Inspection Reports for
Ravenwood Senior Living

19 CSR 30-86.022(7)(E) Locked Exit Doors: Observations, review and interview found the facility failed to ensure delayed egress locks were installed in accordance with requirements, more than one such device was located in an egress path, and required delayed egress signage was not present on the delayed egress door. This deficiency affected 14 of 35 residents.

19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Based on observation, review and interview the facility failed to maintain a complete sprinkler system and an Arbors kitchen sprinkler head showed corrosion, greasy substance, cobwebs/dust and other foreign material which may prevent operation as designed. This deficiency affected 14 of 35 residents.

19 CSR 30-86.047(46) Safe & Effective Medication System: Based on interview and record review, the facility failed to develop and implement a safe and effective medication control system. Staff could not account for discontinued medications and staff administered multiple doses after orders were discontinued.

19 CSR 30-88.010(26)(B) Restraints-Emergency/Protection - Authorized: Based on observation, interview, and record review, the facility failed to ensure the physician was contacted immediately to obtain an order for an emergency restraint and did not document required information following a staff member restraining a resident. The facility also lacked a policy regarding restraints.

19 CSR 30-88.010(29) Dignity/Privacy: Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity when one staff member cursed at and yelled a disrespectful name at a resident. Staff used profanity and disrespectful language during incidents.

19 CSR 30-86.047(19) TB Screen Residents & Staff: Based on interview and record review, the facility staff failed to ensure the required two-step tuberculosis screening test was administered timely for three of five sampled staff members (Cook A, Level One Medication Aide (L1MA) D, and Cook E).

19 CSR 30-86.047(34)(A) Disease/Infection Control, Report Category I: Based on observation, interview, and record review, the facility failed to follow infection control procedures regarding coronavirus disease 2019 (COVID-19) when staff did not wear face coverings or masks while providing care.

19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Observations, interviews, and record review showed refrigerator #2 had inconsistent and unsafe internal temperatures (internal readings up to 48°F with milk at 50°F) while staff relied on an outside thermometer and did not adequately monitor or validate internal refrigerator temperatures. The facility failed to ensure potentially hazardous food was stored at safe temperatures.

19 CSR 30-88.010(29) Dignity/Privacy: Interviews and record review showed the Dietary Manager hugged and kissed two residents against their preferences and was observed or reported to smell of alcohol or be intoxicated at work, making residents uncomfortable and prompting staff reports and corrective action. The facility failed to ensure residents were treated with consideration, respect and full recognition of their dignity and individuality.

19 CSR 30-86.022(10)(A) Hazardous Area Requirements: Surveyor found the facility failed to install or maintain smoke-resistant self-closing doors on all hazardous areas; the facility census was 43 and the deficiency potentially affected all 43 residents.

19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: Surveyor found the facility failed to install and maintain one-hour fire-rated smoke partitions, including an attic partition that was not finished and did not extend from outside wall to outside wall.

19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: Surveyor found the facility failed to inspect and maintain the sprinkler system in accordance with NFPA 25, including dry pendant heads over ten years old noted on an earlier annual inspection.

19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: Surveyor found the facility failed to use only metal, UL or FM fire-resistant rated wastebaskets and observed numerous plastic wastebaskets in resident rooms and common areas.

19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: Surveyor found open and exposed wiring, junction boxes without protective covers, and dead-end open wire not in approved junction boxes, indicating electrical wiring was not maintained in good repair.

19 CSR 30-86.032(21) Water Heater Requirements: Surveyor found missing or improper discharge piping and use of inappropriate plastic piping on temperature and pressure relief valves of water heaters, indicating water heaters were not equipped with properly installed relief valves and discharge piping.

19 CSR 30-86.047(13)(B) EDL Inquiry: Based on interview and record review, the facility failed to ensure the employee disqualification list (EDL) was checked for new employees, prior to contact with residents, for one (Level One Medication Aide (LIMA) A) of five sampled employees; LIMA A's personnel file lacked documentation of an EDL inquiry prior to starting work and an EDL inquiry was dated three months after hire.

19 CSR 30-86.047(47)(A) Physicians Orders Followed: Based on interview and record review the facility staff failed to transcribe the correct dose of a physician-prescribed medication, lorazepam, onto the resident's physician order sheet and Medication Administration Record (MAR), resulting in multiple administrations of the incorrect dosage to Resident #1.