Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
Based 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.Findings include:On 08/25/2025 at 8:57am, V22 (Licensed Practice Nurse) opened
R67's electronic health record, the 7:30am glucose check was red and read as blood glucose before meals
and before bedtime. V22 stated the facility serves breakfast on the first floor between 8:00am to 8:30am. On
08/25/2025 at 8:59am, V30 (Certified Nursing Assistant) was assisting R67 with feeding. R67's food tray
was almost empty except for the cookie. V30 stated she (R67) still wants her cookie. On 08/25/2025 at
9:00am, V22 took R67's blood sugar; the glucometer announced the result as 309. On 08/25/2025 at
9:01am, V22 stated he was supposed to take her blood sugar before breakfast. Review of R67's (08/2025)
MAR (Medication Administration Record documented, in part Blood glucose via Accuchecks before meal
and at HS (hour of sleep) for diabetes. 08/25, 730(7:30am), 144. 1100 (11:00am), 131. Signed by V22
(Licensed Practice Nurse).On 08/26/2025 at 9:54am with V2 (Director of Nursing), V30 stated that she was
present when V22 took her (R67)'s blood sugar on 08/25/2025 at around 9am and the result was at 300 or
something.On 08/26/2025 at 11:41am, V2 (Director of Nursing) stated the expectation is to get the blood
sugar before breakfast. At this time, this surveyor presented V2 the 1st floor mealtimes. V2 stated staff is
expected to get the blood sugar between 7:00am and 7:15am to prevent from getting a false reading. I also
expected the nurse (V22) to document the accurate result, if it is 200 then document 200. Documenting the
correct result will determine the resident's endocrine system is working or an adjustment to her diabetes
medications need to be done. On 08/27/2025 at 10:04am, V50 (Nurse Practitioner) stated blood glucose
monitoring is usually ordered to make sure the resident's diabetes is well controlled. The staff are expected
to document the correct result so when the physician reviews the results, the physician will be able to
determine whether the medication is working appropriately or needs to be adjusted. The expectation is to
follow the physician's order to get the blood sugar; it is usually before meals and before bedtime.R67's
(Active Order as of: 08/25/2025) Order Summary Report documented, in part Diagnoses: (include but not
limited to) hypertension, chronic pain, and Type 2 Diabetes Mellitus. Order Summary: Blood Glucose via
Accuchecks before meals and at bedtime for Diabetes. Order date: 07/30/2025.R67's (08/2025) MAR
(Medication Administration Record documented, in part Blood glucose via Accuchecks before meal and at
HS (hour of sleep) for diabetes. 08/25, 730(7:30am), 144. 1100 (11:00am), 131. Signed by V22 (Licensed
Practice Nurse). The (undated) Mealtimes 1st Floor Dining Area documented in part Breakfast: 7:15am.The
(01/01/2025) Blood Glucose Monitoring documented, in part Policy: It is the policy of this facility to perform
blood glucose monitoring to a diabetic residents as per physician's order. Policy Explanation and
Compliance Guidelines: 1. The facility will perform blood glucose monitoring per physician's orders.
Procedure: 21. Document the procedure.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
145337
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145337
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ryze on the Avenue
3400 South Indiana
Chicago, IL 60616
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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.
Residents Affected - Few
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). V12 stated low air loss mattress should be set
based on the resident's weight to promote healing. If the setting is higher than the resident’s weight,
the surface will be hard, and it will impair with the healing process of the wound.
On 08/26/2025 at 10:58am, V31 (Wound Care Nurse/Licensed Practical Nurse) stated the setting of the low
air loss mattress should be based on the resident’s weight. If the weight falls between a range. Then
the setting should be on the lower side of the range. The purpose of the low air loss mattress is for
prevention and treatment of wounds. When the setting is above the weight of the resident, low air loss
mattress creates a hard surface. A hard surface defeats the purpose of the low air loss mattress.
R77’s (Active Order as of: 08/25/2025) Order Summary Report documented, in part
“Diagnoses: (include but not limited to) quadriplegia, pressure ulcer of sacral region, pressure ulcer
of left and right ankle, and pressure ulcer of other site. Order Summary: Skin. Pressure redistribution
mattress. Order Date: 02/25/2025.”
R77’s (printed: 08/24/2025) Weight and Vital summary documented, in part “08/05/2025:
116lbs.”
R77’s (06/03/2025) Minimum Data Set documented, in part “Section C. Cognitive Patterns.
C0500. BIMS (Brief Interview for Mental Status) Summary Score: 06.” Indicating R77’s
mental status as severely impaired. “Section M. Skin Conditions. M0150. Risk of Pressure
Ulcers/Injuries: 1 – yes. M1200. Skin and Ulcer /Injury Treatments: B. Pressure reducing device for
bed.”
R77’s (05/06/2025) care plan documented, in part “risk for alteration in skin integrity.
Interventions: Pressure redistribution mattress (LAL - Low air loss mattress).
The Operation Manual documented, in part “The (Brand name) pump and overlay system is
indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction
with a comprehensive ulcer management program. Pressure-adjust Knob. Determine the patient’s
weight and set the control know to that weight setting on the control unit. Operating Instruction. Step 6.
Determine the patient’s weight and set the control knob to that weight setting on the control unit.
2.) R7’s medical diagnoses include but are not limited to type 2 diabetes mellitus, diastolic
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145337
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145337
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ryze on the Avenue
3400 South Indiana
Chicago, IL 60616
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
congestive heart failure, essential hypertension, benign neoplasm of right breast, acute kidney failure.
Level of Harm - Actual harm
R7’s Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status score of 13,
indicating R7’s cognition is intact.
Residents Affected - Few
R7’s MDS dated [DATE] section M’s Determination of Pressure Ulcer/Injury Risk documents
in part, “A. Resident has a pressure ulcer/injury, a scare over bony prominence, or a non-removable
dressing/device…No….Is this resident at risk of developing pressure ulcers/injuries? .Yes”
R7’s care plan with initiation date of 08/13/24 and revision date of 04/25/25 documents in part,
“R7 has potential/ at risk for alteration in skin integrity due to risk factors associated with fragile skin,
friction, immobility, decreased sensory awareness, presence of cardiac pacemaker, a PMHx (past medical
history) that includes breast CA (cancer), hemiplegia, hemiparesis….Decrease/minimize risk for skin
breakdown…skin checks by CNA (Certified Nursing Assistant) and floor nurse on bath/shower days
paying particular attention to bony prominences, if impairment is present, follow appropriate skin
impairment protocols…pressure redistribution mattress…remind/assist resident to reposition
frequently.”
On 08/24/25 at 12:01pm R7 stated that she did not have any wounds when she first arrived at the facility.
R7 stated that she developed the wound on her sacrum area at the facility. R7 stated that the
facility’s staff does not clean and reposition her as needed.
On 08/25/25 at 12:15pm V31 (Wound Care Nurse/Licensed Practical Nurse) stated that R7 did not have a
wound when R7 arrived at the facility. V31 stated that R7’s wound to R7’s sacral region was
facility acquired on 05/29/25.
R7’s progress note dated 05/29/25 documents in part, “R7 is chairfast, incontinent of B&B
(bowel and bladder), and totally dependent for ADL’s (Activities of Daily Living). Staff alerted the
wound care team about a skin alteration on the patient’s right buttock, assessment performed,
patient noted with MASD (moisture associated skin dermatitis)…Wound care will continue to monitor
and treat the wound.”
Review of R7’s records show no documentation or indication that R7’s new wound to sacral
area was unavoidable.
R7’s wound assessment dated [DATE] documents in part, “Wound #1 Sacral is an acute
Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer acquired on
05/29/2025 and has received a status of Not Healed. Initial wound encounter measurements are 6.8cm
length x 6.8cm (centimeter) width x 0.1 cm depth, with an area of 46.24 sq (square) cm and a volume of
4.624 cubic cm. No tunneling has been noted. No sinus tract has been noted. No undermining has been
noted…76-100% adherent, yellow slough.”
On 08/26/25 at 2:55pm V2 (Director of Nursing/DON) stated that she assessed R7 the day R7 was sent to
the hospital. V2 stated that R7 appeared lethargic and kept moaning “it hurt, it hurt”. V2
stated that she instructed the nurse to call the doctor for orders to send R7 out to the hospital.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145337
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145337
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ryze on the Avenue
3400 South Indiana
Chicago, IL 60616
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Actual harm
Residents Affected - Few
R7’s progress note dated 06/07/25 documents in part, “NP (nurse practitioner) making
rounds with writer, observed resident lethargic with altered mental status, unstable vital
signs…received order to send resident out 911.”
R7’s hospital discharge records dated 06/16/25 documents in part, “patient was admitted for
workup of AMS (altered mental status) and hypotension…Infectious workup remarkable for
Bacteroides fragilis. CT (Computed Tomography) pelvis showing sacral decubitus ulcer with osseous
destruction of the lower sacrum/coccyx suggestive of osteomyelitis. ID (Infectious Disease) consulted,
recommended IV (Intravenous) CTX (Ceftriaxone) and Flagyl with plan to transition to Augmentin at
discharge…Plastics was consulted due to concern for sacral wound being source of
infection….Attempted minor debridement x2 but patient couldn’t tolerate due to pain.”
R7’s progress note dated 06/17/25 documents in part, “R7 is chairfast, incontinent of bowel
and bladder and requires extensive assistance transferring and completing ADL’s…wound to
sacrum noted as unstageable with palpable bone.”
R7’s wound assessment dated [DATE] documents in part, “clinical stage:
unstageable…Measurements: size (cm) centimeters: 9.00x10.00x1.10 (L x W x D) Length times width
times depth.”
On 08/26/25 at 11:01am V31 (Wound Care Nurse/Licensed Practical Nurse) stated that she assessed
R7’s wound upon readmission from the hospital. V31 stated that R7’s sacral wound had
bone exposed. V31 stated that R7 was in a lot of pain with wound care dressing changes. V31 stated that
R7 has always been compliant and has never refused care.
R7’s MDS dated [DATE] section M’s Determination of Pressure Ulcer/Injury Risk documents
in part, “A. Resident has a pressure ulcer/injury, a scare over bony prominence, or a non-removable
dressing/device…Yes…F1. Number of unstageable pressure ulcers due to coverage of wound
bed by slough and/or eschar…1.”
Facility’s policy titled “Skin Care Prevention” dated 01/2025 documents in part,
“General: All residents will receive appropriate care to decrease the risk of skin breakdown.
Responsible Party: All Nursing Staff. Guideline: 1. The nursing department will review all new
admissions/readmissions to put a plan in place for prevention based on the resident’s activity level,
comorbidities, mental status, risk assessment and other pertinent information. 2. Dependent residents will
be assessed during care for any changes in skin condition including redness and this will be reported to the
nurse. The nurse is responsible for alerting the Health Care Provider. 3. All residents will be evaluated for
changes in their skin condition… 5. All residents unable to reposition themselves will be repositioned
as needed, based on a person-centered approach (minimum of every 2 hours).”
Facility’s policy titled “Residents’ Rights” dated 11/2018 documents in part,
“As a long-term care resident in Illinois, you are guaranteed certain rights, protections and privileges
according to state and federal laws…Your rights to dignity and respect…Your facility must provide
equal access to quality care regardless of diagnosis, condition, or payment source…Your rights to
safety…Your facility must provide services to keep your physical and mental health, at their highest
practical levels.”
Facility’s undated job description titled “Wound Care Nurse” documents in part,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145337
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145337
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Ryze on the Avenue
3400 South Indiana
Chicago, IL 60616
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Level of Harm - Actual harm
“Basic Function: The primary purpose of Wound Care Nurse is to provide for the day-to-day care
needs of the residents in a Skilled Nursing Facility Environment…Essential Duties:…2. Must be
able to identify changes in the resident condition and evaluate the resident care needs…17.Recognize
significant changes in the condition of residents and take necessary action.”
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145337
If continuation sheet
Page 5 of 5
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the August 27, 2025 survey of RYZE ON THE AVENUE?
This was a inspection survey of RYZE ON THE AVENUE on August 27, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at RYZE ON THE AVENUE on August 27, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure services provided by the nursing facility meet professional standards of quality."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.