Ripley Crossing

Inspectors wroteBased on interview and record review, the facility failed to follow appropriate safety measures when assisting a resident in their wheelchair, resulting in the resident falling and sustaining injuries that required hospitalization for 1 of 3 residents reviewed for accidents. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a change in a resident's condition for 1 of 20 residents reviewed for notification of change. (Resident 82)

Inspectors wroteBased on observation, interview and record review, the facility failed to identify a pressure ulcer in a timely manner for 1 of 3 residents reviewed for pressure ulcers. (Resident 1)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper placement of urinary catheter tubing and drainage bag for 1 of 3 residents reviewed for urinary catheters . (Resident 37)

Inspectors wroteBased on observation and interview, the facility failed to appropriately store medications for 1 of 3 medication carts reviewed. (Wing 2 Medication Cart)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control guidelines during a dressing change and touching the floor related to hand hygiene for 1 of 4 residents reviewed for infection control. (Resident B)

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide safe water temperatures between 100 degrees and 120 degrees Fahrenheit per the federal guidelines for 10 of 11 residents' bathroom water access observed. (Rooms 201, 301, 302, 303, 304, 307, 308, 402, 403, and 404)

Inspectors wroteBased upon record review and interview the facility failed to accurately to complete Minimum Data Set assessments for 3 of 18 residents reviewed. (Residents 5, 57, and 61)

Inspectors wroteBased on interview, observation, and record review, the facility failed to adequately monitor a dialysis access site for 1 of 1 resident that received dialysis treatments. (Resident 42)

Inspectors wroteBased on observation and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 5 residents reviewed for resident rights. (Resident F)

Inspectors wroteBased on record review and interview, the facility failed to ensure misappropriation of resident's medications did not occur for 3 of 5 residents reviewed for misappropriation. (Residents B, D, and E)

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure a shower bed was comprehensively inspected for safety or function by the Maintenance staff or by the CNA prior to its use, failed to ensure a resident was repositioned on a shower bed using two staff in accordance with the plan of care, and failed to ensure the resident was rolled toward the CNA providing care in accordance with the CNA training record for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B falling from a shower bed and sustaining a subdural hematoma with midline shift (a potentially fatal traumatic brain injury), a fracture of the left humerus (the largest bone of the upper extremity), and a facial laceration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident care equipment was in safe operating condition for two of two shower beds reviewed. (Wing 3 shower bed and Wing 4 shower bed)

Inspectors wroteBased on record review and interview the facility failed to ensure residents were free from verbal and emotional abuse for 2 of 3 residents reviewed for abuse. (Residents D and B)

Inspectors wroteBased on interview and record review, the facility failed ensure staff reported an allegation of abuse in a timely manner for 2 of 3 residents reviewed for abuse. (Residents D and B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed. (Wing 1 and Wing 3 medication carts)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure appropriate oversight of a resident's medication during 1 of 11 medication administration observations. (Resident 1) Findings Include: An observation of medication administration with RN 5, on 08/16/23 at 2:41 P.M., of Wing 4 indicated the RN prepared a cup of medications for Resident 1. The cup contained one Gabapentin 100 mg (milligrams) tablet and two Tylenol 325 mg tablets. The RN walked into the resident's room at 2:49 P.M. The resident was brushing her teeth in her bathroom and the nurse asked if she just wanted her medications left at the bedside to take at her convenience and the resident indicated, Yes. The RN left the medication cup on her over the bed table and exited the room. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the physician for a change in residents' condition related to the notification of weight changes for 2 of 5 residents reviewed for notification. (Residents 47 and 57)

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was initiated for a resident with an intravaginal device for 1 of 20 residents reviewed for care plans. (Resident 53)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow manufacturer's guidelines related to insulin pen usage for 1 of 11 residents reviewed for Quality of Care. (Resident 135)

Inspectors wroteBased on record review, interview, and observation, the facility failed to ensure a resident's safety during bus transport (Resident 15), follow and implement fall interventions (Resident 57) for 2 of 6 residents reviewed for accident hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to acknowledge a nutrition recommendation and document meal consumption for 1 of 2 residents reviewed for nutrition. (Resident 6)

Inspectors wrote3. Resident 44's clinical record was reviewed on 08/21/23 at 10:26 A.M. A Quarterly MDS assessment, dated 06/07/23, indicated the resident was severely cognitively impaired. The diagnoses included, but were not limited to, stroke, hypertension, anemia, diabetes, anxiety, and depression. A Consultant Pharmacy Communication to Nursing form, dated 05/23/23, indicated the resident's order from the recent hospital discharge was for Bupropion XL (An antidepressant). This medication was entered in the EMAR as Bupropion SR which was not the same dosage form. The response section of the form, signed by the DON and dated 05/25/23, indicated the medication had been changed to XL. The hospital discharge orders, dated 05/20/23, indicated the resident was to continue Bupropion XL (150 mg/24 hours) one oral tablet every 24 hours. The May 2023 EMAR included, but were not limited to the following orders: [...]

Inspectors wroteBased on observation and interview, the facility failed to follow appropriate infection control guidelines during medication administration for 1 of 11 residents observed. (Resident 57)