Inspection Reports for
Diversicare of Ripley
101 Cunningham Drive, Ripley, MS, 38663
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
87% occupied
Based on a January 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 122
Deficiencies: 2
Date: Jan 21, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding food and nutrition services, specifically focusing on staffing adequacy and food quality.
Findings
The facility failed to ensure sufficient dietary staffing to meet residents' nutritional needs, resulting in cold meals and delayed service. Additionally, the food was often overcooked, tough, mushy, and unpalatable, causing dissatisfaction among residents.
Deficiencies (2)
F 0802: The facility failed to provide sufficient dietary staff to prepare and serve meals timely, resulting in cold meals and prolonged delays for eight of twelve sampled residents.
F 0804: The facility failed to ensure food was palatable, attractive, and served at a safe and appetizing temperature for eight of twelve sampled residents.
Report Facts
Resident census: 122
Sampled residents with deficiencies: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Dietary Manager #1 | Regional Dietary Manager | Reported staffing shortages and involvement in meal preparation |
| Regional Dietary Manager #2 | Regional Dietary Manager | New replacement manager, noted lack of steamer and food temperature issues |
| Administrator | Administrator | Discussed kitchen staffing transitions and efforts to address dietary concerns |
| Registered Nurse #1 | Registered Nurse | Reported resident complaints about food quality |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 11, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident fall caused by use of the wrong lift sling, and concerns about food quality and palatability for multiple residents.
Complaint Details
The complaint investigation was substantiated. Resident #1 fell due to use of the wrong lift sling which broke during transfer, causing fractures and actual harm. Multiple residents complained about food quality issues including tough, overcooked, and hard-to-chew meals.
Findings
The facility failed to ensure proper use of lift slings resulting in a resident fall with fractures and actual harm. Additionally, the facility failed to provide palatable, attractive, and safe meals for five residents, with multiple complaints about overcooked, tough, and hard-to-chew food.
Deficiencies (3)
F 0656: The facility failed to implement a comprehensive care plan for a dependent resident, resulting in use of the wrong size lift sling which broke and caused a fall with fracture. Corrective actions were implemented prior to survey.
F 0689: The facility failed to ensure safety during lift transfers by using the wrong lift sling, causing a resident to fall and sustain fractures. Corrective actions were completed prior to survey.
F 0804: The facility failed to provide palatable, attractive, and safe meals for five residents, with observations and interviews revealing overcooked, tough, and hard food that residents could not eat.
Report Facts
Residents reviewed for falls: 3
Residents reviewed for food palatability: 5
Resident #1 weight: 376.3
Lift sling weight ranges - blue sling: 275
Lift sling weight ranges - green sling: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in fall incident involving use of wrong lift sling |
| CNA #2 | Certified Nursing Assistant | Named in fall incident involving use of wrong lift sling |
| Administrator | Administrator | Interviewed regarding fall incident and corrective actions |
| Family Nurse Practitioner | Family Nurse Practitioner | Assessed Resident #1 immediately after fall |
| Director of Clinical Education | Director of Clinical Education | Educated staff on proper lift sling use and conducted audits |
| Assistant Director of Nursing | Assistant Director of Nursing | Verified lift sling guidelines and care plan compliance |
| District Dietary Manager | District Dietary Manager | Interviewed regarding food quality issues and improvement plans |
| Social Worker | Social Worker | Handled grievances related to food complaints |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following the elopement of Resident #1 who left the facility unnoticed and unsupervised on 01/07/24, posing immediate jeopardy to resident health and safety.
Complaint Details
The complaint investigation was triggered by Resident #1's elopement on 01/07/24, which was the second incident after a prior elopement on 12/14/23. The State Agency identified Immediate Jeopardy and Substandard Quality of Care beginning on 01/07/24. The facility submitted a Removal Plan and the Immediate Jeopardy was removed on 01/13/24.
Findings
The facility failed to provide adequate supervision and implement effective care plans to prevent Resident #1, diagnosed with Alzheimer's and Dementia, from eloping the facility twice. The facility also failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program to monitor and prevent such incidents.
Deficiencies (4)
F 0600 - The facility failed to protect Resident #1 from neglect by not preventing her second elopement on 01/07/24, which placed her and other residents at risk of serious injury or death.
F 0656 - The facility failed to develop and implement a comprehensive care plan with effective interventions to prevent Resident #1's elopement risk, despite her known wandering behavior and previous elopement.
F 0689 - The facility failed to provide adequate supervision and maintain a safe environment to prevent Resident #1's elopement on 01/07/24, despite prior knowledge of her exit-seeking behavior and unlocked kitchen door.
F 0867 - The facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program to monitor and prevent Resident #1's elopement, resulting in immediate jeopardy to resident safety.
Report Facts
Residents affected: 3
Temperature at time of elopement: 39
Resident vital signs: 135
Resident vital signs: 72
Resident vital signs: 75
Resident vital signs: 18
Resident vital signs: 96.8
Resident vital signs: 92
Distance resident found from facility: 1850
Time resident unaccounted for: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Witnessed Resident #1 wandering and last saw her before elopement |
| Administrator | Provided statements about elopement investigation and corrective actions | |
| Director of Nursing | DON | Provided statements about supervision, door locks, and staff in-service |
| Certified Nursing Assistant #1 | CNA | Reported Resident #1 wandering and assisted in search |
| Dietary Aide #1 | Dietary Aide | Observed Resident #1 entering kitchen and assisted her out |
| Dietary Aide #2 | Dietary Aide | Observed Resident #1 entering kitchen and passing out snacks |
| Police Officer | Found Resident #1 walking outside and returned her to facility | |
| LPN #2 | Licensed Practical Nurse | Documented Resident #1's wandering behavior and care notes |
| LPN #3 | Licensed Practical Nurse | Last staff to see Resident #1 before elopement and received resident from police |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan and monitoring failures |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding QAPI meetings and incident reporting |
| Senior Director of Clinical Operations | Provided training on abuse and neglect identification | |
| Director of Clinical Education | Initiated staff training on supervision and abuse/neglect | |
| Senior President of Operations | Educated Administrator on QAPI expectations and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 19, 2023
Visit Reason
The inspection was conducted following a complaint investigation triggered by the elopement of Resident #1, who was at risk for wandering and elopement, from the facility on 12/14/2023.
Complaint Details
The complaint investigation was substantiated. Resident #1, who had dementia and was at risk for elopement, left the facility unnoticed on 12/14/23 and was found at another nursing home 380 yards away. The facility failed to prevent the elopement due to a malfunctioning door alarm system and inadequate supervision.
Findings
The facility failed to implement the care plan and provide adequate supervision to prevent the elopement of Resident #1, who left the facility unnoticed and unsupervised. An Immediate Jeopardy (IJ) was identified due to the risk posed to Resident #1 and others. The IJ was removed after corrective actions were implemented between 12/14/23 and 12/15/23, including door repairs, staff in-services, and increased monitoring.
Deficiencies (2)
42 CFR 483.21(b)(1) - The facility failed to develop and implement a complete care plan that met Resident #1's needs to prevent elopement.
42 CFR 483.25(d)(1)(2) - The facility failed to provide adequate supervision and prevent the elopement of Resident #1 through an unarmed door unnoticed.
Report Facts
Residents reviewed: 3
Distance walked by resident: 380
Time resident unaccounted for: 45
Date of admission: Apr 14, 2017
Assessment Reference Date: Oct 27, 2023
Temperature at time of elopement: 52
Date of corrective action completion: Dec 15, 2023
Date Immediate Jeopardy removed: Dec 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Reported elopement and assisted in returning Resident #1 to facility |
| Certified Nursing Assistant #1 | CNA | Assisted in returning Resident #1 to facility and provided observations about the elopement |
| Administrator | Administrator | Interviewed regarding elopement and facility system failures |
| Maintenance Supervisor | Maintenance Supervisor | Reported malfunctioning door antenna and corrective actions taken |
| Director of Nursing | Director of Nursing | Initiated investigation, staff in-services, and corrective actions post-elopement |
| Executive Director | Executive Director | Notified resident's responsible party and reported elopement to state agency |
Inspection Report
Routine
Census: 121
Deficiencies: 8
Date: Aug 31, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide adequate resident accommodations such as proper sling availability and restroom access, failure to maintain a clean and homelike environment, incomplete pre-admission screening, inadequate care plan development and implementation, failure to provide necessary nail care, lack of supervision and assessment for smoking residents, improper medication labeling, and poor food storage and ice machine sanitation.
Deficiencies (8)
F 0558: Facility failed to provide the correct size sling for Resident #26 requiring total lift and failed to provide easy access to Resident #99's personal restroom due to hazardous waste containers blocking access.
F 0584: Facility failed to maintain a clean, comfortable, and homelike environment for Resident #99, including presence of sticky substances, trash, and unemptied urinals in the resident's room.
F 0645: Facility failed to ensure accurate Pre-admission Screening (PASARR) for Resident #1, omitting major mental illness diagnosis of Schizophrenia, resulting in no Level II screening.
F 0656: Facility failed to develop and implement comprehensive care plans related to nail care for Residents #61 and #68 and failed to develop a smoking care plan for Resident #77.
F 0677: Facility failed to provide necessary nail care for Residents #61 and #68, evidenced by long, thick, overgrown toenails.
F 0689: Facility failed to supervise and complete a smoking assessment for Resident #77 who smokes outside the facility premises.
F 0761: Facility failed to label and date eye drops on one medication cart, risking use of expired medication.
F 0812: Facility failed to label food items in refrigerator and freezer and failed to maintain a clean ice maker, with black substance observed inside ice machine door.
Report Facts
Residents reviewed for accommodations: 121
Residents reviewed for care plans: 33
Medication carts observed: 5
Kitchen tours conducted: 3
Urine volume in Resident #99's urinals: 900
Urine volume in Resident #99's urinals: 750
Urine volume in Resident #99's urinals: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) #1 | Confirmed only one blue sling available for Resident #26. | |
| Certified Nurse Assistant (CNA) #2 | Confirmed only one blue sling available for Resident #26. | |
| Laundry Staff #1 | Reported no quick washing of slings and no blue sling currently in laundry. | |
| Director of Nurses (DON) | Confirmed sling availability, care plan issues, and smoking assessment deficiencies. | |
| Licensed Practical Nurse (LPN) #2 | Confirmed only one blue sling available for Resident #26. | |
| Registered Nurse (RN) #1 | Confirmed only one blue sling available for Resident #26 and care plan issues. | |
| Administrator | Acknowledged sling shortage and food labeling and ice machine cleaning issues. | |
| Certified Nursing Assistant (CNA) #4 | Observed unemptied urinals and unclean room for Resident #99. | |
| Housekeeping | Reported cleaning schedules and challenges with Resident #99's room. | |
| Housekeeping Supervisor | Suggested increased cleaning frequency for Resident #99's room. | |
| Social Service Director | Confirmed inaccurate PASARR screening for Resident #1. | |
| Treatment Nurse | Confirmed nail care needs for Residents #61 and #68. | |
| Assistant Director of Nurses (ADON) | Confirmed care plan and smoking care deficiencies. | |
| Licensed Practical Nurse (LPN) #4 | Confirmed care plan not followed for nail care. | |
| Maintenance Supervisor | Reported ice machine cleaning routine and responsibilities. | |
| Dietary Manager (DM) | Reported unlabeled food items and unclean ice machine. | |
| Licensed Practical Nurse (LPN) #5 | Confirmed unlabeled eye drops and discard policy. |
Inspection Report
Routine
Deficiencies: 4
Date: Nov 10, 2021
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations including safety, respiratory care, medication storage, and infection prevention.
Findings
The facility failed to maintain a safe environment by leaving hazardous chemicals unsecured, improperly stored respiratory equipment, unlocked medication carts during administration, and inadequate infection control practices including poor hand hygiene and improper cleaning of shared equipment.
Deficiencies (4)
F 0689: The facility failed to provide a safe environment as a can of chemical disinfectant spray was found unsecured on an open linen cart during the survey.
F 0695: The facility failed to store nebulizer tubing properly and failed to date oxygen tubing for three residents, risking infection spread.
F 0761: Medication carts were left unlocked and unattended during medication administration on multiple occasions, risking resident safety.
F 0880: The facility failed to prevent infection spread by inadequate hand hygiene during meal distribution, improper cleaning of medication carts, ice scoops, and glucometers across multiple hallways.
Report Facts
Residents affected: 4
Residents affected: 3
Medication administration opportunities: 9
Hallways: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed about unsecured disinfectant spray on linen cart |
| CNA #3 | Certified Nursing Assistant | Confirmed chemical spray should not be on linen cart |
| Director of Nursing | Director of Nursing | Interviewed regarding chemical spray, oxygen tubing policies, medication cart security, and infection control |
| RN #1 | Registered Nurse | Observed leaving medication cart unlocked and improper glucometer cleaning |
| LPN #2 | Licensed Practical Nurse | Observed leaving medication cart unlocked and improper glucometer cleaning |
| CNA #4 | Certified Nursing Assistant | Observed failing to perform hand hygiene during meal tray distribution |
| LPN #1 | Licensed Practical Nurse | Observed cleaning glucometer improperly |
| CNA #1 | Certified Nursing Assistant | Observed improper ice scoop use and infection control practices |
| RN #2 | Supervisor | Interviewed about ice passing procedures |
Report
December 18, 2024
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