Ravenswood Village

Inspectors wroteBased on review of medical record, facility reported incident, policy review and staff interview the facility failed to ensure residents were free of significant medication errors. This happened when a nurse pre-poured medications for Resident #8 and mistakenly administered the medications to Resident #52. This affected one (1) of 44 residents. Resident Identifier: #52. Facility Census: 60. This state agency determined this deficient practice constituted immediate jeopardy at past noncompliance beginning 06/09/26. The facility implemented its removal plan and the Immediate Jeopardy was removed on 07/06/26.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure Resident #10 and Resident #22 had call lights within reach. This was a random opportunity for discovery during the Long-Term Care Survey Process. Resident identifiers: #10, #22. Facility Census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to protect residents from resident-to-resident physical abuse. This was true for one (1) of seven (7) residents sampled for abuse during the Long-Term Care Survey Process. Resident identifier: #68. Facility census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to revise the Preadmission Screening and Resident Review (PASARR) when residents were diagnosed with a new diagnosis after being admitted to the facility. This was true for three (3) of six (6) PASARRs' reviewed during the Long Term Care Process Survey. Resident Identifiers: #28, #1 and #42. Facility Census: 58. Findings Included: a) Resident #28 On 03/24/25 at 1:48 PM record review shows Resident #28 has a current medical diagnosis of dementia, anxiety, major depressive mood disorder and psychotic disorder with hallucinations. The Psychotic disorder with hallucinations was a new diagnoses after Resident #28 was admitted to the facility. There is an active order for Aripiprazole for targeted behavior(s) as evidenced by (AEB): auditory hallucinations and hears voices. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) contained all admitting diagnoses. This was true for three (3) of six (6) PASARRs' reviewed during the Long Term Care Process Survey. Resident Identifiers: #28, #14 and #1. Facility Census: 58. Findings Included: a) Resident #28 On 03/24/25 at 1:48 PM record review shows Resident #28 has a current medical diagnoses of dementia, anxiety, major depressive mood disorder and psychotic disorder with hallucinations. According to a list of medical diagnoses present on admission/readmission Resident #28 has a diagnosis of anxiety. According to the PASARR dated 09/24/24 which was provided by the facility, there is no indication of a diagnosis of Anxiety Disorder on the PASARR. [...]

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure residents were free from accident hazards by not having the janitor's closet locked, and completing smoking evaluations for Resident #17. This failed practice was a random opportunity for discovery and had the potential to affect a minimal number of residents residing in the Long Term Care Facility. Resident Identifier: #17 Facility Census: 58.

Inspectors wroteBased upon record review, staff interviews and policy review, the facility failed to ensure antipsychotic, antidepressant, antianxiety medications ordered by the physician had an appropriate diagnosis. This was found to be true in three (3) of five (5) records reviewed during the recertification survey. Resident identifiers: #42, #35, #45. Facility census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to complete the in-room refrigerator temperature logs and to monitor food for proper labeling of the date the food was placed in the refrigerator as stated in the Policy and Procedure #OPS192 Refrigerators: Patient In-Room. This was true for three (3) of four (4) in room refrigerators observed. Resident identifiers: #28, #17 and #1. Facility Census: #58. Findings Included: a) Resident #28 On 03/24/25 at 1:27 PM observation of the Refrigerator/Freezer Temperature Log form, which was located on the front of Resident #28's in-room refrigerator, found nine (9) out of twenty three (23) days had not had a temperature check. In addition, there was food items in the refrigerator that were opened and not dated. [...]

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to complete an accurate Minimum Data Set (MDS) regarding a diagnosis of Post Traumatic Stress Disorder (PTSD). This was found to be true for one (1) of 20 residents sampled in the recertification survey. Resident identifier: #42. Facility census: 58.

Inspectors wroteBased on record review and staff interview, the facility failed to provide Activities of Daily Living (ADL) care to dependent residents by not providing scheduled showers. This failed practice was found true for two (2) of seven (7) residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifiers: #210 and #39. Facility census 58. Findings Included: a) Resident #210 During the initial interview on 03/24/25 at 1:07 PM, Resident #210 stated, I have been here for a little over (2) two weeks and I have only had one (1) shower. A review of the shower schedule on 03/25/25 at 9:30 AM, revealed that Resident #210 was scheduled to receive showers on Mondays and Thursdays on the evening shift. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure it had a complete and accurate medical record related to diagnosis of Post Traumatic Stress Syndrome (PTSD). This failed practice was found true for two (2) of six (6) residents reviewed for unnecessary medications and mood/behavior during the Long-Term Care Survey Process. Resident identifiers: #210, and #42. Facility Census 58. Findings Included: a) Resident #210 A record review on 03/25/25 at 10:54 AM, of Resident #210's current diagnosis revealed a diagnosis of Post Traumatic Stress Syndrome (PTSD) on admission. Further record review revealed a PTSD care plan that read as follows: Focus: Resident exhibits or is at risk for distressed/fluctuating mood symptoms related to: Depression, PTSD, Personality Disorder. Goal: Resident will express anxieties/fears to staff through next review. Interventions: [...]

Inspectors wroteBased on resident and family interview, facility record review and staff interview, the facility failed to ensure there is sufficient qualified staff available at all times to meet the needs of the residents. This practice has the potential to affect more than a limited number of residents. Facility census: 60.

Inspectors wroteBased on observation and staff interview, the facility failed to provide food at a safe and appetizing temperature. This had the potential to affect more than a limited number of residents. Resident identifiers: #49, #16, #40, #4, #32 and #36. Facility census: 60.

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to make prompt efforts to resolve a grievance/concern and to keep the resident's representative notified of progress toward resolution. This was true for one (1) of three (3) grievances reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #4. Facility census: 60. Findings Included: a) Policy Review of the facility's Grievance/Concern policy, with a review date of 06/01/22, directs the facility will: -Contact the person filing the grievance/concern to acknowledge receipt -Investigate the grievance/concern -Take corrective actions, if needed -Notify the person filing the grievance of resolution within 72 hours b) Resident #4 During an interview on 03/13/23 at 11:11 AM, Resident #4 stated she was not able to hear very well without her hearing aid. [...]

Inspectors wroteBased on policy review, record review, and staff interview, the facility failed to ensure an allegation of neglect and a serious bodily injury were reported in a timely manner to the appropriate state agencies. The failure to make a timely report was true for one (1) of three (3) sampled residents with neglect concerns reviewed under reportables during the Long-Term Care Survey Process. Resident identifiers: #27 and #19. Facility census: 60.

Inspectors wroteBased on record review and staff interview the facility failed to ensure resident Minimum data sets were completed and accurately reflected the residents status. Resident #35 had three (3) MDS assessments which were in accurate under section (N) medications. Also for Resident #35 the nutritional Care Area Assessment (CAA) for nutritional status was not fully complete. For Resident #54 the facility failed to complete an accurate MDS in regards to the residents hospice status. This was true for two (2) of 19 sampled residents reviewed during the Long Term Care Survey Process. Resident Identifiers: #35 and #54. Facility Census: 60. Findings Included: A) Resident #35 1) Medications A review of Resident #35's medical record at 7:30 am on 03/15/23 found three (3) MDS with the following assessment reference dates 10/03/22, 01/03/23, and 03/03/23. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure Resident #19's care plan was implemented in the area of falls. This was true for one (1) of 19 sampled residents. Resident Identifiers: #19. Facility Census: 60.

Inspectors wroteBased on observation, staff interview and record review the facility failed to ensure Resident #31's neurological assessments were completed when there was bruise discovered to her right outer eye. In addition Resident #38 had a recommendation from a medical specialist which was not addressed with the attending physician and was not completed prior to surveyor intervention. This was true for two (2) for 19 sampled residents reviewed during the long term care survey process. Resident Identifiers: #31 and #38. Facility census: 60.

Inspectors wroteBased on resident/family interview, record review, and staff interview, the facility failed to assist a resident/resident representative in locating resources, as well as in making appointments, and arranging for transportation to replace a lost hearing aid. This was true for one (1) out of three (3) residents reviewed for grievances. Resident identifier #4. Facility census: 60.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure Resident #19's fall interventions were implemented; therefore, her environment was not as free from accident hazards as possible. This was true for one (1) of two (2) residents reviewed for the care area of accidents during the long term care survey. Resident Identifiers: #19. Facility Census: 60.

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #35 maintained acceptable parameters of nutrition. Resident #35 had abnormal lab values. In response to the lab values the physician ordered a low potassium diet. This order was never implemented by facility staff. This was true for one (1) of five (5) residents reviewed for the care area of nutrition during the long term care survey process. Resident Identifier: #35. Facility Census: 60. Findings Included: a) Resident #35 A review of Resident #35's medical record found a Comprehensive Metabolic Panel (CMP) dated 06/07/22 which indicated the residents potassium level was high at 4.7. A further review of the record found a nurses note dated 06/08/22 written at 12:04 PM which read as follows: Physician Notified (list name,date,time of notification): [...]

Inspectors wroteBased on observation and staff interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift. This was a random opportunity for discovery and had the potential to affect a limited number of residents and visitors wishing to view the information. Facility census: 60.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate medical record for one (1) of 19 sampled residents reviewed in the Long-Term Care Survey process. The facility failed to update a resident Physician Orders for Scope of Treatment (POST) form to reflect the name and contact number of the Hospice agency providing services to resident. Resident identifier: #54. Facility census: 60.

Inspectors wroteBased on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A nurse failed to use a barrier during medication pass and staff failed to change their gloves and sanitize their hands after incontinence care. This was a random opportunity for discovery and has the potential to affect a limited number of residents. Resident identifier: 16 and 55. Facility census: 60.

Inspectors wroteBased on observations and staff interview, the facility failed to maintain the walls in the residents' rooms. This was a random opportunity for discovery. Rooms identifiers: 301, 302, and 307. Facility census: 60.

Inspectors wroteBased on a random opportunity for discovery, through observation and interview, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records. Electronic medical records were left open and visible to those passing by in the hallway of the facility. This random opportunity for discovery. Resident identifiers: Residents #17, #6 and #33. Census: 56.

Inspectors wroteBased on record review, observation, staff and resident interview, the facility failed to provide resident-centered care and services, in accordance with preferences, goals for care and professional standards of practice to meet each resident's physical, mental, and psychosocial needs. This was true for five (5) of eighteen (18) residents reviewed during the Long-term Survey Process Survey (LTCS). For Resident #32, the facility failed to complete an accurate readmission assessment when resident was readmitted , this was true for areas of vital signs including weights and failure to assess and identify pressure ulcers, For Resident #22, the facility failed to follow physician orders for antiseizure medications and Resident #6 the orders for supervision while eating and the special utensils. [...]

Inspectors wroteBased on observation and staff Interview, the facility failed to ensure the facility was free from accident hazards over which it had control. The A-Hall medication cart was left unlocked and unattended on two (2) occasions, allowing access to medications by residents and unauthorized persons. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Facility Census: 56.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the attending physician documented in the resident's medical record that the consulting pharmacist's identified irregularities were reviewed and what, if any, action had been taken to address it. This was true for three (3) out of six (6) residents reviewed for unnecessary medications. Resident identifiers: #51, #34, and #19. Facility census: 56. Findings Included: a) Resident #51 A medical record review, completed on 01/25/22 at 1:45 PM, revealed the consulting pharmacist had completed a medication regimen review (MRR) on 03/05/21. The MRR outlined the following recommendation: -Recommendation: No indication requiring Protonix twice daily, please change to once daily. There was no evidence the attending physician had reviewed the pharmacist's consultation report. There was no physician response documented. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the transmission of communicable diseases and infections including COVID - 19. This was based on improper hand hygiene, wound care and catheter care. A Resident not being placed in transmission based precautions (TBP) per Center for Disease Control and Prevention (CDC) guidelines and visitation being denied. Facility Census 56. Resident Identifies # 30, #53, #32, #46 Findings Included: a) Medication pass On 01/25/22 at 9:24 AM, During medication pass this surveyor observed RN #51 use ABHR (Alcohol- based hand rub) over gloved hands to sanitize used gloves. RN # 51 then attempted to continue with medication pass but was stopped by this surveyor before touching medications. [...]

Inspectors wroteBased on observation, facility policy review and staff interview the facility failed to maintain the Resident #53's dignity by not pulling the curtain during a dressing change. This was a random opportunity for discovery . Resident Identifier # 53 Facility Census: 56. Findings Included: a) Resident #53 A review of the the Facility Policy titled: Wound Dressings: Aseptic No Touch with an effective date of 06/01/96 with a review date: 12/01/21, and a revision date: 12/01/21 found the following: . 7 explain the procedure and provide privacy. On 01/26/22 at 10:35 AM , the Assistant Director of Nursing (ADON) was observed providing wound care to Resident #53's wound on his buttocks. The ADON proceeded to address Resident #53 and explained the procedure. The ADON at this time undressed Resident #53 leaving the curtain open and Resident #53 vulnerable to the view of anyone entering the room. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure three (3) of 18 residents reviewed during the long-term care survey process had a Physician Orders for Scope of Treatment (POST) form completed per directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1). Resident identifiers: #19, #50, and #51. Facility Census: 56.

Inspectors wroteBased on record review, resident and staff interview, the facility failed to ensure one (1) of eighteen (18) sampled residents had Minimum Data Sets (MDS) which were not completed and/or inaccurately coded. The MDS for Resident #22, failed to reflect his cognitive patterns (section C), mood (section D), behaviors (Section E) and medication (Section N) these sections were incomplete and/or inaccurate. Resident identifier: #22. Facility census: 56.

Inspectors wroteBased on record review and staff interview the facility failed to implement a comprehensive care plan for the care area of nutrition. Resident #30's fluid output was not monitored as directed in the care plan. This was true for one (1) of 18 residents reviewed for care plan implementation. Resident Identifier # 30. Facility Census: 56 Findings Included: a) Resident # 30 A review of Resident #30's care plan with an initiated date of 01/03/22 reveals the following: A care plan focus that reads: Resident requires indwelling foley catheter 16fr (french) with 10 ml (milliliters) balloon The care plan interventions included: Monitor output for odor, color, consistency, and amount. On 01/25/22 at 2:25 PM, the DON acknowledged the care plan intervention stated the facility would document the amount of urine produced by Resident #30. [...]

Inspectors wroteBased on record review and staff interview the facility failed to revise the Resident #30's care plan in a timely manner regarding his wishes for end of life care. This was true for one (1) of 18 residents reviewed for care plan implementation. Resident Identifier # 30. Facility Census: 56. Findings Included: a) Resident # 30 A review of the [NAME] Virginia Orders for Scope of Treatment (POST) form dated [DATE] on file in Resident #30's medical record found the following: Section A is selected No CPR (cardiopulmonary resuscitation): Do Not Attempt Resuscitation. Further review of the medical record revealed a physician order dated [DATE] at 12:38 PM, which read do not resuscitate (DNR). A Physician Determination of Capacity dated [DATE] states Resident #30 lacks sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. [...]

Inspectors wroteBased on observation, resident interview, policy review, and staff interview, the facility failed to provide respiratory care and services consistent with professional standards of practice. The facility failed to change humidifier bottles every seven (7) days. The failed practice was true for two (2) of two (2) residents reviewed for respiratory care. Resident identifiers #34 and #19. Facility census: 56.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. This was true for one (1) of six (6) residents reviewed for unnecessary drugs. Resident Identifier: #51. Facility census: 56.

Inspectors wroteBased on observation and interview, the facility failed to ensure the residents were free from significant medication errors. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Census: 56. Resident identifier: Resident #6.

Inspectors wroteBased on observation and staff interview the facility failed to ensure food was stored in a safe and sanitary manner to prevent the spread of Food Borne illness. This failed practice had the potential to affect an isolated number of residents currently residing in the facility. The facility had outdated items stored in the facility's nutritional pantry. In addition the Refrigerator Temperature Log in the nutritional pantry was incomplete. Facility Census: 56. Findings Included: a) Initial Tour of the nutritional pantry During an initial tour of the nutritional pantry beginning at 11:43 am on 01/24/22 with the Certified Dietary Manager (CDM) the following issues were identified: -- One Gallon of Sweet Tea with the name of Resident #15 on it. The manufactured stamped expiration date was 11/12/21 and the tea was opened and a portion of the tea was gone. [...]