor, and document to prevent further development of pressure ulcers for a resident (R3) identified as high risk. The facility failed to document dressing changes on the treatment administration record (TAR). The facility failed to revise individualized care plan to reflect status of multiple facility acquired pressure ulcers, approaches, and goals for care. The facility also failed to properly assess and complete wound documentation timely for facility acquired pressure ulcers. These failures apply to 1 (R3) out of 3 residents reviewed for pressure ulcers.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect the resident's (R3) right to be free from abuse for one of five residents reviewed for abuse. This resulted in R3 suffering psychosocial harm from verbal and emotional abuse by a staff member as evidence by verbalizing hurt feelings and feeling inferior.

Inspectors wroteBased on interviews and record reviews, the facility failed to report an allegation of abuse for R3 within two hours to the state surveying agency for one out of one resident reviewed for abuse reporting.

Inspectors wroteBased on interview and record review the facility failed to affirm the right of the resident to be free from verbal abuse. This deficient practice affected 1 (R2) of 8 residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer scheduled pain medication on time for R1, a hospice resident with prostate and bone cancer, in a sample of 5 residents reviewed for pain management.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the 4 dryers have no accumulation of lint to provide a safe environment to the residents. These failures have the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call lights were within reach for 3 residents (R15, R72 and R120) and failed to ensure linen was provided for one resident (R124). This failure had the potential to affect 4 residents out of a sample of 65 residents reviewed for reasonable accommodation of needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRRs) were completed prior to resident admission. The facility also failed to ensure properly qualified staff completed Level I Pre-admission Screening and Resident Reviews (PASARR)This failure affects 4 (R38, R75, R110, R124) residents in a sample of 65.

Inspectors wroteBased on interview and record review, the facility failed to conduct care plan conferences to include the resident/responsible party in development of their plan of care. This failure affects 4 (R61, R75, R76, and R110) residents in a sample of 65.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment with laundry chute left unlocked and accessible to residents on the 3rd floor dementia unit. The facility also failed to ensure one resident (R48) has no access to an item that could potentially be used as a weapon against staff or other residents. These failures affected one resident (R48) and have the potential to affect 67 residents on the 3rd floor and 66 residents on the 4th floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to label and date respiratory equipment (nasal cannulas and humidifier bottles). The facility also failed to ensure there was a physician's order for oxygen therapy. This failure affected 4 residents (R72, R100, R209, R276) who receive oxygen therapy.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the personal refrigerator temperature log had no missing temperatures, failed to ensure a thermometer is available inside a personal refrigerator and failed to ensure the personal refrigerator has no expired food items. These failures affected 6 (R1, R11, R48, R92, R120, and R202) residents reviewed for personal food in the total sample of 65 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident's ability to safely self-administer medications which affected one resident (R155) when reviewed for self-administration of medications in the total sample of 65 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to document the code status for one resident (R213). This failure affected one resident (R213) in the sample size of 65.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently ensure that one resident (R72) was not confined to his room as evidenced by observations of one resident without documented interventions and R72 verbalizing not getting out of his room. This failure resulted in R72 stating R72 feels like R72 is in a prison and is getting worse. This failure affected one resident (R72) reviewed for involuntary seclusion in a sample of 65 residents.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order for infectious disease consult to treat a resident's diagnosis of hepatitis C. This failure affects 1 resident (R110) in the sample of 65.

Inspectors wroteBased on observation, interview, and record reviewed the facility failed to assure that a resident (R29) with a pressure ulcer received necessary treatment and services to promote healing. This failure affected 1 resident (R29) out of 65 residents reviewed for wound care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident (R129) indwelling catheter bag was changed. This failure affected one resident (R129) in the sample of 65 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an enteral feeding formula was changed in a timely for one resident (R209). This failure affected 1 of 8 residents who receive gastrostomy tube feedings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled substances were stored appropriately. This failure affects 1 resident (R7) in a sample of 65.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident (R129) with an indwelling catheter was placed on Enhanced Barrier Precautions (EBP); failed to ensure a resident (R29) with EBP had a Personal Protective Equipment (PPE) bin in place; and failed to ensure staff don PPE while providing high contact resident care for a resident (R29) with EBP. These failures affected two residents (R29 and R129).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure state survey records were kept publicly for residents to review. This failure has the potential to affect all 223 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure two staff members were present during ADL (Activities of Daily Living) for one of three residents (R2) reviewed for falls. This failure resulted in R2 rolling out of bed to the floor and sustaining a hematoma (bruise that forms under the skin when blood vessels are damaged and leak).

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure adequate staffing to meet the needs of four residents (R4, R12, R20 and R21). This failure has the potential to affect all 210 residents that reside at the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to respond to one dependent resident's (R12) call light within a reasonable amount of time, causing R12 to stay in an uncomfortable position for an extended period. The facility failed to ensure that call lights were within reach for three dependent residents (R20, R21, and R22) who required incontinent care from staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a functional and comfortable environment for residents. This failure affected 3 residents (R9, R10 and R17) who were observed and interviewed for inadequate cooling (and has the potential to affect their roommates R16 and R18), reviewed for comfortable and homelike environment.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that four residents (R20, R21, R22 and R23) received timely incontinent care. This failure has affected four of nine residents reviewed for incontinent care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one dependent resident with a 1:1 feeding order was fed. This failure has affected one (R4) of four residents reviewed for nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the nutritional supplement as ordered by the physician. This failure affected 1 resident (R7) reviewed for therapeutic supplements.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision and individualized fall prevention interventions as indicated in residents' care plans for cognitively impaired residents. The facility also failed to ensure that residents assessed to be at risk for falls don't have repeated falls. These failures affected three residents (R1, R6, and R7), reviewed for falls and fall prevention interventions.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper maintenance and housekeeping services were provided to maintain a clean and sanitary environment related to air vents, water stains, and ceiling tiles throughout all nursing floors. These failures have the potential to affect all 189 residents residing in the facility. On 5/14/24 at 1:06 PM, R4 stated, I told V1 about all the mold, dirt, and dust coming through the vents in the ceiling. V1 was aware and did not have the vents cleaned or fixed. The ceiling tile have all these stains from the third floor leaking down here to the second floor. V5 (Maintenance) spray painted the mold and the dirt on the ceilings, instead of replacing the ceiling tile. The leaking water, mold and dirt makes my nose run and sneeze, just makes me sick. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was served at a palatable temperature. This deficient practice has the potential to affect 190 residents receiving food prepared in the facility's kitchen. Findings Include: On 4/23/24 at 11:48 AM, R2 stated the breakfast is cold at times, R2 would like to eat hot food when the food is supposed to be hot. On 4/23/24 at 12:41 PM, R4 stated the breakfast is cold. On 4/23/24 at 1:15 PM, R3 stated the breakfast is cold and the food does not taste good cold. On 4/24/24 at 1:21 PM, test tray was conducted V10 (Food Service Area Manager), and another surveyor. After last tray on the unit was delivered, observed V10 use a digital thermometer to check temperature of food served. The temperature of the breaded pork chop was 112.4 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow standards of professional practice and facility policy in providing activities of daily living specific to bathing or showering at least once a week in eleven out of eighteen total opportunities in a sample of nine randomly selected residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure by not completing the fall risk evaluation assessments and updating the care plan with new interventions for 1 (R1) resident with history of multiple falls. These failures affected 1 (R1) of 3 residents reviewed for improper nursing care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a comfortable and homelike environment for residents that reside on the second (46 residents) and third floor (57 residents) for two out of four floors in the building.

Inspectors wroteBased on interviews and record review the facility staff failed to report an injury of unknown origin to the surveying state agency within the required time frame for 1 (R3) of 4 residents reviewed for resident injury. The facility also failed to follow the facility policies for reporting an accident, incident, or unusual occurrence.

Inspectors wroteBased on interview, and record review the facility failed to ensure an injury of unknown origin was thoroughly investigated related to bruising for 1 (R3) of 4 residents reviewed for Resident Injury. Findings Include: During staff interviews V2 (Director of Nursing) failed to interview all staff that had direct contact with R3 prior to the bruising. V2 failed to identify an injury of unknown source, did not do a thorough investigation of R3 bruising and failed to follow the facility policy for injury of unknown source as the basis of the conclusion. R3's diagnosis includes and is not limited to Crohn's Disease, Dementia, Calculus of Gallbladder with other Cholecystitis without Obstruction, Vitamin D Deficiency, Colostomy, Chronic Pain, Constipation and Hyperlipidemia. R3 MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 00 indicating severe cognitive impairment. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a homelike environment to 15 (R1, R5, R6, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R25) residents reviewed for home-like environment and has the potential to affect all residents on the second and third floors.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment free from accident hazards for 3 (R3, R6, R7) out of 3 residents reviewed for accident hazards. This failure resulted in R3 getting a laceration that required 14 sutures to R3's left hand.

Inspectors wroteBased on interview and record review, the facility failed to provide personal trust fund allowance to 1 (R2) resident. This failure affected 1 (R2) out of 3 residents reviewed for access to resident funds.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide comfortable environment for residents by not ensuring residents have routine access to warm/hot water. This failure has the potential to affect 2 (R1 and R3) of 3 residents reviewed for access to warm/hot water.

Inspectors wroteBased on observation, interview and record review the facility failed to follow its policy and procedures for Fall Prevention for one (R1) of three residents reviewed for falls. This failure resulted in R1 sustaining a fall resulting in a head injury and R1 requiring stitches to the left eyebrow.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow their call light system policy by failing to maintain a properly functioning call light system that allows residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area. This deficient practice has the potential to affect all 173 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Daily Nurse Staffing was posted in a prominent place readily accessible to residents and visitors and failed to ensure the Daily Nurse Staffing information was complete. This failure affected all 167 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure refrigerated items were stored at an appropriate temperature, failed to ensure red meat was stored on a shelf below crème pies, failed to ensure drainage pipes were clear to prevent sewage backup in the kitchen, and failed to maintain foods at an appropriate temperature before plating. These failures have the potential to affect 162 residents receiving meals from the kitchen. Findings Include: On 8/13/23 at 9:30 am, small refrigerator in main kitchen outside thermometer and inside thermometer read 60 degrees. Surveyor touched the racks inside the refrigerator for temperature and the racks were not cold. Opened condiments and liquid substances were observed. On 8/13/23 at 9:35 am, surveyor observed water on floor in the main kitchen by the three compartment sinks. Coming from a drain in the floor. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to date humidifier bottles, failed to ensure humidifier bottle was changed weekly, and failed to ensure nasal canula was connected to the oxygen concentrator to deliver prescribed oxygen to a resident. These failures affected 4 (R15, R65, R99 and R362) residents reviewed for respiratory care in the total sample of 57 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a sufficient number of skilled licensed nurses to provide nursing related services to meet resident needs. This failure affected 2 residents, (R29 and R141) and has the potential to affect all 46 residents on the second-floor unit.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the code status order entered in the resident's electronic medical record (EMR) correlates to the resident's physician orders for life-sustaining treatment (POLST) form which affected one resident (R150) in the sample of 57 residents.

Inspectors wroteBased on interview and record review the facility failed to report a serious bodily injury to State Agency within the mandated time frame and failed to develop policies and procedures which ensures reporting of serious bodily injury within the mandated time frame. These failures affected 1 (R15) resident reviewed for reporting of incident and accident in the total sample of 57 residents.

Inspectors wroteBased on observation, interview and record the facility failed to provide pressure ulcer prevention measures correctly to 3 residents (R15, R48, R83). This failure has the potential to affect all 3 residents (R15, R48, R83) out of the sample of 57 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an accurate count of a controlled substance which affected one resident (R27) in the sample of 57 residents reviewed for narcotics accountability.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a less than five percent (5%) medication error rate. There were 3 medication errors out of 27 medication opportunities, resulting in a 11.11% medication error rate and affected 2 residents (R130 and R141) observed for medication pass.

Inspectors wroteBased on observation, interview and record review, the facility failed to discard expired insulin medication and failed to refrigerate unopened eye drop medication per pharmacy instructions which affected two residents (R66, R67) in the sample of 57 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to date opened boxes of food in the refrigerator and freezer, properly thaw meat, and store clean dishes and utensils under sanitary conditions. This had the potential to affect all resident who receive food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for two (R497, R500) of seven residents reviewed for baseline care plans in the sample of 33.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their Infusion Therapy policy by not dating and labeling a resident's (R151) peripheral intravenous catheter (PIV). This deficiency had the potential to affect 1 (R151) out of 1 resident reviewed for peripheral intravenous catheters in a sample of 35 residents. Findings Include: On 6/14/2022 at 11:45 AM, R151 was observed with a right hand peripheral intravenous catheter (PIV), 20 gauge, saline locked. PIV site noted with a transparent dressing in place. Transparent dressing observed with no labeling of date or initials of who inserted the PIV. On 6/14/2022 at 11:45 AM R151 stated, they gave me some of that water in a bag through this thing, but it's finish now though. They gonna take it out. On 6/15/2022 at 12:35 PM, R151 was observed with a different right forearm PIV, 20 gauge, saline locked. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to follow their Transmission Based Precautions policy by allowing a visitor in a resident's (R503) room without wearing the appropriate personal protective equipment (PPE). This affected one (R503) out one resident reviewed for transmission-based precautions in a sample of 35 residents.