Ryze on the Avenue

In the surveyor’s words

From the most serious findings on record at Ryze on the Avenue, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 15, 2026

  Based 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.Findings include: Facility reported incident/FRI dated 02/27/2026, documents that the facility reported an altercation between R4 and R5. The FRI documents that R4 was noted with a laceration to his head. […]

• Actual harm, isolatedF686Aug 27, 2025

  Based on interview and record review the facility failed to assure that one resident (R7) with intact skin, received the necessary treatment and services to prevent the development pressure wounds. This failure resulted in R7's development and worsening of one pressure ulcer, requiring hospitalization for wound infection and surgical intervention of wound. The facility failed to ensure one resident's (R77) low air loss mattress was set at the correct settings. These failures affected two residents (R7 and R77) in a total sample size of 66. Findings include: 1.) On 08/24/2025 at 11:48am, R77 was lying on a low air loss mattress; setting was at 280lbs. This observation was pointed out to V12 (Registered Nurse/RN). […]

• Actual harm, isolatedF600Jun 18, 2025

  Based 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. Findings include: 1.) R4 is [AGE] year-old with diagnosis including but not limited to: paraplegia, major depressive disorder, polyneuropathy, cerebral infarction and obesity. R4 has a BIMS (Brief Interview of Mental Status) score of 15, which indicates cognitively intact. R5 is [AGE] year-old with diagnosis including but not limited to, other specified disorders of bone, hypokalemia, multiple myeloma and type 2 diabetes mellitus. […]

• Actual harm, isolatedF686May 7, 2025

  Based 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 . Findings include: R1's medical diagnoses include but are not limited to displaced fracture of lesser trochanter of right femur, muscle weakness, cognitive communication deficit, type 2 diabetes mellitus, pressure ulcer of unspecified heel unspecified stage, pressure ulcer of sacral region stage 3, acute diastolic heart failure. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 9, which indicates R1's cognition is moderately impaired. […]

• Actual harm, isolatedF689Apr 23, 2025

  Based 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. […]