Ravenwood Specialty Care

In the surveyor’s words

From the most serious findings on record at Ravenwood Specialty Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 3, 2026

  Based on observation, clinical record review, emergency medical services (EMS) report review, hospital record review, and staff interviews, the facility failed to ensure door alarm response procedures and resident supervision to prevent elopement (leaving without permission) for 1 of 8 residents reviewed (Resident #23) for nursing supervision. Resident #23, required staff assistance of 1 person with ambulation and transfers, exited the facility undetected through an alarmed door, fell near a roadway, and sustained a subdural hematoma (blood collection between brain and skull), facial fractures, and lacerations (cuts) requiring hospitalization. The facility staff disarmed the sounding alarm and failed to account for the residents in the building for approximately 2 hours. […]

• Immediate jeopardy, isolatedF689Oct 5, 2022

  Based on clinical record review, staff and resident interviews and observations, the facility failed to provide adequate supervision to ensure the environment was as free of hazards as possible. Observation on 9/19/2022 at 9:55 am revealed 7 male residents on the B wing CCDI (Chronic Confusion or Dementing Illness) unit. Resident #18 had his breakfast tray in front of him with several bites gone. Tour of the entire unit at 9:55 am failed to reveal any staff member present on the unit. This failure resulted in Immediate Jeopardy to the health, safety and security of the 7 residents. The facility reported a total census of 122 with 7 male residents on the B Wing (CCDI) unit. […]

• Actual harm, isolatedF689Jun 18, 2026

  Based on clinical review, staff interview, family interview, facility investigation, incident report, hospital record review, and facility policy the facility failed to ensure safe handling of equipment during resident assistance which resulted with a hematoma, laceration, unnecessary pain, 3 units of blood, prolonged hospitalization, wound assessments, and wound care for 1 out of 3 residents reviewed (Resident #2). The facility reported a census of 137. Findings include:Resident #2's Clinical Census printed 6/15/26 listed an admission date of 6/6/26 and a discharge date of 6/9/26. The Care Plan Focus dated 6/8/26 related to Resident #2's activities of daily living. […]

• Actual harm, isolatedF684May 21, 2026

  Based on clinical record review, hospital record review, external clinic record review and staff interview the facility failed to assess a wound and document complete assessments for 1 of 4 residents reviewed (Resident #9). Resident #9 required emergency medical services including a foot amputation. The facility reported a census of 131 residents.Findings include:Resident #9's Minimum Data Set (MDS) dated [DATE] documented an admission date of 3/15/24. The MDS identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS had no documentation of rejection of care behaviors. Resident #9 didn't have bowel or bladder incontinence (loss of control). […]

• Actual harm, isolatedF689May 21, 2026

  Based on clinical record review, resident and staff interview and policy review the facility failed to provide an adequate intervention after a resident fell for 1 of 4 residents reviewed for falls (Resident #1). The facility used a mechanical lift to get Resident #1 off the floor and into his bed despite complaints of hip pain and not wanting to move his leg. Upon assessment, the hospital found a fracture in Resident #1's leg. The facility reported a census of 131 residents.Findings include:Resident #1's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 10/30/25 from home. The MDS identified a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS indicated Resident #1 had a fall since the prior assessment. […]