Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Lauderdale Community Living Center during CMS and state inspections, most recent first.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not ensure that a CPR certified staff member was present at all times, as required by policy, with 16 out of 40 days lacking such coverage. This occurred despite a significant number of residents being Full Code and in need of immediate CPR if required. The DON confirmed that continuous CPR certified staff coverage was expected.
The facility did not ensure an RN was on duty for at least 8 consecutive hours daily on multiple occasions, and the DON's nursing license lapsed during the review period. Time sheet reviews and interviews confirmed gaps in RN coverage and a period when the DON did not have an active license, contrary to facility policy and regulatory requirements.
For 31 consecutive days, the facility did not post daily staffing sheets that included the actual hours worked by RNs, LPNs, and CNAs. Observations and interviews confirmed that the required information was missing from the posted sheets, and the DON acknowledged the omission.
The facility did not provide adequate dietary staff with the required competencies after the Dietary Manager was terminated, resulting in unsanitary kitchen conditions and insufficient food supplies, including the lack of a 3-day emergency food supply. The RD confirmed not knowing how to fulfill key job duties, and observations revealed multiple sanitation issues in the kitchen and storage areas.
The facility did not serve meals as listed on the posted menus for three consecutive days, instead making multiple substitutions due to lack of inventory. The RD confirmed that the posted menus should be followed to meet residents' nutritional needs, but necessary food items were unavailable, resulting in changes to main dishes, sides, and desserts for all residents receiving meals.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
The QAPI Committee did not identify or address ongoing issues with supervision, infection control, and staff competency. Meeting minutes were incomplete, and there was no evidence of infection control review. An LPN used a blood glucose meter on a resident, cleaned it improperly, and then prepared to use it on another resident without proper disinfection. There was no documentation of staff education on proper cleaning protocols, and supervisory audits were inconsistent or undocumented.
A resident with severe cognitive impairment and multiple medical conditions did not receive required care plan interventions for hydration and nutrition. Staff failed to ensure water was within reach, did not provide scheduled snacks, and did not offer necessary assistance during meals, as confirmed by observations and staff interviews.
A resident with severe cognitive impairment, as indicated by a low BIMS score and multiple diagnoses including dementia, was not provided with a care plan conference that included their family representative. Despite facility policy requiring family involvement for such residents, only the resident was invited to care plan meetings, and the family representative was not contacted or included.
The facility did not ensure that a resident received proper care for existing pressure ulcers and failed to implement adequate preventive measures to stop new ulcers from developing.
Nursing staff left an open and unattended razor on a bedside table next to a resident who was dependent on staff for personal hygiene and had a history of using objects to scratch their skin. Facility policy required immediate disposal of sharps, but this was not followed, as confirmed by both an LPN and the DON.
The facility did not ensure adequate nursing staff or maintain a licensed nurse in charge on each shift, as required by policy. On multiple days, staffing records showed insufficient RN and LPN coverage, with PPD nursing hours below expectations and no 24-hour nursing presence, as confirmed by the DON. The facility also received a low staffing rating and could not provide all requested timesheet documentation.
Staff failed to secure and properly store medications and biologicals, including leaving refrigerated medications at incorrect temperatures, not maintaining complete temperature logs, and leaving medication rooms and carts unlocked and unattended. These actions resulted in medications being accessible and potentially compromised.
Staff responsible for caring for residents with severe cognitive impairment did not receive required behavioral health or dementia care training. Multiple staff members, including CNAs and a housekeeper, confirmed they had not received formal training, and the facility's training system lacked dementia care modules. This deficiency was identified through medical record review and staff interviews involving residents with dementia and related diagnoses.
A resident with severe cognitive impairment and a history of wandering exited the facility through a malfunctioning, unsecured door without staff awareness. The door alarm did not sound, and the resident was later found outside with head injuries after traveling down an embankment. Staff were unaware of the elopement until notified by police, and subsequent inspection revealed multiple security and maintenance failures with exit doors and alarms.
The facility failed to securely store medications, with instances of medications left unattended in residents' rooms and an unlocked medication cart. Residents self-administered medications without proper authorization, and opened, undated, and expired medications were found in the storage room. Staff confirmed these actions were against policy.
The facility failed to maintain sanitary conditions in food preparation and serving areas, with issues such as a brown dried liquid on the oven door, carbon buildup on frying pans, and a rusted mesh skimmer. Wet nesting of steam table pans and a shiny film on the convection oven were also observed. The DM confirmed these issues, acknowledging the need for cleaning and replacement. The facility's cleaning policy was not followed, affecting meal service for 34 residents.
Two nurses failed to follow infection control practices during medication administration for two residents. An LPN did not perform hand hygiene before donning gloves, and an RN failed to clean a stethoscope after use, despite facility policies requiring these actions. The DON confirmed the necessity of these practices.
A facility failed to accurately assess a resident with wandering behavior, resulting in a deficiency. Despite the care plan identifying the resident as an elopement risk and wanderer, the quarterly MDS assessments did not reflect this behavior. Observations confirmed the resident's wandering, and interviews with the DON and MDS Coordinator acknowledged the oversight.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Ensure 24/7 Presence of CPR Certified Staff
Penalty
Summary
The facility failed to ensure that a staff member certified in Cardiopulmonary Resuscitation (CPR) was present in the facility at all times, as required by facility policy and necessary for the care of residents. Review of employee timesheets over multiple date ranges revealed that for 16 out of 40 days reviewed, there was not a CPR certified staff member working in the facility for the full 24-hour period. The facility census was 35 at the time of survey entrance, and a review of the Resident Status List showed that 30 out of 52 residents were listed as Full Code, indicating they would require CPR in the event of cardiac or respiratory arrest. During an interview, the Director of Nursing (DON) confirmed that a CPR certified staff member should be present at all times.
Failure to Maintain RN Coverage and Active DON License
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for 15 out of 54 days reviewed. This was identified through a review of facility policy, employee time sheets, and interviews. The facility's staffing policy requires sufficient numbers of staff with the necessary skills and competency to provide care and services for all residents. However, time sheet reviews revealed multiple dates where no RN was present for the required 8-hour period, and the facility was unable to provide additional documentation for those dates when requested. During interviews, the DON acknowledged that there should be an RN on duty daily and confirmed that her own time was sometimes manually entered when she covered RN shifts, but also noted she was off during one of the weeks in question. Additionally, the facility failed to ensure that the Director of Nursing (DON) maintained a current and active nursing license during the review period. A check of the State of Tennessee Department of Health Division of Health Licensure website showed the DON's license had lapsed, and the DON confirmed in an interview that her license had expired and was later renewed. These findings indicate lapses in both staffing and licensure compliance as required by facility policy and state regulations.
Failure to Post Actual Hours Worked on Daily Staffing Sheets
Penalty
Summary
The facility failed to post daily staffing sheets that included the actual number of hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) for a period of 31 consecutive days. Review of the posted daily staffing sheets from 7/12/2025 to 8/11/2025 showed that the required information was missing. Multiple observations in the facility's front entrance lobby on different dates confirmed that the posted sheets did not include the actual hours worked by each discipline. During an interview, the Director of Nursing (DON) acknowledged that the posted daily staffing sheets should have included this information, but the deficiency persisted throughout the observed period.
Insufficient Dietary Staffing and Poor Kitchen Sanitation
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skill sets to carry out the functions of the food and nutrition services after the Dietary Manager was terminated. Policy review indicated that support services staff, including dietary, are required to ensure resident needs are met. Observations over several days revealed the kitchen lacked standard cleaning schedules, with evidence of poor sanitation such as dried substances and loose particles on food containers, unclean stainless steel tables and storage racks, and a powdery substance on the floor and boxes in the dry storage area. The ice machine was also found with dried spills and white streaks both inside and outside. Interviews confirmed that the Dietary Department was operating without a Dietary Manager, and the Registered Dietitian (RD) admitted to not knowing how to perform the necessary job functions, including ordering adequate food supplies. The RD also confirmed the absence of a required 3-day emergency food supply, stating that the previous Dietary Manager would deplete this supply to compensate for insufficient regular food orders. The Administrator verified that the Dietary Manager had been let go due to lack of competencies and skill sets necessary for the role.
Failure to Serve Meals According to Posted Menus
Penalty
Summary
The facility failed to serve food items as listed on the posted menus for three consecutive days during the recertification survey. Review of the menus and direct observation revealed that the meals served did not match the planned menus for each day. On multiple occasions, substitutions were made due to the lack of necessary food items in inventory, as confirmed by the Registered Dietitian. For example, instead of serving beef ravioli, pork riblet, and cornmeal crusted chicken as planned, the facility served meat loaf, roast pork, and pulled pork, among other substitutions. Additionally, side dishes and desserts were also changed from what was originally posted. The Registered Dietitian confirmed that the posted menu should be followed to meet the nutritional needs of the residents, and acknowledged that the changes were made because the required food items were not available. The census at the time was 35, with all residents receiving meals that did not align with the posted menus. There is no mention of specific residents' medical histories or conditions in the report.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
QAPI Committee Failed to Address Infection Control and Supervision Deficiencies
Penalty
Summary
The QAPI Committee failed to identify and address ongoing quality deficiencies, including inadequate supervision, ineffective infection control practices, and lack of staff competency in resident care. Meeting minutes from April, May, and June 2025 showed blank or incomplete documentation, with no evidence of infection control review or nursing department oversight. The committee did not perform root cause analysis, develop corrective plans, or ensure implementation of systems to maintain acceptable standards. There was also a lack of clinical guidance and oversight for resident care policies and procedures. During direct observation, an LPN used a multi-use blood glucose meter on one resident, cleaned it with a hand sanitizing wipe not recommended by the manufacturer, and then prepared to use it on another resident without proper disinfection. The facility could not provide documentation of staff education on blood glucose monitoring or cleaning protocols prior to the incident. Interviews with the DON and Administrator confirmed inconsistent or undocumented supervision and audits, and the Medical Director had not participated in a QAPI meeting to discuss the Immediate Jeopardy event.
Failure to Implement Hydration and Nutrition Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for a resident with significant medical needs, including Alzheimer's Disease, dysphagia, diabetes, abnormal weight loss, and congestive heart failure. The resident was assessed as having severe cognitive impairment and required total assistance with eating. The care plan specified that the resident should have access to cool, fresh water at the bedside and receive snacks at 10:00 AM and 2:00 PM due to ongoing weight loss. Observations revealed that the water pitcher was repeatedly placed out of the resident's reach, and staff did not ensure the resident had access to water as required by the care plan. Additionally, staff did not provide the necessary assistance during meals, as a CNA set up the meal tray and encouraged the resident to eat but did not remain to provide further help or encouragement. The resident was also observed attempting to eat breakfast without staff present to assist, despite needing total assistance. Interviews with staff confirmed that the resident had not received the scheduled snacks and that the care plan interventions were not being followed as required.
Failure to Involve Family Representative in Care Planning for Cognitively Impaired Resident
Penalty
Summary
The facility failed to conduct a care plan conference with the family representative for one resident who was severely cognitively impaired. According to facility policy, residents and their family members are to be encouraged to participate in the development of the comprehensive assessment and care plan, and representatives are to be invited to care planning conferences. Medical record review showed that the resident was admitted with diagnoses including dementia, diabetes, hypertension, and COPD, and had a Brief Interview for Mental Status (BIMS) score of 4 or 5, indicating severe cognitive impairment. Despite this, the resident's family representative reported never being invited to a care plan meeting. Interviews with facility staff revealed that the Social Service Director considered the resident to be his own responsible party and stated that only the resident was invited to care plan meetings. However, the Director of Nursing confirmed that with a BIMS score of 5, the resident should not be considered their own responsible party and that the family should have been invited to participate in care planning. This failure to involve the family representative in the care planning process for a resident with severe cognitive impairment was identified through policy review, medical record review, and staff and family interviews.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not provided with adequate preventive care to avoid the formation of new pressure ulcers.
Unattended Razor Left at Bedside
Penalty
Summary
Nursing staff failed to provide an environment free from accident hazards by leaving an open and unattended razor on a bedside table next to a resident's bed. Facility policy requires that contaminated sharps be discarded immediately into designated containers, but this protocol was not followed. The open razor was observed during a room check, and both an LPN and the Director of Nursing confirmed that razors should not be left open and unattended. The resident involved had a history of cerebral infarction, PTSD, anxiety, diabetes, depression, and seizures, and was assessed as cognitively intact but dependent on staff for personal hygiene, including shaving. The resident's care plan noted a risk for behaviors related to using objects to scratch the skin, which had previously led to skin compromise. Despite these risks, the razor was left accessible at the bedside, contrary to facility policy and the resident's care needs.
Failure to Provide Sufficient Nursing Staff and 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents and to ensure a licensed nurse was in charge on each shift, as required by facility policy and federal regulations. Review of the facility's staffing policy indicated that licensed nurses and certified nursing assistants (CNAs) should be available 24 hours a day, with staffing levels determined by resident care needs. However, analysis of the CMS Payroll-Based Journal (PBJ) Staffing Data Report and employee timesheets for the second quarter of 2025 revealed that on eight separate days, the facility did not meet these requirements. Specifically, there were days when no Registered Nurse (RN) or Licensed Practical Nurse (LPN) was present for a full 24-hour period, and the per patient day (PPD) staffing hours were below expected levels. The facility also received a 1-star staffing rating and was unable to provide additional requested timesheet documentation for the identified dates. Interviews confirmed the deficiency, with the Director of Nursing (DON) acknowledging that a nurse should always be present in the facility. The census during the period in question ranged from 32 to 39 residents, and on the identified dates, the facility failed to provide the required 24 hours of nursing coverage. This lack of adequate staffing was directly observed through the review of timesheets and staffing data, and no additional information about specific residents' medical histories or conditions was provided in the report.
Failure to Secure and Properly Store Medications and Biologicals
Penalty
Summary
Facility staff failed to ensure proper storage and security of medications and biologicals as required by policy and professional standards. Refrigerated medications were found stored outside the recommended temperature range, with the medication refrigerator observed at 65°F due to an ajar door caused by ice buildup, and water was present on the refrigerator floor and on medications. The refrigerator contained various insulin products, Tuberculin Serum, and an emergency supply box with additional medications. Temperature logs for the medication refrigerator were incomplete and inconsistent for several months, with multiple days missing entries. The Director of Nursing confirmed that medications stored outside the recommended temperature range could be rendered ineffective and that temperature logs should be maintained daily. Additionally, two LPNs were observed leaving the medication room unlocked and unattended, with medications accessible and out of staff sight for several minutes on separate occasions. The medication cart in the B Hall was also found unlocked and unattended beside the nurses' station. Staff interviews confirmed that these actions were contrary to facility policy, which requires all medication storage areas to be locked and attended by authorized personnel at all times.
Failure to Provide Behavioral Health and Dementia Training to Staff
Penalty
Summary
The facility failed to provide required behavioral health training, specifically dementia care training, to staff responsible for residents with severe cognitive impairment. Medical record reviews showed that three residents with diagnoses including dementia, Alzheimer's disease, and other significant comorbidities were under the care of staff who had not received formal training in dementia management. The Minimum Data Set (MDS) assessments for these residents indicated severe cognitive impairment, with BIMS scores ranging from 3 to 6. Despite these residents' needs, the facility was unable to provide documentation of any behavioral health or dementia-specific training for its staff. Interviews with staff members, including CNAs and a housekeeper, confirmed the lack of formal dementia care training. One CNA reported receiving only informal guidance from another aide during orientation, while others stated they had not received any dementia training at all. The Regional Nurse acknowledged that the facility's computerized training system did not include dementia care modules, and confirmed the absence of such training for staff. This lack of training was consistent across both new and long-term employees, as evidenced by their statements during interviews.
Failure to Prevent Elopement Due to Malfunctioning Exit Door and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, hallucinations, and a history of exit-seeking and wandering behaviors eloped from the facility without staff knowledge. The resident was able to exit through an unlocked and unsecured door on C Hall that malfunctioned and did not trigger an alarm. The resident left his wheelchair at the door, traveled down a steep embankment, and was found on the ground near a two-way street by a passerby, having sustained head injuries that required hospital evaluation. At the time of the incident, the temperature outside was 37 degrees Fahrenheit, and facility staff were unaware that the resident had left the building until notified by local law enforcement. Review of facility policies indicated that residents at risk for wandering or elopement were to be monitored and necessary precautions taken to ensure their safety. However, documentation and staff statements revealed that the exit door alarm did not function properly, and the door had a history of malfunctioning for close to a year. Additionally, window alarms in a resident room near the exit were found to be nonfunctional during a subsequent facility tour, and other doors and hardware were observed to be in disrepair or not properly secured. Staff interviews confirmed that no alarm sounded when the resident exited, and the maintenance director acknowledged longstanding issues with the door's closure mechanism. The facility's failure to provide adequate supervision and maintain a secure environment resulted in the resident's unsupervised exit and subsequent injury. The incident was not immediately detected by staff, and the resident was only discovered after being found by a member of the public and reported to the police. The facility's lack of effective monitoring and failure to address known safety hazards with exit doors and alarms directly contributed to the resident's elopement and injury.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper and secure storage of medications, as evidenced by several observations and interviews. Medications were left unattended in residents' rooms, including a medication cup with 13 medications and 2 eye drops left on a resident's over-the-bed table by an LPN. Another resident was observed self-administering approximately 15 pills without proper authorization or assessment. Additionally, medications were left at the bedside of other residents, including a cream and wound cleanser, which were confirmed by staff to be against policy. Furthermore, a medication cart was left unlocked and unattended during administration, and the medication storage room contained opened, undated, and expired medications. A vial of Tuberculin was found opened and undated, and Osmolite nutritional supplements were opened and not discarded within the required timeframe. These findings indicate a failure to adhere to the facility's policies on medication storage and administration, as confirmed by interviews with the Director of Nursing and other staff members.
Sanitation Deficiencies in Food Preparation and Serving Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the food preparation and serving areas, as evidenced by several observations and interviews. The oven door was found to have a brown dried liquid on the glass and top, and there was a significant carbon buildup on three frying pans. Additionally, a rusted mesh skimmer was observed hanging with the frying pans. The Director of Food and Nutrition Services (DM) confirmed these issues during interviews, acknowledging the need for cleaning and replacement of the affected items. Further observations revealed that steam table pans were wet nesting on top of each other, which was confirmed by the DM as inappropriate. The top of the convection oven and its doors were also noted to have a shiny film, indicating a lack of cleanliness. The facility's policy on cleaning schedules, dated 8/31/2018, mandates that the Food and Nutrition Services staff maintain sanitation through compliance with comprehensive cleaning schedules, which was not adhered to in this instance. The facility had a census of 34 residents, all of whom received meal trays from the kitchen, potentially impacting their meal service.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to infection control practices during medication administration for two residents. Specifically, two nurses, an LPN and an RN, did not perform hand hygiene as required by the facility's policies. The LPN did not wash hands before donning gloves while administering medication to a resident with chronic kidney disease, polyneuropathy, anxiety, and depression. This oversight occurred despite the facility's policy mandating hand hygiene before and after direct contact with residents and before handling medications. Additionally, the RN failed to sanitize reusable equipment after exiting a resident's room with enhanced barrier precautions. The RN did not clean the stethoscope after checking the placement of a PEG tube for a resident with multiple diagnoses, including stroke, anemia, coronary artery disease, heart failure, hypertension, diabetes, hemiplegia, and seizure. The RN placed the stethoscope around her neck without cleaning it, only doing so after being prompted. The Director of Nursing confirmed that proper hand hygiene and cleaning of reusable equipment with a bleach wipe are required practices.
Failure to Accurately Assess Wandering Behavior
Penalty
Summary
The facility failed to accurately assess a resident with wandering behavior, leading to a deficiency in the accuracy of assessments. The facility's policy on Elopement/Unsafe Wandering Plan requires residents to be evaluated for unsafe wandering or elopement potential during each care planning review. Resident #32, who was admitted with diagnoses including cognitive deficits, vascular dementia, and Alzheimer's disease, was identified as an elopement risk and wanderer in the care plan. However, the quarterly Minimum Data Set (MDS) assessments did not reflect this behavior, as they indicated that wandering behavior was not exhibited. Observations over several days confirmed that Resident #32 was wandering aimlessly within the facility. Interviews with the Director of Nursing and the MDS Coordinator confirmed that Resident #32 was indeed a wanderer and should have been coded as such on the MDS.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
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) |
|---|---|---|---|---|
| Ripley Healthcare And Rehab Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Haywood Post Acute | 11.3 mi | ★★★★★ | 0 | 0 |
| Covington Post Acute | 14.1 mi | ★★★★★ | 9 | 0 |
| Magnolia Creek Nursing And Rehabilitation | 16 mi | ★★★★★ | 7 | 0 |
| Dyersburg Health And Rehabilitation Center | 23.3 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.