Diversicare of Ripley

Inspectors wroteBased on observation, resident and staff interviews, record review, staffing schedule review, and Payroll Based Journal (PBJ) staffing data report review, the facility failed to provide sufficient nursing staff to meet the needs of residents for six (6) of 119 residents and five (5) of 77 occupied rooms in the facility. This resulted in delayed call light response times, delayed toileting and incontinence care, and delayed assistance with activities of daily living for multiple residents, placing residents at risk for unmet care needs, skin breakdown, falls, and decreased quality of life. Resident #28, Resident #75, Resident #94, Resident #103, Resident #116, and Resident #122.

Inspectors wroteBased on staff interviews, record review, Payroll-Based Journal (PBJ) staffing data report review, and facility policy review, the facility failed to accurately submit staffing data into the PBJ system, in accordance with CMS (Centers for Medicare and Medicaid Services) reporting requirements, for one (1) of four (4) quarters reviewed (Fourth Quarter 2025, July 1 - September 30, 2025). Findings Include:Review of the facility policy titled Payroll Based Journal Entry Submission, unrevised, revealed under Policy: CMS (Centers for Medicare and Medicaid Services) regulations for Payroll Based Journal (PBJ) entries submission are adhered to. Record review of the PBJ Staffing Data Report revealed the facility submitted excessively low weekend staffing for the fourth quarter (July - September 2025). [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure concerns voiced during Resident Council meetings were addressed and resolved to residents' satisfaction in accordance with the requirements. Specifically, the facility failed to effectively respond to and resolve ongoing food-related concerns, including meals served cold and meats described as too tough to chew, which were repeatedly documented in Resident Council meeting minutes from August 2025 through December 2025, placing residents at risk for continued dissatisfaction for five (5) of six (6) months reviewed.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure medication carts were secured to prevent unauthorized access for two (2) of five (5) medication carts observed (A Wing and E Wing).

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to implement the comprehensive care plan for one (1) of 21 residents sampled. (Resident #111)Findings Include:Review of facility policy titled Care Plans with effective date: October 2021, revealed, Policy .Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Record review of Resident #111's Care Plan Report revised 12/10/25 revealed a Self-Care Deficit related to Mobility impairment, ROM (range of motion) limitations, Self-care impairment, related to spastic cerebral palsy, peripheral neuropathy, and spina bifida. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident who required assistance received activities of daily living (ADL) care, including grooming and personal hygiene services such as shaving, in accordance with the resident's assessed needs, for one (1) of 21 residents. (Resident #111) Findings Include:Review of facility policy titled ADLs (Activities of Daily Living), with an effective date of August 2021, revealed the facility policy is to ensure activities of daily living are provided in accordance with accepted standards of practice, the resident's care plan, and reasonable accommodation of the resident's choices and preferences. The policy further identified hygiene activities of daily living to include bathing, dressing, grooming, and oral care. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident received the necessary treatment and services to promote healing of a pressure wound for one (1) of two (2) pressure wounds reviewed. Resident #120Findings Include:Review of the facility policy titled Clean Dressing Change, unrevised, revealed under Guideline: It is the policy of this center to provide wound care in a manner to decrease the potential for infection and/or cross contamination. Physician's orders will specify the type of dressing and frequency of changes. Record review of Resident #120's wound measurements dated 2/4/26 revealed a Stage 3 pressure ulcer/injury to the sacrum measuring 1.41 centimeters (cm) in length, 1.24 centimeters (cm) in width, and 0.2 centimeters (cm) in depth. [...]

Inspectors wroteBased on observations, resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident was provided with the required adaptive equipment during meals for one (1) of four (4) residents reviewed for dining. Resident #33. Findings Include: Review of the facility policy titled Assistive Devices revealed under, Policy statement: Assistive devices/utensils will be provided as identified in the individualized plan of care to maintain or improve a resident's/patient's ability to eat or drink independently. An interview with Resident #33 on 2/8/26 at 4:10 PM revealed the resident required a divided plate to feed himself independently. The resident stated he did not always receive the divided plate with meals and further stated that when the divided plate was not provided, he was unable to feed himself using utensils. [...]

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to utilize enhanced barrier precautions while providing care for two (2) of five (5) care areas observed. Resident #5 and Resident #120. Findings Include: Review of the undated facility Infection Control Guide revealed that EBP refers to the expanded use of PPE (Personal Protective Equipment) and refers to the use of gowns and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's (Multidrug-Resistant Organism) to staff hands and clothing Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDRO's. [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure sufficient staffing in the dietary department to meet the nutritional needs of residents for eight (8) of 12 sampled residents (Resident #2, Resident #3, Resident 4, Resident #5, Resident #6, Resident #7, Resident #9, Resident #10.) Specifically, the facility did not employ adequate dietary staff to prepare and serve meals in a timely manner, resulting in residents receiving cold meals and prolonged delays during meal service.

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review, the facility failed to ensure the food was palatable and had an appetizing appearance for eight (8) of twelve sampled residents. Resident #2, Resident #3, Resident 4, Resident #5, Resident #6, Resident #7, Resident #9, and Resident #10 Findings Include: Review of the facility policy titled Food: Quality and Palatability with a revision date of 2/2023 revealed under, Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. An interview with the Regional Dietary Manager (RDM) #1 on 1/21/25 at 9:15 AM revealed the kitchen staffing continued to be the biggest concern for the dietary department. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to prevent the possibility of the spread of foodborne illness as evidenced by thawing meat at room temperature and using unsafe food handling practices for food preparation for one (1) of two (2) kitchen tours.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to submit accurate data into the Payroll Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. Fiscal Year Quater 2024 (July 1-September 30)

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a care plan for Activities of Daily Living) (ADL) care plan (Resident #8, #58, and #104) and for respiratory care (Resident #73) for (4) four of twenty-four care plans reviewed. Findings Include: Review of the facility policy titled, Care Area Assessment (CAA) Process and Care Planning, dated October 2024, revealed, under The RAI (Resident Assessment Instrument) and Care Planning: the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives, and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident#8 A record review of Resident #8's care plan titled; [...]

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to provide needed services for residents who were unable to carry out their Activities of Daily Living (ADL's) for three (3) of 23 sampled residents. (Resident #8, Resident # 58, and Resident #104) This was cited as a pattern due to a previous citation with the last Annual Recertification Survey 8/31/23. Findings Include: (Cross-reference F725) Review of the facility policy titled, ADL's (Activities of Daily Living) with effective date of August 2021 revealed Policy: Ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide dignity to residents, as evidenced by leaving indwelling urinary catheter bags and tubing uncovered for three (3) of eleven residents with a catheter reviewed. Resident #58, #99 and #103.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to ensure that oxygen tubing and an oxygen concentrator humidifier water bottle was changed as ordered for one (1) of eight (8) residents with oxygen observed.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide sufficient nursing staff to meet the resident's activities of daily living (ADL) needs for for three (3) of five (5) residents reviewed for ADLs. (Resident # 8, #55 and #104)

Inspectors wroteBased on observation, resident and staff interview, and record review the facility failed to ensure medications were stored appropriately and not left in the resident's room for one (1) of 23 sampled residents.

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review, the facility failed to provide a resident with alternative food items (Resident #59) and failed to honor a resident's food preferences (Resident #83) for two (2) of nine (9) residents sampled for dining services.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to keep kitchen trash properly contained and disposed of safely for one (1) of two (2) kitchen tours.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure that a comprehensive care plan was implemented for a dependent resident who was transferred via a mechanical lift using the wrong size sling which resulted in the sling breaking and causing the resident to sustain a fall with fracture for one (1) of three (3) residents reviewed. Resident #1. Based on implementation of corrective actions completed on 8/30/24 prior to the State Agency (SA) entrance on 9/11/24, it was determined to be Past Non-Compliance (PNC). Findings Included: Review of the facility policy, MDS (Minimum Data Set) and Care Plans with effective date of August 2019, revealed that care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review the facility failed to ensure the safety of a dependent resident during a lift transfer by using the wrong lift sling resulting in a strap on the sling breaking. Resident #1 fell to the floor and sustained fractures as a result of the fall for one (1) of three (3) residents reviewed for falls. Resident #1 Based on implementation of corrective actions completed on 8/30/24 prior to the State Agency (SA) entrance on 9/11/24, it was determined to be Past Non-Compliance (PNC). Findings Included: Review of the facility policy, Lift 4 Care - Safe 4 All dated May 2024, revealed under guideline, 7. In order to maintain patient's and residents' safety, patients and residents should be lifted or transferred by the lift and sling which is deemed appropriate after the lift evaluation is completed. [...]

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review the facility failed to provide meals that included palatable food for five (5) of five (5) residents reviewed. Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6. Findings Include: Record review of the facility policy titled, Dining and Meal Service with effective date of January 1, 2017, revealed .Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutritional and special dietary needs. Resident #2 On 09/11/24 at 8:25 AM, an interview and observation revealed Resident #2 sitting up in his bed in his room with his breakfast tray on his overbed table. He revealed that he had been at that facility about 18 months and stated, You don't need to ask me about the food here because it's not good. [...]

Inspectors wroteBased on interviews, record review and facility policy review the facility failed to protect the resident's right to be free from neglect as evidenced by failure of the staff to communicate and put measures in place to prevent the second elopement of Resident #1 who left the faciity on [DATE] unnoticed and unsupervised. Resident #1 was one (1) of three (3) residents reviewed. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement effective comprehensive care plan interventions for Resident #1 who was at risk for elopement. Resident #1 was one (1) of three (3) wandering residents reviewed. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. A local Police Officer was dispatched and found Resident #1 walking in the middle of the street approximately 1850 feet from the facility and she had no shoes and no coat on. [...]

Inspectors wroteBased on interviews, record review and facility policy review the facility failed to supervise and prevent the elopement of Resident #1 who left the faciity on [DATE] for the second time unnoticed and unsupervised. Resident #1 was one (1) of three (3) residents reviewed. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. A local Police Officer was dispatched and found Resident #1 walking in the middle of the street approximately 1850 feet from the facility and she had no shoes and no coat on. [...]

Inspectors wroteBased on interviews, record review and facility policy review the facility failed to monitor and implement a Quality Assurance (QA) program that prevented an elopement for Resident #1 who had previously eloped from the facility on 12/14/23 and continued to seek an exit from the building for one (1) of three (3) residents reviewed. Resident #1. Resident #1 was allowed to exit the facility on 01/07/24 unnoticed and unsupervised at an unknown time and was discovered to be missing from the facility at approximately 8:10 PM. On 01/07/24 at approximately 8:00 PM, the police department received a 911 call from an unknown bystander who had seen an elderly lady walking with no shoes on who appeared to belong to a nursing home. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement the plan of care for Resident #1 who was at risk for elopement. Resident #1 was one (1) of three (3) residents reviewed. The facility failed to provide supervision to prevent the elopement of Resident #1, who was a wandering risk. Resident #1 had a Care Plan that documented that she was at risk for elopement. Facility #1 did not provide the supervision as outlined in the care plan to Resident #1 to prevent her from eloping. Resident #1 left the facility unnoticed and unsupervised at an unknown time and was discovered by the staff at another nursing home (Facility #2) approximately 380 yards from the facility. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review the facility failed to supervise and prevent the elopement of Resident #1, who was assessed as an elopement risk and left Facility #1 through an unarmed door on 12/14/23 unnoticed. Resident #1 was one (1) of three (3) residents reviewed. The facility failed to provide supervision to prevent the elopement of Resident #1, who was a wandering risk. Res #1 walked 380 yards away from Facility #1 to Facility #2 and was discovered by staff at Facility #2 as Res #1 was attempting to get inside their building. Resident #1 left Facility #1 unnoticed and unsupervised at an unknown time. Facility #2 allowed the resident inside their nursing home and contacted Facility #1 at 9:04 PM to see if they had any resident missing and they discovered that it was Resident #1 and went to pick her up and return her to the facility. [...]

Inspectors wroteBased on observation, staff interviews and facility policy review, the facility failed to label food items in the refrigerator and freezer and failed to maintain a clean ice maker for one (1) of three (3) kitchen tours. Findings Include: Record review of the facility policy titled food storage with an effective date of 11/01/17 revealed under, Policy: It is the policy of this center to store, prepare and serve food that is stored in accordance with federal, state, and local sanitary codes. Also revealed under, Policy Interpretation and Implementation . 5. Foods will be labeled as to content and dated . Record review of the facility policy titled Ice Machines with an effective date of 9/01/14 revealed Purpose: To maintain dietary refrigeration equipment to preserve food at safe regulated temperatures. [...]

Inspectors wroteBased on observation, staff and resident interviews, and record review the facility failed to provide the correct size sling for a resident who needed to be transferred with a total lift (Resident #26) and to provide easy access to a resident's personal restroom (Resident #99) for two (2) of 121 residents reviewed for accommodations during the survey.

Inspectors wroteBased on observation, staff and resident interviews and facility policy review, the facility failed to ensure a resident resided in a clean comfortable homelike environment for one (1) of thirty residents reviewed.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure a resident admitted to the facility had an accurate Pre-admission Screen (PAS) to ensure the resident was appropriate for nursing home placement for one (1) of two (2) residents reviewed for Pre-admission Screening and Resident Review (PASARR).

Inspectors wroteBased on observations, staff interviews, record review and facility policy review the facility failed to develop and implement comprehensive care plans related to nail care for Resident #61 and #68 and failed to develop a smoking care plan for Resident #77 for three (3) of 33 care plans reviewed. Findings Include: Record review of the facility policy titled, Comprehensive Care Plan, dated 05/01/12, revealed, .Practice Guidelines:1. The Interdisciplinary care plan is implemented to guide health care center staff in necessary care and services to obtain the highest practicable physical, mental and psychosocial well-being of the resident .3. Interdisciplinary team communicates mental and psychosocial problems, needs, and concerns to the care planning team for inclusion in the overall plan of care . [...]

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review the facility failed to provide the necessary nail care for a resident as evidenced by long, thick, overgrown toe nails for two (2) of thirty residents on sample. Resident #61 and Resident #68. Findings Include: Record review of a typed statement on facility letterhead, undated, and signed by the Administrator revealed, (Formal Name of Facility) does not have a general ADL (Activities of Daily Living) Policy. Record review of a typed statement on facility letterhead and signed by the facility Administrator revealed, (Formal Name of Facility) adopted Clinical Nursing Skills and Techniques, [NAME] and [NAME] as a supplementary policy and procedure care guide. Category: Clinical. Effective Date: [...]

Inspectors wroteBased on observation, staff and resident interview and facility policy review, the facility failed to supervise and complete a smoking assessment for one (1) of three (3) residents who smoked. Resident #77. Findings Include: Record review of facility policy titled, Safe Smoking, dated 11/01/16, revealed, Purpose .2. To assess the ability to smoke and determine any measures needed to protect residents from possible self-inflicted injury during smoking. Procedure 1. Any resident who identified themselves as desiring to smoke will be assessed for safety related to smoking. This assessment will be reviewed and updated with any change of condition . On 08/30/23 at 9:33 AM, during an observation and interview, observed Resident #77 awake, lying in his bed. Observed a pack of cigarettes and a lighter laying on the bed side table in his room. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to label and date eye drops on one (1) of five (5) medication carts observed during medication administration for C Hall medication cart. Findings Include: Record review of Facility Policy, dated 04/22, titled Medication Storage, revealed, It is the policy .that medication storage complies with state and federal laws and regulations . Expired, contaminated, or deteriorated medications are immediately removed from stock and disposed of according to procedures for medication destruction and reordered from the pharmacy if a current order exists. An observation on [DATE] at 8:40 AM, during medication pass with Licensed Practical Nurse (LPN) #5, revealed the eye drops for Resident #10 were not dated on the bottle or box. The date the eye drops were filled from the pharmacy was [DATE]. [...]