Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ripley Crossing during CMS and state inspections, most recent first.
A resident with a history of falls and multiple medical conditions was being pushed in a wheelchair by an LPN without foot pedals attached, contrary to facility policy. As the wheelchair was pushed over a rug, the resident's feet dropped to the floor, causing a forward fall that resulted in facial fractures and a severe nosebleed requiring hospitalization and further interventions.
Failure to notify the physician of a resident’s change in condition occurred after a choking episode. A resident with dementia and other diagnoses choked in the dining room, required the Heimlich maneuver, turned pale, and then coughed up a piece of waffle. The ADON assisted with assessment and the POA was notified, but the record lacked documentation that the physician or NP was notified.
Delayed Identification of Sacral Pressure Ulcer: A resident with dementia, schizophrenia, pneumonia, and dependence for hygiene and transfers developed a sacral DTI that was first documented after prior skin checks showed no concerns. The wound quickly progressed to an unstageable pressure ulcer, and the record lacked documentation that the sacral area was identified earlier before necrotic tissue and moisture were noted. Staff reported the resident was very ill, weak, eating poorly, and sometimes refused turning, care, and supplements.
Failure to provide appropriate catheter care was identified for a resident with an indwelling urinary catheter when the drainage bag was observed hanging from a recliner with part of the bag touching the floor. The resident was cognitively intact, required staff assistance for transfers, and had diagnoses including ESRD, DM, HTN, hip fracture, anemia, and a recent UTI. CNA stated the bag should be hung below the bladder and kept off the floor, and the facility policy required the tubing and drainage bag to be kept off the floor.
An expired Humalog insulin pen for a resident was found on the Wing 2 med cart during survey. RN 3 said the resident received insulin before meals and that the pen had been used that day and likely the day before as well, even though the label showed it should have been discarded earlier. The facility policy stated outdated drugs and biologicals are to be returned to the pharmacy or destroyed.
A registered nurse failed to follow infection control protocols during wound care for a resident with a malignant breast wound and a heel wound. After picking up soiled gauze from the floor, the nurse did not remove gloves or perform hand hygiene before continuing with wound cleaning and dressing changes, contrary to facility policy. This lapse was observed and confirmed by staff interview.
The facility failed to maintain safe water temperatures in residents' bathrooms, with temperatures exceeding federal guidelines. Observations showed water temperatures as high as 128 degrees Fahrenheit, causing discomfort to residents. The Maintenance Director acknowledged the issue and attempted to adjust the water heaters, but there was no specific policy in place regarding water temperatures.
The facility failed to accurately complete MDS assessments for three residents. One resident's assessment incorrectly indicated no terminal diagnosis despite receiving Hospice care. Another resident's assessment inaccurately documented a GDR of antipsychotic medications that did not occur. A third resident's assessment was incomplete, missing evaluations for cognitive patterns and mood. These deficiencies highlight lapses in the facility's assessment processes.
A facility failed to adequately monitor a dialysis access site for a resident with an AV shunt, who received dialysis three times a week. The resident's shunt was not assessed on non-dialysis days, despite a physician's order to check it every shift. The order was not included in the EMAR/ETAR, leading to a lack of documentation and routine assessment. The DON acknowledged the oversight, which resulted in non-compliance with the facility's policy and the physician's order.
A facility failed to treat a resident with dignity and respect, as observed when a CNA spoke disrespectfully to a resident with severe cognitive impairment. The resident, who has dementia, reported that some staff were mean to her. The facility's policy emphasizes treating residents with dignity, which was not adhered to in this instance.
An RN at the facility misappropriated medications for three residents, including Norco and Percocet, by signing out the drugs on days they were not scheduled to work. The electronic medication administration records did not match the signed-out medications, indicating the medications were not administered as prescribed. The residents involved had varying levels of cognitive impairment, and the facility's policy on identifying misappropriation events was not effectively implemented.
A resident with severe cognitive impairment fell from a shower bed due to inadequate safety checks and improper handling by a CNA, resulting in fatal injuries. The facility failed to ensure the shower bed was inspected for safety, and the CNA did not follow the care plan requiring two staff members for repositioning. The maintenance director had altered the shower bed without following manufacturer's instructions, contributing to the accident.
The facility failed to maintain safe shower beds, leading to a resident's fall from a bed on Wing 3. The bed lacked weight limit markers and had inadequate railings. Maintenance checks were insufficient, focusing only on wheel function and pin presence, not structural integrity. A similar bed on Wing 4 had a weight capacity sticker but shared maintenance issues. The facility's policy required regular maintenance, but records were incomplete, and staff training did not emphasize structural inspections.
Two residents, both cognitively intact, experienced verbal and emotional abuse by a CNA who yelled at one resident for assisting her roommate. The incident, which upset both residents, was not reported immediately despite facility policies requiring prompt reporting and investigation of abuse allegations. The CNA continued to work following the incident, highlighting a deficiency in the facility's protection of residents from abuse.
The facility failed to report an allegation of abuse involving two residents in a timely manner. CNA 5 spoke loudly to a resident, causing distress, but CNA 3 did not report the incident. LPN 2 heard the commotion but only reported it at the end of her shift. The incident was not documented or reported to the Administrator or SSD until discovered later, violating the facility's policy on immediate reporting of abuse allegations.
Failure to Use Wheelchair Foot Pedals Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to follow appropriate safety measures while assisting a resident in a wheelchair, resulting in the resident falling and sustaining significant injuries. Specifically, a nurse was pushing the resident in his wheelchair to the front lobby for a dialysis appointment without attaching the foot pedals. As the wheelchair was pushed over a rug, the resident's feet fell to the floor, causing him to fall forward out of the wheelchair and sustain facial trauma, including a nasal and septal fracture, and a severe nosebleed. The resident required hospitalization, where he experienced complications such as recurrent bleeding, the need for nasal packing, limb restraints due to agitation, and a blood transfusion for anemia. The resident had a documented history of falls and was at risk due to weakness from chronic obstructive pulmonary disease and end stage renal disease requiring hemodialysis. The care plan in place prior to the incident included assistance with transfers but did not specify the use of foot pedals when staff propelled the wheelchair. Facility policy required foot pedals to be in place when residents could not self-propel, but this was not followed. Interviews with staff confirmed that foot pedals were not used during the incident, and that facility policy and best practices were not adhered to at the time of the fall.
Failure to Notify Physician After Choking Incident
Penalty
Summary
The facility failed to notify the physician of a change in condition for 1 of 20 residents reviewed for notification of change. Resident 82 had diagnoses including dementia, diabetes, depression, respiratory failure, and food in the respiratory tract, and a Quarterly MDS dated 10/23/2025 indicated the resident was severely cognitively impaired. On 09/22/2025, a nurse was called to the dining room after a CNA reported the resident was choking. The Heimlich maneuver was attempted when the resident’s face turned pale, and after three to five attempts the resident began talking, her color returned, and she coughed up a soggy piece of waffle. The ADON was called to help assess the resident, and the POA was notified. The clinical record did not contain documentation that the physician was notified of the choking incident. During interview, RN 2 stated that after a resident choked, the resident would be assessed, the family and physician would be notified, and the event would be documented. The DON stated she remembered talking to the NP about the choking episode, but there was no documentation that the NP was notified after the incident. The facility policy titled, Change in a Resident's Condition or Status, stated the facility promptly notifies the resident, attending physician, and resident representative of changes in the resident's medical or mental condition and/or status.
Delayed Identification of Sacral Pressure Ulcer
Penalty
Summary
The facility failed to identify a pressure ulcer in a timely manner for one resident reviewed for pressure ulcers. The resident had multiple diagnoses including anemia, hypertension, heart failure, pneumonia, dementia, and schizophrenia, and was dependent on staff for personal hygiene and transfers. A quarterly MDS indicated the resident was moderately cognitively impaired. The physician’s order required weekly skin assessments, and the weekly skin assessments from July 1 through August 3, 2025 indicated no new skin concerns. A Weekly Wound Observation Tool dated 08/04/2025 documented the first finding of a deep tissue injury on the resident’s sacrum measuring 45 mm by 20 mm. Two days later, the wound was documented as an unstageable pressure ulcer. A wound doctor note later described the sacral wound as an unstageable DTI measuring 5 cm by 3 cm with intact skin, and a quarterly MDS again identified a deep tissue injury on the sacrum. The clinical record lacked documentation showing the sacral wound was identified before it was found with necrotic tissue and moisture. Staff interviews indicated the resident sometimes refused care, was very weak and sick at the end of summer, had pneumonia, was eating small amounts, refused turning, and refused supplements at times.
Improper Urinary Catheter Drainage Bag Placement
Penalty
Summary
Failure to provide appropriate catheter care was identified for one resident with an indwelling urinary catheter. Resident 37 was observed sitting in a recliner in her room with the urinary catheter drainage collection bag hanging from the side of the recliner and approximately three inches of the bag touching the floor. This condition was observed twice while the resident was in the recliner after therapy. The resident was cognitively intact, had diagnoses including anemia, hip fracture, end stage renal disease, hypertension, diabetes, and a urinary tract infection in the last 30 days, and required staff assistance for transfers. CNA 3 stated the catheter collection bag should be hung lower than the resident's bladder and not touching the floor. The facility policy titled Catheter Care, Urinary indicated the catheter tubing and drainage bag should be kept off the floor.
Expired Insulin Pen Stored on Medication Cart
Penalty
Summary
The facility failed to appropriately store medications for 1 of 3 medication carts reviewed, specifically the Wing 2 Medication Cart. On observation, the cart contained a 1/4 full Humalog insulin pen for Resident 10 with a sticker showing it had been opened on a prior date and should have been discarded by another date. During interview, RN 3 stated the resident received insulin every day before meals and that the pen had been used to administer insulin to the resident before breakfast and before lunch that day; RN 3 also stated the resident probably received insulin from the pen the day before as well. The medication was expired and should have been discarded on the date indicated on the label. The facility policy on Storage of Medications stated that all drugs and biologicals are to be stored in a safe, secure, and orderly manner, and that discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
A deficiency occurred when a registered nurse failed to follow infection control guidelines during a wound dressing change for a resident with a malignant neoplasm of the right breast and other significant medical conditions. During the procedure, the nurse performed hand hygiene and donned appropriate personal protective equipment before starting, but when a piece of saturated gauze fell to the floor, the nurse picked it up and discarded it without removing gloves or performing hand hygiene. The nurse then proceeded to clean the resident's wound and apply a new dressing, and subsequently performed a second dressing change on the resident's right foot, again without performing hand hygiene between the two dressing changes or after handling the soiled gauze from the floor. Facility policy required staff to avoid unnecessary touching of environmental surfaces, perform hand hygiene after removing soiled dressings, and don new gloves before continuing with wound care. The nurse's actions were inconsistent with these policies, as confirmed by both observation and staff interview. The resident involved was severely cognitively impaired and had a history of refusing treatment for the breast wound, which was prone to flare-ups and bleeding. The failure to adhere to infection control protocols was directly observed and documented during the survey.
Facility Fails to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain safe water temperatures in residents' bathrooms, as required by federal guidelines, which specify a range between 100 and 120 degrees Fahrenheit. During observations and interviews, it was found that the water temperatures in 10 out of 11 residents' bathrooms exceeded this range, with temperatures recorded as high as 128 degrees Fahrenheit. Residents reported that the water was too hot to keep a hand under without discomfort, although no burns were reported. The Maintenance Director acknowledged the issue, noting that he attempted to keep water temperatures at 120 degrees and tested them monthly, but sometimes recorded temperatures as high as 125 degrees. Further investigation revealed that the water temperature logs for the facility showed consistent readings above the recommended range, with temperatures between 111 and 114 degrees Fahrenheit across different halls in the months of August, September, and October. The Maintenance Director indicated that he had recently acquired a new thermometer and adjusted the water heaters to lower the temperature. However, there was no existing policy related to water temperatures, and the facility claimed to follow federal guidelines. The Administrator confirmed the absence of a specific policy on water temperatures.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents. For Resident 5, the MDS assessment incorrectly indicated that the resident did not have a terminal diagnosis, despite receiving Hospice care for a terminal condition. The MDS Coordinator acknowledged the error, noting that the information was obtained from the resident's paper chart. Resident 57's MDS assessment inaccurately documented a gradual dose reduction (GDR) of antipsychotic medications, which had not occurred. The Social Service Director (SSD) was uncertain why the documentation reflected a GDR, and the MDS Coordinator confirmed the absence of a facility policy on MDS assessments, relying instead on the Resident Assessment Instrument (RAI) manual. For Resident 61, the MDS assessment was incomplete, missing evaluations for sections C (Cognitive Patterns) and D (Mood). The MDS Coordinator was unaware of the omission, and the SSD, responsible for these sections, could not explain why they were not completed. Progress notes indicated the resident expressed feelings of sadness due to family visitation issues. These deficiencies highlight lapses in the facility's assessment processes, leading to inaccurate or incomplete resident evaluations.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to adequately monitor a dialysis access site for a resident who received dialysis treatments. The resident, who was moderately cognitively impaired and diagnosed with End Stage Renal Disease, diabetes, and heart failure, had an arteriovenous (AV) shunt in his left arm for dialysis. Although the nurses applied numbing cream before the resident went out for dialysis, they did not assess the shunt on non-dialysis days. The facility's policy required the dialysis access site to be checked every shift for patency by auscultating for a bruit and palpating for a thrill, but this was not consistently done. The physician's order to assess the dialysis shunt every shift was not included in the resident's Electronic Medication Administration Record/Electronic Treatment Administration Record (EMAR/ETAR), leading to a lack of documentation and routine assessment on non-dialysis days. The Director of Nursing acknowledged that the nurses likely did not assess the shunt every shift because the order was not visible in the EMAR/ETAR. This oversight resulted in the facility not adhering to its policy and the physician's order, potentially compromising the resident's care.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as observed during an incident involving a Certified Nurse Aide (CNA) and Resident F. During an observation, the CNA was heard speaking disrespectfully to Resident F, stating, "I'm not dealing with people telling me to shut up. Well then someone else can deal with you then!" before exiting the room. The CNA returned shortly after noticing she was being observed and began asking the resident about her clothing preferences for the day. Resident F, who was noted to have severe cognitive impairment due to non-Alzheimer's dementia, expressed during an interview that some staff members were mean to her, although she could not recall their names. The resident's clinical record indicated she had short-term memory issues but was otherwise alert and communicated regularly with her family. The facility's policy on dignity, which was reviewed, emphasized that residents should be treated with dignity and respect at all times, highlighting a failure in adherence to this policy.
Misappropriation of Medications by RN
Penalty
Summary
The facility failed to prevent the misappropriation of medications for three residents. Resident B, who was cognitively intact, had a physician's order for Norco to be administered as needed for pain. However, records showed that RN 2 signed out the medication on a day they were not scheduled to work, and the medication was not administered according to the electronic medication administration record. Resident B confirmed that she had not taken the medication recently due to its side effects. Similarly, Resident D, who was severely cognitively impaired, had a physician's order for Percocet for breakthrough pain. RN 2 signed out the medication on a day they were not scheduled, and the medication was administered by another nurse according to the records. Resident E, who was moderately cognitively impaired, had a physician's order for Norco to be administered as needed for pain. RN 2 signed out the medication on multiple occasions, but the electronic medication administration record showed that the medication was not administered on those days. The facility's policy on abuse and neglect indicated that they would identify events that may constitute misappropriation of property, but the misappropriation occurred nonetheless.
Failure to Ensure Shower Bed Safety Leads to Resident's Fatal Fall
Penalty
Summary
The facility failed to ensure the safety of a resident during a shower, leading to a severe accident. The incident involved a shower bed that was not comprehensively inspected for safety or function by the maintenance staff or the CNA prior to its use. The resident, who was severely cognitively impaired and dependent on staff for various activities, was being showered by a CNA who did not follow proper procedure guidelines. The CNA attempted to reposition the resident on the shower bed alone, contrary to the care plan that required two staff members for such tasks. During this process, the side rail of the shower bed gave way, resulting in the resident falling and sustaining serious injuries, including a subdural hematoma, a fracture of the left humerus, and a facial laceration. The resident's medical history included conditions such as stroke, hemiplegia, hypertension, renal insufficiency, diabetes, dementia, seizure disorder, anxiety, and depression. The resident required extensive assistance for bed mobility and was dependent on staff for bathing and showering. Despite these needs, the CNA was the only staff member present during the shower, and the shower bed was not properly checked for safety, as evidenced by the mechanical failure of the side rail. The maintenance director had previously altered the shower bed by replacing pipes and putting it back into service without following the manufacturer's instructions for safety checks. Interviews with staff revealed that the maintenance director did not conduct routine checks on the shower beds, and there was a lack of documented safety inspections. The CNA involved in the incident was terminated, and it was noted that the maintenance director had replaced parts of the shower bed with materials not specified by the manufacturer. The facility's policies and procedures for accident prevention and resident supervision were not adequately followed, contributing to the incident that resulted in the resident's death.
Removal Plan
- The altered shower bed was taken out of service.
- The Maintenance Director received education to never alter medical equipment and to replace parts with the manufacturer's instructions.
- All residents who required the use of the shower bed were identified and the assignment sheet and care plan were updated.
- All staff were educated on the correct use, safety inspection, safety features of the bed and all safety measures to be taken related to the shower bed.
Failure to Maintain Safe Shower Beds
Penalty
Summary
The facility failed to ensure that resident care equipment, specifically shower beds, was in safe operating condition. On Wing 3, a shower bed was involved in an incident where a resident, referred to as Resident B, fell out of the bed during use. The bed, made of PVC pipes, lacked identifying markers for weight limits and had railings that were only six inches high. The Maintenance Director noted that the pins holding the railings in place were often lost, and there were no documented routine checks on the beds. After the incident, it was discovered that one of the pins was missing, and the bed was taken out of service for inspection. However, the inspection did not reveal any problems, and the bed was returned to service. On Wing 4, a similar shower bed was observed, which had a sticker indicating a 500-pound weight capacity. The Maintenance Director had recently replaced the pins and plastic strips holding them in place. During an interview, Maintenance Staff 5 revealed that a cap was missing from one of the stationary corners of the Wing 3 shower bed, and the PVC was broken, which compromised the bed's integrity. The maintenance staff did not perform routine checks on the shower beds, only ensuring that the wheels were functional. The Maintenance Director admitted to replacing the pipes with heavier ones after the incident but was unsure of the beds' age or original specifications. The facility's Preventative Maintenance Program policy required the Maintenance Director to maintain a schedule of maintenance services to ensure equipment safety, following manufacturers' guidelines. However, the Maintenance Checklist documentation only showed checks from May to July 2024, with no records of checks before May. Staff training included checking for the presence of pins but did not emphasize inspecting the structure for cracks or loose pieces. The manufacturer's operation instructions highlighted the importance of keeping rails up and checking for fractures, which were not consistently followed.
Failure to Protect Residents from Verbal and Emotional Abuse
Penalty
Summary
The facility failed to ensure residents were free from verbal and emotional abuse, as evidenced by an incident involving two residents, identified as Residents D and B. Resident D, who was cognitively intact and diagnosed with Parkinson's disease and hypertension, reported being mistreated by a CNA. The incident occurred when Resident D was assisting her roommate, Resident B, with her blankets. CNA 5 entered the room, mistakenly believing Resident D was trying to transfer Resident B into bed, and yelled at her to return to her side of the room. This confrontation upset both residents, with Resident B becoming teary-eyed. The incident was corroborated by a progress note from an LPN and interviews with the residents and another CNA. Resident B, also cognitively intact and diagnosed with stroke, diabetes, anxiety, and depression, confirmed the account of the incident. She stated that CNA 5 yelled at Resident D, which upset her. Both residents indicated that CNA 5 had a history of yelling in the facility, although they had not reported it previously. CNA 3, who was present during the incident, confirmed the events and noted that CNA 5's voice was louder than normal. Despite witnessing the incident, CNA 3 did not report it to the nurse on duty, as she was preoccupied with other tasks. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and reporting of any allegations or suspicions of abuse. However, the incident was not reported immediately, and CNA 5 continued to work the rest of the shift and the following day. The facility's administrator confirmed that staff are trained on abuse and neglect upon hire and annually, and that signs are posted throughout the facility to encourage reporting. Despite these measures, the incident involving CNA 5 was not addressed in a timely manner, leading to a deficiency in protecting residents from verbal and emotional abuse.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving two residents, identified as Residents D and B. On the evening of May 18, CNA 3 and CNA 5 were assisting Resident B when CNA 5 began speaking loudly to Resident D, who was holding onto Resident B's wheelchair. CNA 5 instructed Resident D to move to her side of the room, and when Resident D responded, CNA 5's voice grew louder, causing Resident B to become teary-eyed. CNA 3 intervened by removing CNA 5 from the room but did not report the incident to the nurse on duty. CNA 5 continued to work the rest of the shift and the following day without the incident being reported. LPN 2, who was on duty, heard yelling from the direction of the residents' room and found Resident B in bed and Resident D on her own bed, with both CNAs absent from the room. Resident D expressed that CNA 5 accused her of trying to help Resident B walk, and she felt the CNAs were rude. LPN 2 attempted to calm the situation and reported the incident to the oncoming nurse at the end of her shift. The incident was not documented in the residents' records, and the Administrator or SSD were not notified until the SSD discovered the incident in the progress notes on May 20. The facility's policy requires immediate reporting of abuse allegations to the Administrator, state agency, and other required agencies within specific timeframes. However, the incident was not reported within the required timeframe, and the staff involved were not immediately educated on the importance of reporting abuse. The failure to report the incident promptly led to a delay in addressing the situation and ensuring the residents' safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Milan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Manderley Health Care Center | 8.3 mi | ★★★★★ | 11 | 0 |
| Silver Memories Health Care | 8.7 mi | ★★★★★ | 11 | 0 |
| St Andrews Health Campus | 9.6 mi | ★★★★★ | 7 | 0 |
| Waters Of Batesville, The | 10.5 mi | ★★★★★ | 15 | 0 |
| Waters Of Dillsboro-ross Manor, The | 10.9 mi | ★★★★★ | 11 | 0 |
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