Ravenswood Village

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Jul 9, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF803Jul 9, 2026

  Based on observation, tray testing, menu and recipie review and staff interview the facility failed to ensure menus were followed for the preperation of fish and that food was palatable. This had the potential to affect more than an isolated number of residents. Facility census: 60.Findings included: a) On 07/08/26, a test tray was provided to the State Agency Surveyors for taste testing. The following items were served on the test tray: -Herb Roasted Fish-Dinner Roll-Gelatin Cubes with Whipped Cream-Garlic Seasoned Potatoes-Spring Vegetable Blend -Chicken Noodle Casserole Aside from the Chicken Noodle Casserole, which was a soup consistency, the food had very little taste. The recipe for the fish included several spices that were not apparent on the serving. […]

• No harm, potential for more than minimal, patternF809Jul 9, 2026

  Based on staff interview and resident interview the facility failed to ensure three (3) of 60 residents were served their dinner meal at a time that was comparable with the normal dinner service in the facility. Resident identifiers: #35, #9, and #48. Facility census: 60. Findings included: a) During an interview with Resident #35, at 7:15 PM on 07/07/26, she stated she was hungry.On 07/07/26 at 7:15 PM, Surveyors recognized that Resident#4, Resident #9, Resident #35, and Resident #48 had not yet been served their dinner meals.In an interview with Dietary Staff #71, at 7:35 PM, she stated the residents left the dining room and their meal tickets were put to the side where no one saw them until after 7:00 PM. […]

• No harm, potential for more than minimal, patternF842Jul 9, 2026

  Based on record review and staff interview, the facility failed to ensure complete and accurate medical records for Resident #25, Resident #30, Resident #34, Resident #64, and Resident #66. This was true for one (1) of three (3) sampled for hospitalization and four (4) of five (5) sampled for Activities of Daily Living during the Long-Term Care Survey process. Resident identifiers: #64, #25, #30, #34, and #66. Facility census: 60. Findings included: a) Resident #64 Review of the eInteract Hospital Transfer form, for the hospital transfer on 06/22/26, showed the date of transfer as 09/17/25 in multiple places on the form. In an interview with Director of Nursing (DON), on 07/09/26 at 9:05AM, she confirmed the dates were inaccurate on the hospital transfer form. […]

• No harm, potential for more than minimal, patternF644Mar 26, 2025

  Based 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. […]