Inspection Reports for
Ravenwood Terrace Senior Living

19 CSR 30-86.047(28)(H) Individual Service Plan - Review Requirements: The facility failed to update one resident's (Resident #4's) Individualized Service Plan (ISP) after the resident sustained multiple falls with injuries. The resident's ISP contained no updates or new interventions added following the resident's falls.

19 CSR 30-86.022(10)(A) Hazardous Area Requirements: Observed hallway closets used for storage and/or water heaters missing trim around attic access creating an open gap between the attic and the closet in the Ravenwood building.

19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of: Observed a bed frame and mattress stored in a resident bathroom in the Arbors building, indicating unnecessary combustible storage.

19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements: Observed non-approved trash receptacles including a mesh metal trash can in one room and unapproved plastic trash cans in other rooms in the Arbors building instead of only metal or UL-/FM-fire-resistant rated wastebaskets.

19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: Record review and interview found the facility failed to have building wiring inspected every two years; the last electrical certification was February 21, 2023.

19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles: Observed multiple resident rooms with unapproved extension cords, power strips and mini-fridges plugged into power strips or adapters, creating electrical hazards in the Ravenwood building.

19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily: Based on observation, interview, and record review the facility failed to eliminate urine odors in Resident #1's room; observers found a trash can with a soiled adult diaper and a strong odor of urine throughout the room and from the bedding.

19 CSR 30-86.047(38) Assist to be Clean & Odor Free: Based on interview and record review the facility failed to ensure Resident #1 was groomed and free from odor; shower logs documented multiple refusals without adequate assistance or alternative offerings and observations showed the resident's hair and beard were long/unkempt with a very pungent urine odor.

19 CSR 30-86.047(51)A(X)(1) Schedule II Meds-Reconcile Each Shift, Record: Based on interview and record review, the facility failed to ensure inventories of Schedule II controlled substances were reconciled each shift, as staff did not initial or sign the Controlled Dosage System count sheets on numerous shift changes for multiple residents. The missing shift-change initials/signatures resulted in unavailable or unverified controlled substance counts for affected residents.

19 CSR 30-86.047(35) Protective Oversight: Based on observation, interview and record review, the facility failed to provide protective oversight to one resident identified at high risk for elopement who eloped through a window and walked to a nearby college campus. Records and interviews noted missing or removed window stoppers and inadequate staff monitoring.

19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected: Surveyor found the facility failed to have electrical wiring inspections performed every two years; the last inspection had expired and this affected all residents.

19 CSR 30-87.020(12) Floor Surfaces: Based on observation, interview and record review the facility failed to ensure the kitchen floor was clean. The surveyor observed dark debris along baseboards and door jambs, debris under cabinets and behind the refrigerator, and dark grease drips on the floor under the oven.

19 CSR 30-87.030(3) Clean Clothing, Hair Restraints: Based on observation, interview and record review facility staff failed to wear a hair restraint when in the kitchen. The inspector observed Dietary Staff A working with uncovered food and initially without a hair net.

19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: Based on observation, interview and record review the facility failed to protect food from potential contamination during preparation and service. Staff were observed leaving food uncovered on counters and handling and plating food with bare hands.

19 CSR 30-87.030(16) Food Storage-Not in Toilet Rm or Vestibule: Based on observation and interview the facility failed to ensure food was stored in a manner which protects it from contamination. Observations included large plastic buckets with lids not secured in a cabinet, a scoop left in a container, and open bags of dry cereal in storage.

19 CSR 30-87.030(65) Nonfood Contact Surfaces,Cleaned as Needed: Based on observation, interview and record review the facility failed to keep the oven, shelves and surfaces of cabinets clean. Observations included ovens with thick layers of dark grease and burned food debris, splattered and dirty refrigerator/ice machine surfaces, and grease drips on and under the oven.

19 CSR 30-86.047(36) Proper Care Per Individual Service Plan: Based on observation, interview and record review the facility failed to ensure one resident received care appropriate to their needs during transfers. Staff were observed transferring the resident without use of a gait belt and using unsafe pivot/lift techniques.