Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Diversicare Of Ripley during CMS and state inspections, most recent first.
The facility failed to provide enough nursing staff and nurse aides to meet resident needs, despite its own assessment calling for more direct-care staff. Residents reported long waits for toileting, incontinence care, and call light response, including being left wet for extended periods and waiting 55 minutes or longer for help. Observations confirmed multiple call lights sounding for 12 to 20 minutes without response, while staff were at the nurses’ station or medication cart. CNAs and an LPN reported weekend shortages, one aide covering an entire hall at times, and nurses not always helping with call lights.
Inaccurate PBJ Staffing Submission: The facility failed to accurately submit direct care staffing data into the PBJ system for a quarter reviewed. The PBJ report showed excessively low weekend staffing, and staff interviews revealed that CNAs who transported dialysis residents on Saturdays also worked on the floor afterward, but those hours were not captured because the payroll system could not change their role from van driver to CNA. The Administrator also stated that salaried leaders worked many weekends as RN supervisor, but those direct care hours were not captured, and he confirmed the PBJ was not accurate.
Unresolved Resident Council Food Grievances: The facility failed to promptly resolve repeated resident grievances about food quality and service. Resident Council minutes and grievance forms showed ongoing complaints that meals were cold, pork chops and fried chicken were too tough or hard to chew, fish quality was poor, breakfast service was incomplete, and ice cream was melted or soft. An Administrator acknowledged awareness of the complaints and confirmed the prior grievances remained unresolved. Several residents involved were cognitively intact, while one had moderately impaired cognition.
Medication carts were observed unlocked and unattended on two wings. An LPN on each wing stated she had walked away from the cart and forgot to lock it, and the DON stated carts should never be left unlocked and staff were aware they must remain locked when not in use.
Failure to Follow Personal Hygiene Care Plan: A resident with spastic cerebral palsy, peripheral neuropathy, and spina bifida had a care plan for substantial to maximum assistance with personal hygiene, but staff did not consistently shave him as part of that care. The resident reported he was not shaved when he was supposed to be, had visible facial hair over multiple observations, and staff confirmed shaving was part of his bath-day hygiene care but could not say when he was last shaved.
Failure to provide regular shaving and grooming assistance: A resident with Spina Bifida, psoriasis, and need for personal care assistance was observed with about one inch of facial hair and stated he was not shaved consistently when due. CNAs said shaving usually occurred with bath days, but sometimes was delayed if there was not much facial hair growth, and staff could not identify when he was last shaved. The DON stated residents were expected to be adequately groomed and presentable, and the ADNS confirmed shaving was part of the resident's personal hygiene.
Failure to provide appropriate pressure ulcer care occurred for a resident with an unhealed sacral PU and total urine and bowel incontinence. During wound care observation, the resident had no dressing on the sacral wound and was wearing a urine-saturated brief. The treatment record included orders for routine dressing changes and replacement if soiled or dislodged, but there was no indication the dressing was replaced when needed. The resident stated staff often removed soiled dressings and did not usually replace them, and the RN confirmed the dressing was absent.
A resident who needed a divided plate to eat independently was served breakfast on a regular plate even though the tray card specified the adaptive equipment. The resident said he did not always receive the divided plate and could not feed himself with utensils when it was missing. An LPN confirmed the resident required the divided plate, while the Administrator stated the facility was out of divided plates and had to borrow some from another facility.
Staff failed to use EBP during observed care for two residents. An RN provided PEG tube site care for one resident with a PEG tube and wound care for another resident with a chronic sacral wound, but wore gloves without a gown during both treatments. The RN stated she had been trained on EBP but forgot to apply the gown, and the DON confirmed staff were expected to use EBP for residents with chronic wounds and indwelling devices.
The facility failed to provide adequate dietary staffing, resulting in residents receiving cold and unpalatable meals. Observations and interviews revealed that the kitchen was consistently short-staffed, leading to delays in meal service and poor food quality. Residents reported receiving improperly cooked meals, with overcooked meats and mushy vegetables, and expressed dissatisfaction with the limited food choices. The lack of insulated boxes and a steamer in the kitchen further contributed to the issues with meal temperature and quality.
The facility failed to provide palatable and properly heated meals to residents, with reports of cold, overcooked, and unappetizing food. Staffing shortages and lack of proper equipment in the dietary department contributed to the issue, affecting eight out of twelve sampled residents.
The facility was found to have unsafe food handling practices, including thawing meat at room temperature and improper disposal of raw chicken skin, which could lead to foodborne illness. Dietary staff confirmed these practices were against policy, and the Regional Dietary Manager acknowledged the potential for illness.
The facility failed to accurately report staffing data in the PBJ system for the fourth quarter of 2024, leading to a deficiency for low weekend staffing. Manual entry errors and delayed updates contributed to the inaccuracies, as confirmed by interviews with the Workforce Management Coordinator, Human Resource Coordinator, and Administrator. Verification showed that additional staff were present and providing care, but not recorded in the system.
The facility failed to implement care plans for several residents, leading to deficiencies in their care. A resident with a self-care deficit had unkempt nails and facial hair, while another with severe cognitive deficits had dirty fingernails. A third resident reported not receiving scheduled showers, resulting in greasy hair and odor. Additionally, a resident with respiratory issues did not have their oxygen tubing and humidifier bottles changed as required, posing a risk of infection.
The facility failed to provide necessary ADL assistance for three residents, leading to deficiencies in personal care. A resident had long, dirty fingernails and an unkempt beard, despite being cognitively intact and expressing a desire for care. Another resident had dirty fingernails and required a two-person assist with ADLs, while a third resident missed scheduled showers, resulting in greasy hair and body odor. Staff confirmed these deficiencies, and the residents' cognitive and physical conditions were noted.
The facility failed to maintain the dignity of three residents by not covering their urinary catheter bags and tubing, as required by policy. A resident with severe cognitive deficits was observed with an uncovered catheter bag visible from the hallway. Another resident with moderate cognitive deficits expressed discomfort with his exposed catheter bag. A third resident, cognitively intact, was observed with an exposed catheter bag containing a brown substance. Staff confirmed that the catheter bags should have been covered to uphold the residents' dignity.
A facility failed to change a resident's oxygen tubing and humidifier water bottle as ordered, with observations showing the equipment was not updated since 11/29. Staff interviews confirmed the oversight, and the DON acknowledged the failure to follow the physician's order. The resident, with respiratory conditions, was cognitively intact.
The facility failed to provide adequate nursing staff to meet the ADL needs of three residents. A resident with cognitive deficits had unclean fingernails, while another resident missed scheduled baths due to staff being too busy. The DON confirmed ongoing staffing issues, particularly on the 3 PM-11 PM shift, with frequent call-ins leading to understaffing. Despite offering incentives and having nurses assist, the facility struggled to provide necessary care.
A resident's medications, including inhalers and a nebulizer, were found unsecured on a bedside table, contrary to facility policy requiring locked storage. The resident, cognitively intact, stated the inhalers were for emergencies. An LPN and the DON confirmed the medications should have been secured, highlighting a lapse in adherence to medication storage protocols.
Two residents in an LTC facility experienced deficiencies in dining services. One resident was denied alternative food items until all residents were served, despite staff claims of sufficient food availability. Another resident's preference for sausage over bacon was not honored due to a computer glitch, leading to repeated receipt of food she could not eat. The Dietary Manager acknowledged the issues but failed to resolve them adequately.
The facility failed to properly contain and dispose of kitchen trash, as observed during a kitchen tour. Two trash barrels were found overflowing and uncovered, with empty boxes stacked on top. Dietary staff confirmed the unsanitary condition, citing a lack of time due to shift change and meal preparation. The Regional Dietary Manager confirmed that trash should be emptied once per shift and as needed, with lids intact for safe disposal.
A resident in an LTC facility suffered a fall and fracture due to the use of an incorrect sling during a transfer. The care plan specified an extra-large blue sling, but two CNAs used a green sling, which was not suitable for the resident's weight. The CNAs did not check the care plan or Kardex, leading to the incident.
A resident in an LTC facility fell and sustained fractures during a lift transfer due to the use of an inappropriate sling. The staff used a green sling instead of the care-planned blue sling for bariatric residents, leading to a strap breaking and the resident falling. The resident, who was morbidly obese and cognitively intact, required surgery for a femur fracture. Staff interviews revealed a lack of awareness regarding the correct sling to use, contributing to the incident.
The facility failed to provide palatable and properly prepared meals, as evidenced by multiple resident complaints and staff confirmations. Residents reported that food was often hard, overcooked, and difficult to chew, with issues noted with pancakes, meat, and bread. Staff acknowledged these problems, attributing them to overcooking and prolonged steam table exposure. Despite a new District Dietary Manager, the facility did not meet its policy standards for nourishing and attractive meals.
Insufficient Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and failed to have enough nurse aides scheduled to match its own assessed staffing needs. The facility’s Center Assessment Tool dated 6/18/25 identified a need for 13-15 licensed nursing staff providing direct care daily and 25-35 nurse aides over a 24-hour period, but the posted Daily Nurse Staffing Form for 2/8/26 showed only 21 nurse aides scheduled across day, evening, and night shifts. The PBJ Staffing Data Report also showed the facility triggered for excessively low weekend staffing for the fourth quarter. Resident interviews and observations showed repeated delays in call light response and personal care. Resident #103 stated she sometimes remained wet for up to two hours before aides changed her and said call lights sometimes took up to two hours to be answered, with waits over an hour occurring two to three times a week, especially on the 3 PM to 11 PM shift. Resident #28 reported waiting 55 minutes after pressing the call light while soiled during the night. Resident #75 and a family member reported call lights sounding for 30-45 minutes, and Resident #116 stated weekend staffing was always short and residents had to wait longer than usual for help. Additional observations confirmed multiple unanswered call lights and delayed staff response. Resident #94 was observed waiting with a call light sounding for approximately 12 minutes before staff responded, and the resident stated she needed to be changed and was wet. Later, call lights from several rooms were observed sounding for approximately 15-20 minutes without staff response while a nurse sat at the nurses’ station and another stood at the medication cart. An LPN confirmed multiple call lights were sounding and stated she did not stop medication pass to address resident needs. CNAs reported that staffing was short on weekends, that one aide sometimes covered an entire hall, and that nurses did not always assist with call lights. The Administrator acknowledged the facility had dropped below expected staffing hours per patient day on several days and stated call light response time was a concern and had resulted in delays in care and unmet care needs.
Inaccurate PBJ Staffing Submission
Penalty
Summary
The facility failed to accurately submit direct care staffing information into the Payroll-Based Journal (PBJ) system for the fourth quarter of 2025, based on payroll and other verifiable and auditable data. Review of the facility policy titled Payroll Based Journal Entry Submission showed that CMS regulations for PBJ entry submission were to be adhered to, but review of the PBJ Staffing Data Report found excessively low weekend staffing reported for July through September 2025. During interviews, the Workforce Manager Coordinator stated that CNAs transported dialysis residents on Saturdays and then returned to the facility to work on the floor assisting with baths, call lights, meal trays, and feeding residents, but those hours were not captured because the payroll system could not change the role from van driver to CNA. The Administrator stated the PBJ was submitted through the corporate office and that salaried staff, including the DON, ADON, and Discharge Care Coordinator, worked many weekends as RN supervisor, but the facility was unable to make payroll system changes to capture those direct care hours. He confirmed the PBJ was not accurate for that quarter.
Unresolved Resident Council Food Grievances
Penalty
Summary
The facility failed to honor residents’ right to voice grievances and to ensure that concerns raised in Resident Council meetings were promptly addressed and resolved to residents’ satisfaction. Facility policy titled Customer Concern (Grievance) Policy stated that the center actively seeks a resolution after receiving a concern and keeps the customer apprised of progress toward resolution, with prompt response to customer concerns. However, the record showed repeated food-related complaints documented in Resident Council minutes from August 2025 through December 2025 that remained unresolved over multiple meetings. Resident Council minutes documented ongoing concerns that meals were served cold, meats such as pork chops and fried chicken were too tough or hard to chew, fish quality was poor, breakfast items were inconsistent with the posted menu, and ice cream was melted or soft when received. The concerns were recorded as not resolved to residents’ satisfaction in multiple months, including old business items that remained open and new business items showing the same complaints continued to be raised by groups of residents. Customer Concern/Grievance Communication Forms from the same meetings reflected the same complaints, including cold food, tough pork chops, thin or overcooked fish, cold soup items, and melted ice cream. During a Resident Council meeting on 2/10/2026, nine residents attended and seven voiced that meals were often cold and certain meats were too tough to chew, stating the concerns had been ongoing for several months. The Administrator stated in interview that he was aware of the ongoing food-related complaints and confirmed the previous resident grievances were unresolved. The record also identified several residents involved in the council meetings, including cognitively intact residents with BIMS scores of 14 and 15, one resident with a BIMS score of 9 indicating moderately impaired cognition, and another resident with a diagnosis of unspecified dementia but a BIMS score of 15.
Unlocked Medication Carts
Penalty
Summary
Medication carts were not kept locked and secure when not in use, as required by facility policy and accepted medication storage principles. During observation, the medication cart on E Wing was found unlocked and unattended, and an LPN stated she had walked down the hall to administer a medication and forgot to lock the cart, adding that the cart should always be secured when she leaves it. Later, the medication cart on A Wing was also observed unlocked and unattended, and an LPN stated she had walked down the hall and forgot to lock the medication cart, stating it should always be secured when not in use. The DON stated medication carts should never be left unlocked and that staff were aware carts must remain locked when not in use.
Failure to Follow Personal Hygiene Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for one resident whose care plan identified a self-care deficit related to mobility impairment, range of motion limitations, and self-care impairment associated with spastic cerebral palsy, peripheral neuropathy, and spina bifida. The care plan directed that the resident receive substantial to maximum assistance with personal hygiene. Facility policy stated that care plans are to be developed by the interdisciplinary team and revised as needed according to resident status or change. During observation and interviews, the resident stated he was not getting shaved all the time when he was supposed to and said staff did it when they took a notion to do it. The resident had facial hair approximately one inch long on his cheeks, above his upper lip, and on his chin, and he could not say when he had last been shaved. A CNA confirmed the facial hair was long and that it had been a while since he had been shaved. The resident remained unshaven during later observations. Another CNA stated the resident is shaved during bath days as part of personal hygiene, and the ADNS confirmed shaving is part of his personal hygiene care plan and that if he was not shaved, the plan of care was not being followed. The MDS Coordinator also confirmed there was no specific shaving care plan, but shaving was included under personal hygiene and should have been followed.
Failure to Provide Regular Shaving and Grooming Assistance
Penalty
Summary
The facility failed to ensure Resident #111 received ADL care, including grooming and personal hygiene services such as shaving, in accordance with his assessed needs. The facility policy titled ADLs stated that hygiene activities include bathing, dressing, grooming, and oral care, and that ADLs are to be provided in accordance with accepted standards of practice, the resident's care plan, and the resident's choices and preferences. Resident #111 was admitted with diagnoses including Spina Bifida, Psoriasis, and need for assistance with personal care, and his MDS showed a BIMS score of 11, indicating moderate cognitive impairment. During interview and observation, the resident stated he did not get shaved all the time when he was supposed to and said staff did it when they took a notion to do it. He had approximately one inch of facial hair on his cheeks, upper lip, and chin, and he could not say when he was last shaved. A CNA stated he usually got shaved when he received baths on Tuesday, Thursday, and Saturday, but sometimes staff would wait until the next bath day if he did not have much facial hair growth. Additional observations on the following day showed the resident remained unshaved, and staff interviews confirmed his facial hair was long and that they did not know when he was last shaved. The DON stated the expectation was that residents be adequately groomed, including being shaved and presentable, and the ADNS stated the resident was to be shaved during baths as part of his personal hygiene.
Failure to Maintain Dressing on Sacral Pressure Ulcer
Penalty
Summary
Failure to provide appropriate pressure ulcer care occurred for Resident #120, who had an unhealed sacral pressure ulcer/injury and was always incontinent of urine and bowel. The resident’s wound measurements on 2/4/26 showed a Stage 3 pressure ulcer to the sacrum measuring 1.41 cm by 1.24 cm by 0.2 cm. The facility policy for clean dressing changes stated wound care was to be provided in a manner to decrease the potential for infection and/or cross-contamination, and physician orders were to specify the dressing type and frequency of changes. During observation of wound care with RN #1 on 2/9/26 at 2:20 PM, the resident did not have a dressing intact on the sacral wound and was wearing an incontinence brief saturated with urine. The treatment record showed an order to cleanse the sacral wound, apply calcium alginate Ag, and cover with a foam dressing every Monday, Wednesday, and Friday, with an additional order to replace the dressing every 8 hours as needed if soiled or dislodged, but there was no indication the dressing was replaced when soiled or dislodged during February. The resident stated staff often removed the dressing when it became soiled and did not usually replace it. RN #1 confirmed the dressing was absent and stated that if the dressing was not intact, stool and urine could enter the wound and urine could cause the wound edges to become macerated and deteriorate the wound. The DON stated staff were expected to notify the nurse when the dressing came off or was soiled so the wound would receive consistent treatment.
Failure to Provide Required Divided Plate for Independent Eating
Penalty
Summary
The facility failed to ensure Resident #33 was provided with required adaptive eating equipment during meals. The resident stated he needed a divided plate to feed himself independently and reported he did not always receive it; when it was not provided, he was unable to feed himself using utensils. The resident had been admitted with Friedreich Ataxia and was cognitively intact, with an MDS BIMS score of 15. During an observation of breakfast, Resident #33 was served oatmeal, a sausage patty, and toast on a regular plate even though the tray card indicated he was to receive a divided plate with meals. An LPN confirmed the resident did not have a divided plate and stated he required it to eat independently. The Administrator stated the facility was out of divided plates and had to borrow some from another facility, and the Dietary Manager stated dietary staff were responsible for checking the tray line to ensure adaptive equipment was provided.
Failure to Use Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to utilize Enhanced Barrier Precautions while providing care for two residents during observed care activities. Review of the facility Infection Control Guide stated that EBP involves the expanded use of PPE, including gowns and gloves during high-contact resident care activities for residents with wounds or indwelling medical devices when Contact Precautions do not otherwise apply. The Infection Preventionist stated that staff were expected to use EBP during wound care and care for residents with indwelling devices, and that the purpose was to prevent staff from passing germs or bacteria to residents. For one resident, the record showed diagnoses including anoxic brain damage and dysphagia, with a PEG tube used for hydration flushes and enteral feedings if the resident did not eat enough meals. During observed PEG tube site care, the RN wore gloves but did not wear a gown while performing the care, and later confirmed she had forgotten to put one on despite being trained on EBP. For a second resident, the record showed a sacral wound with a treatment order for daily wound care on Monday, Wednesday, and Friday. During observed sacral wound care, the RN performed the treatment without a gown for EBP and later confirmed she did not wear one, stating she had been trained on the precautions but forgot to apply the gown. The DON confirmed staff were expected to practice EBP for residents with chronic wounds.
Inadequate Dietary Staffing Leads to Cold and Unpalatable Meals
Penalty
Summary
The facility failed to ensure sufficient staffing in the dietary department, which resulted in the inability to meet the nutritional needs of residents. Observations and interviews revealed that the facility did not employ adequate dietary staff to prepare and serve meals in a timely manner, leading to residents receiving cold meals and experiencing prolonged delays during meal service. The Regional Dietary Manager (RDM) confirmed the ongoing staffing issues, noting that the kitchen was consistently short-staffed, and he had to assist in meal preparation himself. Additionally, the facility's Administrator acknowledged the staffing challenges and expressed concerns about the frequent changes in dietary management. Multiple residents expressed dissatisfaction with the quality and temperature of the food served. Residents reported receiving meals that were cold, improperly cooked, and unpalatable. Specific complaints included overcooked meats, mushy vegetables, and limited food choices. Observations confirmed that meal trays were placed on uncovered tray racks, contributing to the food cooling before reaching the residents. The new RDM noted the absence of a steamer in the kitchen, which affected the quality of cooked vegetables, and highlighted the lack of insulated boxes for maintaining food temperature during distribution. The report included detailed accounts from several residents, all of whom were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores. These residents had various medical diagnoses, including Chronic Obstructive Pulmonary Disease, Dysphasia, Type 2 Diabetes Mellitus, and Acute Chronic Diastolic Heart Failure. Despite their medical conditions, the residents consistently reported issues with the food service, emphasizing the facility's failure to provide meals that met their nutritional and dietary needs.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. This deficiency was observed in eight out of twelve sampled residents. The facility's policy on food quality and palatability, revised in February 2023, mandates that food should be prepared in a manner that conserves nutritive value, flavor, and appearance, and should be served at a safe and appetizing temperature. However, multiple residents reported that the food was often cold, overcooked, or undercooked, and lacked flavor and appeal. Interviews with residents revealed significant dissatisfaction with the food quality. One resident reported eating grilled cheese and soup daily due to the unpalatability of the menu items, while another described the food as not fit to eat, citing issues with overcooked and mushy vegetables and tough meat. Several residents mentioned that the food was consistently cold, with one resident stating that it was as if the food had been in the refrigerator. Observations confirmed that meal trays were left uncovered on tray racks, contributing to the food being served cold. The facility's dietary department faced staffing challenges, as noted by the Regional Dietary Manager, who highlighted ongoing staff shortages and transitions within the department. The Administrator acknowledged awareness of the dietary concerns and mentioned efforts to address them, although the issues persisted. The new Regional Dietary Manager observed that the kitchen lacked a steamer, which contributed to the poor texture of vegetables. The absence of insulated boxes for tray distribution was also identified as a factor in the food being served cold.
Unsafe Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to safe food handling practices, which could lead to the spread of foodborne illness. During a kitchen tour, it was observed that five packs of kielbasa sausages were left to thaw at room temperature in a two-compartment sink without running water. This practice contradicts the facility's policy, which requires thawing frozen items in a refrigerator or under cold running water to prevent bacterial growth. Dietary Staff confirmed that the meat should not have been left out at room temperature, acknowledging the potential for bacteria growth. Additionally, a brown box containing raw chicken skin was found on the kitchen floor, with the skin resting on the outer edges of the box. The box was observed to drip pink-tinged watery drainage onto the floor and the drainboard of the sink. Dietary Staff admitted that the chicken skin should have been disposed of in the garbage during preparation to prevent contamination. The Regional Dietary Manager confirmed these unsafe practices and acknowledged that they could lead to illness.
Inaccurate PBJ Submissions Lead to Staffing Deficiency
Penalty
Summary
The facility failed to submit accurate data into the Payroll Based Journal (PBJ) system for one of the four quarters reviewed, specifically the fourth quarter of 2024. The facility's policy on PBJ entry submission, dated 2022, requires collaboration with Human Resources and Payroll to capture payroll hours for clinical team members and submit them accurately. However, interviews with the Workforce Management Coordinator and the Human Resource Coordinator revealed discrepancies in the reporting process. The Workforce Management Coordinator admitted that salary employees who worked weekends had their hours entered manually, which she believed led to inaccuracies. The Human Resource Coordinator confirmed that staff schedule changes were typically entered into the system on Monday or Tuesday after the weekend, which could result in inaccurate reports if submitted before these updates. The Administrator acknowledged the issue, noting that the PBJ submissions were sent to corporate staff on Monday mornings, and if weekend changes were not entered by then, the data was inaccurate. This resulted in the facility being flagged for low weekend staffing. A review of the facility's staffing validation computer printout confirmed that additional staff who worked were not entered into the system. Verification by the State Agency showed that these staff members were present and providing resident care, further highlighting the inaccuracies in the PBJ submissions.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for several residents, leading to deficiencies in their care. Resident #8, who was admitted with a need for assistance with personal care and a contracture in the left hand, had a care plan that included daily nail, hair, and oral care. However, observations revealed that his fingernails were long and dirty, and his facial hair was unkempt. Despite expressing a desire for grooming, the care plan interventions were not followed, as confirmed by the MDS nurse. Resident #58, who had severe cognitive deficits and was admitted with hemiplegia and hemiparesis, also had a care plan for daily nail, hair, and oral care. Observations showed that his fingernails were dirty with a brown substance underneath, and this was confirmed by a CNA. The MDS Coordinator acknowledged that the care plan was not adhered to, as the resident's nails remained unclean. Resident #104, who was cognitively intact and had a self-care deficit, reported not receiving scheduled showers and hair care, resulting in greasy hair and a mild odor. The MDS Coordinator confirmed that the care plan, which included assistance with bathing and daily grooming, was not followed. Additionally, Resident #73, who had respiratory issues, had a care plan requiring weekly changes of oxygen tubing and humidifier bottles. Observations revealed that these were not changed as ordered, and the DON confirmed the care plan was not followed, posing a risk of infection.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for three residents, leading to deficiencies in personal care. Resident #8 was observed with long, jagged fingernails with a thick brown substance underneath and an unkempt beard. Despite expressing a desire for nail and beard care, there was no documentation of recent refusals of ADL care, and the Director of Nursing confirmed that the resident should have received these services. Resident #8 was cognitively intact, as indicated by a BIMS score of 15, and had a diagnosis requiring assistance with personal care. Resident #58 was observed with a brown substance under the fingernails of his right hand on multiple occasions. CNA #5 confirmed the presence of dirt and acknowledged the responsibility to clean residents' nails during baths or showers. Resident #58 required a two-person assist with ADLs and had severe cognitive deficits, as indicated by a BIMS score of 4. His diagnoses included hemiplegia and hemiparesis following a cerebral infarction, aphasia, and chronic obstructive pulmonary disease. Resident #104 reported not having received a shower since a specific date, resulting in greasy hair and body odor. CNA #5 confirmed that Resident #104 missed a scheduled shower and should have received one to maintain cleanliness and prevent odor. The Assistant Director of Nursing verified that Resident #104's hair was oily and that she should have received her scheduled shower. Resident #104 was cognitively intact, with a BIMS score of 15, and had diagnoses including difficulty in walking and a need for assistance with personal care.
Failure to Maintain Resident Dignity by Not Covering Catheter Bags
Penalty
Summary
The facility failed to uphold the dignity of three residents by not covering their indwelling urinary catheter bags and tubing, as required by the facility's policy. Resident #58 was observed with a catheter bag containing urine visible from the hallway without a privacy bag. Interviews with CNA #5 and the Assistant Director of Nursing confirmed that the catheter bag should have been covered to maintain the resident's dignity. Resident #58 had severe cognitive deficits, as indicated by a BIMS score of 04. Resident #99 was seen with a catheter bag attached to his wheelchair, visible from the hallway, and not covered by a privacy bag. The resident expressed discomfort with the exposure of his catheter bag. CNA #6 and the Assistant Director of Nursing confirmed that the catheter bag should have been covered. Resident #99 had moderate cognitive deficits, with a BIMS score of 11. Resident #103 was observed with an exposed catheter bag containing a brown substance, which the resident found unpleasant. LPN #1 and the Director of Nurses confirmed that the catheter bag should have been covered to respect the resident's dignity. Resident #103 was cognitively intact, with a BIMS score of 15.
Failure to Change Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing and an oxygen concentrator humidifier water bottle were changed as ordered for a resident. The facility's policy, updated on 8/1/2024, requires that oxygen with humidification be provided according to a physician's order. For Resident #73, the order dated 12/6/24 specified that the oxygen tubing and humidifier bottle should be changed weekly, and external filters should be cleansed every Friday. However, observations on 12/15/24 and 12/16/24 revealed that the oxygen tubing was dated 11/29, and the humidifier water bottle was empty and undated, indicating that the facility did not follow the physician's order. Interviews with staff, including an LPN and the DON, confirmed that the nightshift nurses were responsible for changing the oxygen tubing and humidifier bottles weekly. The DON acknowledged that the facility failed to follow the physician's order, as the tubing and humidifier bottle had not been changed since 11/29. The resident involved, who was admitted with medical diagnoses including Acute Respiratory Failure with Hypoxia, Unspecified Asthma, and Chronic Obstructive Pulmonary Disease, had a BIMS score of 15, indicating cognitive intactness. The failure to change the equipment as ordered was recognized as important to prevent potential infections.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the activities of daily living (ADL) needs of three residents. Resident #8, who was cognitively intact, had long, jagged fingernails with a thick brown substance underneath and an unkempt beard. He expressed a desire for personal grooming but reported that no one was available to assist him. Certified Nurse Assistant (CNA) #4 confirmed the resident's condition and attributed the lack of care to staffing shortages. Resident #58, who had severe cognitive deficits, was observed with a brown substance under his fingernails on multiple occasions. CNA #5 acknowledged the responsibility to clean the resident's nails during bathing but cited staffing issues as a barrier to providing adequate care. Resident #104, also cognitively intact, reported missing scheduled baths due to staff being too busy. Her hair was greasy, and she noted an odor, indicating a lack of personal hygiene care. CNA #5 confirmed that Resident #104's hair should have been washed on her scheduled bath days but was not. The Director of Nursing (DON) acknowledged ongoing staffing concerns, particularly on the 3 PM-11 PM shift, with frequent call-ins leading to understaffing. The facility attempted to mitigate this by offering incentives and having nurses assist with care, but the issue persisted, affecting the quality of care provided to residents.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored appropriately, as evidenced by the observation of two inhalers and a nebulizer machine with unopened medication packages left on the bedside table of a resident. The resident, who was cognitively intact with a BIMS score of 15, stated that the inhalers were for emergency use. However, the medications were not secured in a locked compartment as required, which was confirmed by both an LPN and the Director of Nurses. The LPN acknowledged that the medications should have been returned to the medication cart, and the DON emphasized the risk of wandering residents accessing unsecured medications. The resident involved had been admitted to the facility with medical diagnoses including Chronic Respiratory Failure, Pulmonary Fibrosis, and Atelectasis. Despite the resident's cognitive intactness, the facility's lack of a specific policy for medication storage contributed to the oversight. The facility relied on medication administration competencies and standards of practice, which were not adequately followed in this instance, leading to the deficiency.
Failure to Provide Alternative Food Items and Honor Preferences
Penalty
Summary
The facility failed to provide alternative food items and honor food preferences for two residents, leading to deficiencies in dining services. Resident #59 expressed dissatisfaction with the food, stating that requests for alternative items were denied until all residents were served, due to concerns about food shortages. This was confirmed by multiple staff interviews, including a CNA and the Dietary Manager, who indicated that the practice was to ensure all residents were served before providing additional servings or alternatives. The District Dietary Manager contradicted this practice, stating there was always enough food and alternatives available. Resident #83 experienced a failure in honoring her food preferences due to a computer system glitch. Despite expressing her preference for sausage over bacon due to her inability to chew bacon without bottom dentures, she continued to receive bacon. The Dietary Manager acknowledged the issue, noting that the meal ticket incorrectly listed bacon as a preference, despite having been updated in the system. The Dietary Manager admitted to not following up adequately to resolve the issue, resulting in the resident repeatedly receiving food she could not eat.
Improper Disposal of Kitchen Trash
Penalty
Summary
The facility failed to properly contain and dispose of kitchen trash during a kitchen tour. The facility's policy requires that all garbage and refuse be collected and disposed of safely and efficiently, with the dining service director ensuring that garbage is removed from the kitchen routinely and at the end of the workday. During an observation on 12/15/24, two trash barrels in the kitchen were found to be full, overflowing, and uncovered, with multiple empty boxes stacked on top. Dietary Staff #1 confirmed the unsanitary condition, attributing it to a lack of time to empty the garbage due to a shift change and dinner meal preparation. The Regional Dietary Manager later confirmed that kitchen trash should be emptied once per shift and as needed, with lids remaining intact to ensure safe waste disposal.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who required assistance with transfers due to a physical functioning deficit. The care plan specified the use of a total lift with an extra-large blue sling, appropriate for the resident's weight of 376.3 pounds. However, during a transfer, two CNAs used a green sling, which was not suitable for the resident's weight, leading to the sling breaking and the resident falling to the floor, resulting in a fracture. The incident occurred when the CNAs, who were responsible for transferring the resident from her bed to a wheelchair, used the wrong sling. They admitted to using the green sling because it was the one they had always used, without checking the care plan or the Kardex for the correct sling size. The CNAs were unaware that the care plan specified the use of the extra-large blue sling, which was necessary due to the resident's weight and physical condition. The MDS Coordinator confirmed that the care plan was not followed, which directly led to the resident's fall and injury. The facility's policy required that care plans be developed and maintained according to RAI guidelines, but this was not adhered to in this case. The failure to follow the care plan and use the correct equipment resulted in a significant injury to the resident.
Removal Plan
- Resident #1 was assessed by Nurse Practitioner immediately after the fall and was sent out to the emergency room.
- Lift was inspected following the incident with no identified concerns by Maintenance.
- The lift and sling involved in the accident were removed from the floor by Administrator and remained out of service immediately.
- All lifts and slings were assessed for any disrepair by Administrator and four yellow slings, one blue sling and one green sling were removed due to being worn, and in ill repair. New replacements were ordered.
- New lift slings arrived, they were numbered, dated, and put in service.
- The Kardex was reviewed for all residents for appropriate lift and sling use by the Director of Clinical Education (DCE).
- CNA #1 and CNA #2 were educated on proper lift and sling use and return demonstration was completed by the DCE.
- Checkoffs were completed by the DCE with all staff which were initiated and continue throughout all shifts until everyone completed.
- New Lift Transfer assessments were completed by the ADON on all current residents and care plans were updated.
- Therapy referrals were made as needed by the ADON for anyone who required a lift and lift sling.
- Care Plans and Kardex updated as needed by the ADON.
- Team huddles with lift/transfer education completed by the DCE.
- State Agency, Ombudsman, and Attorney General (AG's) office notified by Director of Nursing.
- In-Service on Lift/Transfer Program and Transfer Belts, Abuse/Neglect/Exploitation, and Elder Justice Program were completed by the DCE for all staff members with 100% compliance.
- Topics included: Performance of lift usage, inspecting the sling prior to use, laundering slings and where to find them, and on the Kardex - only using care planned sling colors.
- In-Services initiated with Housekeeping and Laundry Manager on sling inspection and guidelines by the DCE.
- Hoyer Lift Policy and Procedures were reviewed with CNA #1 and CNA #2 and all other staff by the DCE.
- Audits on all Lift Assessments were completed and are on-going by the ADON.
- Quality Assurance and Performance Improvement (QAPI) meeting was held and all required staff members were in attendance. Plan to continue the weekly audits and bring results to the monthly QAPI meetings for three months.
Inappropriate Sling Use Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure the safety of a dependent resident during a lift transfer, resulting in a fall and subsequent injuries. The incident involved the use of an inappropriate lift sling for a resident who was morbidly obese. The staff used a green sling, which was not suitable for the resident's weight, instead of the care-planned blue sling designed for bariatric use. During the transfer from bed to wheelchair, the right shoulder strap of the green sling broke, causing the resident to fall to the floor and sustain fractures. The resident, who was cognitively intact and required assistance with personal care due to severe obesity, experienced a traumatic fall. The fall was witnessed by two CNAs who were performing the transfer. The resident landed on her right side, hitting her head and complaining of pain in her right shoulder and left hip. Emergency medical services were called, and the resident was transported to the hospital, where she underwent surgery for a comminuted mildly displaced left intertrochanteric femur fracture. Interviews with staff revealed that the CNAs were unaware of the correct sling to use, as they had always used the green sling for this resident. The facility's policy required the use of appropriate slings based on lift evaluations, but this was not adhered to. The CNAs admitted to not checking the care plan or Kardex for the correct sling, leading to the use of an unsuitable sling that could not support the resident's weight, ultimately resulting in the fall and injury.
Removal Plan
- Resident #1 was assessed by Nurse Practitioner immediately after the fall and was sent out to the emergency room.
- Lift was inspected following the incident with no identified concerns by Maintenance.
- The lift and sling involved in the accident were removed from the floor by Administrator and remained out of service immediately.
- All lifts and slings were assessed for any disrepair by Administrator and four yellow slings, one blue sling and one green sling were removed due to being worn, and in ill repair. New replacements were ordered. New lift slings arrived, they were numbered, dated, and put in service.
- The Kardex was reviewed for all residents for appropriate lift and sling use by the DCE.
- CNA #1 and CNA #2 were educated on proper lift and sling use and return demonstration was completed by the DCE.
- Checkoffs were completed by the DCE with all staff which were initiated and continue throughout all shifts until everyone completed.
- New Lift Transfer assessments were completed by the ADON on all current residents and care plans were updated.
- Therapy referrals were made as needed by the ADON for anyone who required a lift and lift sling.
- Care Plans and Kardex updated as needed by the ADON.
- Team huddles with lift/transfer education completed by the DCE.
- State Agency, Ombudsman, and Attorney General (AG's) office notified by Director of Nursing.
- In-Service on Lift/Transfer Program and Transfer Belts, Abuse/Neglect/Exploitation, and Elder Justice Program were completed by the DCE for all staff members with 100% compliance.
- Topics included: Performance of lift usage, inspecting the sling prior to use, laundering slings and where to find them, and on the Kardex - only using care planned sling colors.
- In-Services initiated with Housekeeping and Laundry Manager on sling inspection and guidelines by the DCE.
- Hoyer Lift Policy and Procedures were reviewed with CNA #1 and CNA #2 and all other staff by the DCE.
- Audits on all Lift Assessments were completed and are on-going by the ADON.
- Quality Assurance and Performance Improvement (QAPI) meeting was held and all required staff members were in attendance. Plan to continue the weekly audits and bring results to the monthly QAPI meetings for three months.
Deficiency in Meal Quality and Palatability
Penalty
Summary
The facility failed to provide palatable and properly prepared meals to its residents, as evidenced by multiple complaints and observations. Residents reported that the food was often hard, overcooked, and difficult to chew, with specific issues noted with pancakes, meat, and bread. For instance, Resident #2 and Resident #3 both reported that their pancakes were too hard to cut and eat, and Resident #5, who is the Resident Council President, mentioned that she often did not eat the food because it was not appetizing. Staff members, including a Registered Nurse and a Certified Occupational Therapy Assistant, confirmed the residents' complaints, noting that the food was often too tough and hard to chew, particularly for residents with dentures or no teeth. The District Dietary Manager acknowledged the issues with the food, attributing some of the problems to overcooking and leaving food on the steam table for too long. The Social Worker also confirmed that there had been numerous complaints about the food being cold and tough, and that the facility had experienced significant staff turnover in the dietary department. The report highlights that the facility's policy requires meals to be nourishing, palatable, and attractive, yet the observations and interviews indicate a failure to meet these standards. Residents with specific dietary needs, such as those with dysphagia, were particularly affected by the poor quality of the meals. Despite the presence of a new District Dietary Manager, the issues with meal preparation and palatability persisted, impacting the residents' satisfaction and nutritional intake.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 45 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ripley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rest Haven Health And Rehabilitation | 0 mi | ★★★★★ | 8 | 0 |
| Tippah County Nursing Home | 0.2 mi | ★★★★★ | 7 | 0 |
| Ashland Health And Rehabilitation | 13.9 mi | ★★★★★ | 2 | 0 |
| New Albany Health & Rehab Center | 16.6 mi | ★★★★★ | 0 | 0 |
| Union Co Health And Rehab Center, Inc | 18.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.