Ripley Crossing

In the surveyor’s words

From the most serious findings on record at Ripley Crossing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 10, 2024

  Based 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. […]

• Actual harm, isolatedF689Dec 16, 2025

  Based 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)Findings include: A Health Status Note, dated 09/08/2025 at 11:17 A.M., indicated a nurse was pushing the resident in his wheelchair up to the front lobby to leave for a dialysis treatment. The resident's feet fell to the floor causing the resident to fall forward out of the wheelchair. The resident fell face first onto the floor and immediately began to bleed from the nose. The resident was assessed for injuries, and his nose was bleeding a large amount. […]

• No harm, potential for more than minimal, patternF921Oct 22, 2024

  Based 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) Findings include: During an interview and observation on 10/17/24 at 10:35 A.M., Resident 61 indicated the water was hot but she had never been burned. The resident was standing at the sink in her room combing her hair and was able to safely walk around her room unassisted. The water stream was too hot to keep a hand under the water flow without discomfort. […]

• No harm, potential for more than minimal, patternF761Aug 22, 2023

  Based 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) Findings include: 1. The medication cart on Wing 1 was observed on 08/21/23 at 3:42 P.M., with LPN 7. The top drawer of the cart contained several medication cups containing pills nested together. The LPN indicated it was medications for the 4:00 P.M. medication pass. The cups were labeled with the residents' initials only. She was unaware of the facility policy. […]

• No harm, potential for more than minimal, patternF812Aug 16, 2021

  Based on observation, interview, and record review, the facility failed to follow appropriate guidelines related to labeling food items and storing non-food items in the snack refrigerators for 5 of 5 refrigerators observed (Snack Refrigerators on Wing 4, 3, 2, 1, and 5); the use of hair nets in the kitchen, and food and utensil handling for 3 of 4 staff observations related to food serving. (Dietary Manager, QMA 17, and Activity Aide 4) Findings include: 1. During the initial tour of the kitchen on 08/09/21 at 10:08 A.M., the DM's (Dietary Manager) hair net was on the back of her head with six inches of her bangs exposed as she walked around the kitchen and into the walk-in refrigerator where there were trays of food prepared for the day's meals. […]