Ryze West

In the surveyor’s words

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

• Immediate jeopardy, patternF684Jun 16, 2021

  Based on observation, interview and record review, the facility failed to provide sufficient nursing staff and failed to follow their medication policy to ensure residents received essential medications to treat their medical conditions as ordered by their physician. There was no nurse to pass medications on one portion of a resident hallway and as a result, 26 residents (R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32) did not receive their scheduled medications on 5/15/2021 and 5/16/2021 on the day shift (7:00 AM - 3:00 PM). These failures had the potential to cause negative medical outcomes for all 26 residents. These failures resulted in an Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF684Sep 21, 2022

  Based on observation, interview and record review, the facility failed provide care and services for the management of a resident's diabetes by not following physician orders to administer insulin medication as ordered, failed to document insulin administration and glucose level, and failed to have staff knowledgeable about the use of an insulin pen. These failures affected 1 of 38 residents (R6) diagnosed with diabetic mellitus receiving insulin. As a result of this failure R6 was administered 300 units of insulin and R6's blood sugar measured 205 mg/dl when insulin was administered. This facility failure has the potential for R6 experiencing adverse effects and complications of unstable blood sugar including but not limited to: Diabetic ketoacidosis, [CONDITION(S)] and [CONDITION(S)]. […]

• Immediate jeopardy, isolatedF689Feb 22, 2022

  Based on observation, interviews and record review, the facility failed to have a system in place to alert staff when an illegal drug enters the facility, if a resident uses illegal drugs within the facility and discourage the possession of an illegal drug by a resident and failed to have a care plan and implement interventions to decrease a resident's repeated use of an illegal drug. This applies to one of three residents (R11) reviewed for illegal substances and has the potential to affect 56 residents who are known drug users. As a result, R11 with a known history of illegal drug use, had repeated overdose from illegal drugs while in the facility. This was identified as an immediate jeopardy situation which began on 02/07/2022, when R11 was found on the floor unresponsive. […]

• Actual harm, isolatedF686Jun 25, 2026

  Based on observation, interview and record review, the facility failed to prevent one resident at high risk for pressure ulcer development (R3) from acquiring a new facility acquired pressure ulcer and failed to order and perform a wound treatment to promote healing of R3's right buttock wound initially identified as a partial thickness wound/moisture associated skin damage (MASD). These failures affected one resident (R3) out of three residents reviewed for pressure ulcers. As a result of these failures, R3's right buttock wound progressed to a stage 3 pressure ulcer.Findings include:R3's medical diagnoses include but are not limited to pressure ulcer stage 3, muscle weakness, cognitive communication, and essential hypertension.R3's Minimum Data Set (MDS) dated [DATE] has a Brief… […]

• Actual harm, isolatedF880May 22, 2025

  Based on interview and record review, the facility failed to administer ordered topical medication used for lice and scabies exposure; failed to document notification of physician and or nurse practitioner of residents' exposure to lice and scabies; failed to obtain an order for Contact precautions for lice and scabies isolation; failed to perform isolation assessments and infection criteria evaluations for residents exposed to lice and scabies; failed to perform a proper room deep cleaning for residents exposed to lice and scabies; and failed to follow their facility policies for residents with confirmed cases of and exposure to lice and scabies. […]