Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
53% occupied
Based on a February 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 2
Date: Feb 26, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction related to a facility inspection conducted on February 26, 2024.
Findings
The facility failed to ensure delayed egress locks were installed according to NFPA 101 standards and failed to maintain a complete sprinkler system free of corrosion and damage. These deficiencies affected 14 out of 35 residents.
Deficiencies (2)
19 CSR 30-86.022(7)(E) Locked Exit Doors: The facility failed to ensure delayed egress locks were installed in accordance with NFPA 101, and more than one such device was located in an egress path. Required signage was missing on the delayed egress door.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: The facility failed to maintain a complete sprinkler system free of corrosion and damage. Corroded sprinkler heads with green corrosion and foreign materials were observed and require replacement.
Report Facts
Facility census: 35
Residents affected: 14
Inspection Report
Plan of Correction
Census: 44
Deficiencies: 3
Date: Sep 1, 2023
Visit Reason
The inspection was conducted to investigate deficiencies related to medication administration, restraint use, and resident dignity/privacy at Ravenwood Assisted Living by Americare.
Findings
The facility failed to develop and implement a safe and effective medication system, failed to ensure proper handling and documentation of discontinued medications, failed to obtain timely physician orders for emergency restraints, and failed to ensure residents were treated with dignity and respect. The facility census was 44 at the time of inspection.
Deficiencies (3)
19 CSR 30-86.047(46) Safe & Effective Medication System. The facility failed to develop and implement a safe medication system as staff could not account for discontinued medications and administered multiple doses incorrectly.
19 CSR 30-88.010(26)(B) Restraints-Emergency/Protection - Authorized. The facility failed to ensure immediate physician orders for emergency restraints and lacked a restraint policy.
19 CSR 30-88.010(29) Dignity/Privacy. The facility failed to ensure residents were treated with dignity and respect as staff used profanity and disrespectful language toward residents.
Report Facts
Facility census: 44
Medication tablets missing: 110
Medication tablets delivered: 150
Medication tablets remaining: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amy R Phillips | Administrator | Signed plan of correction |
| DON J | Director of Nursing | Interviewed regarding medication administration and restraint policies |
| CMA B | Certified Medical Assistant | Interviewed regarding medication administration |
| CMA C | Certified Medical Assistant | Interviewed regarding medication administration and resident care |
| CMA D | Certified Medical Assistant | Interviewed regarding medication administration |
| CMA E | Certified Medical Assistant | Interviewed regarding medication administration and resident incident |
| CMA F | Certified Medical Assistant | Interviewed regarding resident incident |
| CMA G | Certified Medical Assistant | Provided written statement on medication administration |
| DON K | Director of Nursing | Interviewed regarding medication administration and narcotic destruction |
| DON L | Director of Nursing | Interviewed regarding medication orders and administration |
| Cook H | Dietary Cook | Involved in resident incident and cited for inappropriate conduct |
| Dietary Manager | Interviewed regarding resident treatment | |
| Medical Director | Interviewed regarding resident aggressive behavior |
Inspection Report
Plan of Correction
Census: 36
Deficiencies: 2
Date: Sep 1, 2022
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening requirements and infection control procedures, including COVID-19 protocols, at Ravenwood-Assisted Living by America.
Findings
The facility failed to ensure timely two-step tuberculosis screening for three of five sampled staff members and did not consistently enforce mask-wearing policies among staff during the COVID-19 pandemic. The facility census was 36 at the time of inspection.
Deficiencies (2)
19 CSR 30-86.047(19) TB Screen Residents & Staff: The facility staff failed to ensure the required two-step tuberculosis screening test was administered timely for three of five sampled staff members. The facility census was 36.
19 CSR 30-86.047(34)(A) Disease/Infection Control, Report Category I: The facility failed to follow infection control procedures regarding COVID-19 when staff did not wear face coverings or masks while providing care in a health care environment. The facility census was 36.
Report Facts
Facility census: 36
Sampled staff members: 5
Staff failing timely TB screening: 3
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 2
Date: Jun 3, 2021
Visit Reason
The inspection was conducted to assess compliance with food safety regulations and resident dignity/privacy standards following observed deficiencies and complaints.
Complaint Details
The complaint investigation substantiated that the Dietary Manager was intoxicated at work, kissed and hugged residents without consent, and created an uncomfortable environment for residents.
Findings
The facility failed to maintain proper food storage temperatures, with refrigerator temperatures exceeding safe limits. Additionally, the Dietary Manager engaged in inappropriate behavior towards residents, including intoxication and unwanted physical contact.
Deficiencies (2)
A7015: The facility failed to ensure staff stored food properly and did not adequately monitor refrigerator temperatures, resulting in potentially hazardous food being stored above safe temperature limits.
A8030: The facility failed to treat residents with dignity and respect when the Dietary Manager hugged and kissed residents against their preferences while intoxicated.
Report Facts
Facility census: 38
Inspection date: Jun 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Named in findings related to intoxication and inappropriate conduct with residents | |
| Administrator | Conducted temperature checks and involved in corrective actions | |
| Certified Medication Aide (CMA) A | Certified Medication Aide | Reported observations of Dietary Manager's intoxication and inappropriate behavior |
| Certified Medication Aide (CMA) B | Certified Medication Aide | Reported observations of Dietary Manager's intoxication and inappropriate behavior |
| Certified Medication Aide (CMA) C | Certified Medication Aide | Reported observations of Dietary Manager's intoxication and inappropriate behavior |
| Director of Nursing (DON) | Director of Nursing | Involved in investigation and reported incidents related to Dietary Manager |
Inspection Report
Life Safety
Census: 43
Deficiencies: 6
Date: Jan 9, 2019
Visit Reason
The inspection was a fire safety inspection conducted on January 9, 2019, to evaluate compliance with hazardous area requirements, smoke section partitions, sprinkler system maintenance/testing, wastebasket fire-resistance, electrical wiring, and water heater requirements.
Findings
The facility failed to meet multiple fire safety regulations including lack of self-closing doors on hazardous areas, missing one-hour fire-rated smoke partitions, failure to inspect and maintain the sprinkler system, use of non-fire-resistant wastebaskets, electrical wiring hazards, and improper water heater discharge piping. These deficiencies potentially affected all 43 residents present during the inspection.
Deficiencies (6)
19 CSR 30-86.022(10)(A) Hazardous Area Requirements: The facility failed to install or maintain smoke resistant self-closing doors on all hazardous areas. The sprinkler riser mechanical room door did not operate.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds: The facility failed to install and maintain one-hour fire-rated smoke partitions in the attic of the Arbors building.
19 CSR 30-86.022(11)(B) Sprinkler System Maintenance/Testing: The facility failed to inspect and maintain the sprinkler system according to NFPA 25, 1998 edition. The annual inspection report noted dry pendant heads over 10 years old.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: The facility used plastic waste baskets that were not fire-resistant in multiple locations including resident rooms and offices.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: The facility failed to maintain electrical wiring in good repair. Open wires without protective covers were observed in the attic.
19 CSR 30-86.032(21) Water Heater Requirements: The facility failed to ensure all water heaters had properly installed temperature and pressure relief valves and proper discharge piping.
Report Facts
Facility census: 43
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unknown Administrator | Administrator | Interviewed regarding awareness of fire safety requirements and deficiencies |
Inspection Report
Plan of Correction
Census: 42
Deficiencies: 1
Date: Nov 9, 2018
Visit Reason
The inspection was conducted to investigate compliance with employment screening requirements, specifically the Employee Disqualification List (EDL) inquiry for new employees prior to contact with residents.
Findings
The facility failed to ensure that the EDL was checked for new employees prior to resident contact. One sampled employee did not have documented EDL inquiry prior to starting work.
Deficiencies (1)
19 CSR 30-86.047(13)(B) EDL Inquiry: The facility did not document an EDL inquiry prior to a new employee starting work, violating the requirement to verify employee disqualification status before resident contact.
Report Facts
Facility census: 42
Inspection Report
Plan of Correction
Census: 41
Deficiencies: 1
Date: May 1, 2018
Visit Reason
The document is a plan of correction following a survey completed on 05/01/2018 at Ravenwood-Assisted Living by America. The visit was related to deficiencies found in medication orders and transcription errors.
Findings
The facility staff failed to transcribe the correct dose of Lorazepam prescribed by the physician for one resident, resulting in multiple instances of incorrect medication administration.
Deficiencies (1)
A4798 Medication Orders: The facility staff failed to transcribe the correct dose of Lorazepam prescribed for one resident, leading to multiple incorrect dosages administered.
Report Facts
Facility census: 41
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON A | Director of Nursing | Named in interview regarding responsibility for transcription of physician orders and medication errors |
Viewing
Loading inspection reports...
