RAVENWOOD TERRACE ASSISTED LIVING.

PRINTED: 06/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X4} PROVIDER/SUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER (X2} MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED — 8B. WING 16411D 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 RAVENWOOD TERRACE-ASSISTED LIVING B) (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX | (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG | REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENGED TO THE APPROPRIATE DATE DEFICIENCY) A4755| 19 CSR 30-86.047(28)(H) Individual Service Plan A4755 - Review Requirements _ The facility may admit or retain an individual for _ residency in an assisted living facility only if the _ individual does not require hospitalization or | | Skilled nursing placement as defined in this rule, _ and only if the facility: | _ (H) Reviews the ISP with the resident, or legal _ representative of the resident, at least annually or : when there is a significant change in the resident ' . 8 Condition which may require a change in services; II | This regulation is not met as evidenced by: , Based on interview and record review, the facility | failed to update one resident's (Resident #4's), . Individualized Service Plan (ISP) after the | resident sustained multiple falls with injuries, of _ four sampled residents. The facility census was i _ Review of the Plan of Care/ISP dated 6/10/2019 | showed the Plan of Care/ISP for the resident | should be completed upon admission, _ readmission, change of condition and every six | months. The individualized plan of care is a | communication tool among caregivers and directs _ the care. 1. Review of Resident #4's face sheet showed _ the following: | “Resident admitted to facility on 8/23/24: _ Diagnosis included Alzheimer's disease, | dementia with mood disturbance, anxiety and i _ hypertension. Review of the resident's Community Based _ Assessment (CBA) dated 8/23/24, showed the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM GBIg CHY211 Hf continuation sheet 1 of 7 Q pol (yore NAME OF PROVIDER OR SUPPLIER Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 16411D RAVENWOOD TERRACE-ASSISTED LIVING BY (X4) ID PREFIX TAG A4755 (X2) MULTIPLE CONSTRUCTION A. BUILDING: B. WING MOBERLY, MO 65270 SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 following: -Resident dependent on staff for bathing and grooming; -Incontinent of bowel and bladder; -Independent with mobility, ambulates as desired all over building; -Resident confused to time, place and person. Review of the resident's Individual Service Plan.( ISP) dated 8/4/24, showed the resident at risk for falls and directed staff to monitor environment for wet spots or items placed below field of vision on floor. The ISP directed staff to keep call light close and answered promptly. Monitor for steadiness and balance. Instruct resident not to make sudden position changes. Review of the resident's Nurse Progress Notes showed the following: ~On 1/3/25 at 1:30 P.M., Certified Medication Aide (CMA) and dietary staff were in the front dining room when the resident took off in a dead sprint to the back of the building in the common area, When staff got back there, the resident had fallen and there was blood on the floor. The resident had quarter size laceration above the right eye and slight bruising underneath the eye. Fall happened at 8:15 A.M.. Director of Nursing (DON) and physician notified and resident sent to the Emergency Room (ER) for stitches above the right eye. Resident currently has urinary tract infection (UTI); -On 1/27/25 at 5:49 A.M., resident fell and this CMA notified on call nurse. Physician ordered to send resident to the hospital. (There was no documentation regarding any injury to the resident in the note); -On 2/19/25 at 4:48 P.M., resident found on floor bleeding from right side of head. Two CMAs assisted resident up into a chair and applied Missouri Department of Health and Senior Services STATE FORM 6899 CROSS-REFERENCED TO THE APPROPRIATE CHY2114 PRINTED: 06/02/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 05/20/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD PROVIDER'S PLAN OF CORRECTION (X5) {EACH CORRECTIVE ACTION SHOULD BE COMPLETE DATE DEFICIENCY) if continuation sheet 2 of 7 PRINTED: 06/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 464110 B.WING 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADORESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY} RAVENWOOD TERRACE-ASSISTED LIVING BY A4755} Continued From page 2 pressure to wound until bleeding stopped. Vitals taken, physician, family and hospice notified; -On 2/28/25 at 5:30 A.M., another resident came and told staff the resident had fallen outside his/her door. CMAs went and checked the resident and moved him/her to a chair. Vital signs taken. DON, family, and hospice notified. Review of the resident's CBA, dated 2/28/25, showed the following: -Resident dependent on staff for bathing and grooming; -Incontinent of bowel and bladder, -Independent with mobility, ambulates as desired all over building; -Resident confused to time, place and person. -Resident has been put on hospice this month (2/6/25), they come two times weekly or as needed. Resident ambulates all over facility. Resident has fallen and hit head, was sent out for sutures. Review of the resident's [SP dated 8/4/24, showed there were no updates or new interventions added after the resident's falls. Review of the resident's Nurse Progress Notes showed the following: -On 3/27/25 at 10:30 P.M. the resident came running out of his/her room and fell. Notified on call, hospice, and family member; -On 3/28/25 at 2:27 A.M., resident brought back to facility. The resident received six stitches in his/her forehead; -On 3/29/25 at 5:22 A.M., the resident had been up all night and was very anxious, as needed (PRN) medications given and not effective. Resident was very unsteady. At 12:00 A.M., the CMA went to check on the resident and found the resident on the floor. The CMA had another CMA Missouri Department of Health and Senior Services STATE FORM 6899 CHY211 If continuation sheet 3 of 7 PRINTED: 06/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 16411D B. WING 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) RAVENWOOD TERRACE-ASSISTED LIVING BY A4755 Continued From page 3 assist getting the resident up. The hospice nurse was notified and notified the resident's family member; -On 3/30/25 at 7:00 P.M., personal care attendant (PCA) in room heard a resident yelling someone was on floor. PCA and Certified Medication Technician (CMT) assisted the resident off the floor. Skin tear to back of right hand and a scrape on left knee. CMT dressed resident's right hand and PCA stayed with resident until the resident was ready for bed. Review of the resident's ISP dated 8/4/24, showed there were no updates reflecting the resident's falls or new interventions added after the resident's falis in March 2025. Review of the resident's Nurse Progress Notes showed the following: -On 4/2/25 at 4:55 P.M., the resident was seen out of the window fast paced walking. When the CMA got outside to check on the resident he/she was sitting on the ground; -On 4/6/25 at 5:10 A.M., the CMA went to get the resident ready for the day and found the resident on the floor. CMA checked for injuries and took vitals. Hospice and on call notified; -On 4/7/25 at 4:30 A.M., CMAs found the resident on the floor between bed and chair. Resident had a scrape that was bleeding on the outside of the left knee. CMA took vitals, got resident up and into bed. On call, hospice and family notified; -On 4/11/25 at 12:00 A.M., a staff member walked by and saw the resident on floor in back of the common area. Resident's forehead was lacerated, and the resident had a skin tear to the right wrist. Hospice notified and came to assess resident. Director of Nurses (DON), Administrator and family notified; -On 5/2/25 at 8:30 P.M., the resident was in bed Missouri Department of Health and Senior Services STATE FORM 6899 CHY211 if continuation sheet 4 of 7 PRINTED: 06/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xf) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER; A. BUILDING: COMPLETED 16411D B. WING 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES | PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) RAVENWOOD TERRACE-ASSISTED LIVING BY A4755| Continued From page 4 and CMA in med room when resident's camera caught a loud bang. Staff ran into resident's room and found the resident on the floor with a swollen area on his/her head. Review of the resident's ISP dated 8/4/24, showed no updates reflecting the resident's falls or new interventions added to address the resident's falls after multiple falls in April and May 2025. Review of the resident's Fall Risk Evaluation, dated 5/2/25, showed the following: -Resident had three or more falls in last six months; -Interventions put in place and added to ISP included communicated with physician and responsible party; -Resident cognitively impaired; ~Poor safety awareness, and mental status varied over the course of the day; -Interventions added to ISP include toilet schedule while awake, pain evaluation and frequent visualization of resident (none of these interventions were found on the resident's SP); -Staff to take resident to bathroom every 2 hours; -Resident ambulates with steady gait and no appliance; -Balance-No reported history at this time; -Resident score of 6 indicating moderate fail risk. Review of the resident's Nurse Progress Notes showed the following: -On 5/4/25 at 7:00 P.M., CMA saw on resident's camera the resident had fallen out of bed. CMA got resident up and checked for injuries. CMA took vitals contacted on call, hospice and family; -On 5/8/25 at 3:15 P.M., the resident was found outside laying on the ground. Voices no complaints of pain, some bleeding on forehead. Missouri Department of Health and Senior Services STATE FORM 6889 CHY211 If continuation sheet 5 of 7 PRINTED: 06/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULFIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER; A. BUILDING: COMPLETED 16441D B.WING 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 (X4) 1D SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) RAVENWOOD TERRACE-ASSISTED LIVING BY A4755| Continued From page 5 Resident was warm to the touch. Staff cleaned spot on resident's forehead and will continue to monitor. CMA called hospice and asked nurse to come out and assess resident. Hospice instructed staff to give resident 0.25 milliliters morphine liquid (opioid pain medication) and hydralazine (medication used to treat high blood pressure) due to raised blood pressure. Nurses put a dressing over the wound and would order extra wound supplies for the resident; -On 5/11/25 at 6:00 P.M., CMA was walking out of the medication room when he/she heard a loud thud come from the resident's room. The CMA and other staff went to the resident's room and found the resident on the floor. When staff got the resident up, they noticed the resident's head was bleeding through the bandage the resident had on. Hospice was contacted and was sending out a nurse to assess the resident. Family notified; -On 5/13/25 at 9:56 A.M., the resident had been laying in bed when staff heard a noise from the resident's room. The resident had fallen on the floor in his/her room. Staff assisted resident off the floor, hospice and family notified; -On 5/14/25 8:57 A.M., while passing medications, the CMA heard a loud noise and went down the hallway to the resident's room and found the resident laying on the floor by the maintenance room door. Staff notified the DON, hospice, on call, and family. Review of the resident's ISP dated 8/4/24, showed no updates reflecting the resident's falls or new interventions added after the resident's multiples falls in May 2025. During an interview on 5/20/25 at 3:55 P.M., CMA A said the resident waiked very fast and staff were directed to get the resident to slow down by having the resident sit and calm down. Missouri Department of Health and Senior Services STATE FORM 6899 CHY211 If continuation sheet 6 of 7 PRINTED: 06/02/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1} PROVIDER/SUPPLIER/CLIA (X2} MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 16411D B. WING 05/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) RAVENWOOD TERRACE-ASSISTED LIVING BY Continued From page 6 During an interview on 5/20/25 at 3:35 P.M., Resident #4’s family member said the resident has had several falls. The resident always seemed to hit his/her head when he/she fell. On 5/8/25 the resident went out the patio door and fell. The family member was not sure how long the resident was outside before staff found the resident. During an interview on 5/20/25 at 3:55 P.M., the DON said the resident walked fast, causing the resident to fall. Staff were directed to have the resident sit down when the resident walked fast to prevent the resident from falling and to notify hospice after each fall. On 5/8/25, facility staff notified her the resident was found outside the patio door on the sidewalk. Review of camera footage showed the resident was outside for a total of 30 minutes and the DON came to the facility to assess the resident. During an interview on 6/2/25 at 8:28 A.M., the Administrator said she was new to facility and unsure of the facility ISP policy. She would expect staff to update the resident's ISP after each fall. The Administrator said the Director of Nurses was responsible for completing the residents ISPs. Missouri Department of Health and Senior Services STATE FORM 6899 CHY211 If continuation sheet 7 of 7 PL A N O F C O R R EC T | ON Provider/Supplier Name: | Ravenwood Terrace Assisted Living by Americare Street Address, City, Zip: ) 1830 Ravenwood Drive Moberly Mo 65270 6/20/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER | 16411D 1D PREFIX TAG COMPLETION PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULO BE CROSS-REFERENCED 70 THE APPROPRIATE DEFICIENCY} DATE 7/3/2025 Facility will update Residents Individualized Service Plan, when Residents falls occur. A4755 Corrective Action for Resident Affected: 1. Resident # 4 's ISP was immediately reviewed and updated to reflect fall history, injury details, new interventions, and revised care needs. 2. The Director of Nursing, direct care staff, met to ensure that the plan of care address fall prevention and injuries 3. Fall risk assessment review is completed. 7/3/2025 Measurers to Identify and Correct incomplete or Outdated Plans: 1. The Director of Nursing/Program Manager conducted a comprehensive review of all current residents with a history of fails had appropriate and up-to-date care plan interventions documented. Any missing or outdated information was promptly revised to reflect current care needs. 1/3/2025 Changes to prevent Reoccurrence: 1. A Fall review checklist was implemented to be completed after every resident fall. This check list includes verification that: A. The Family responsible party was notified. B. Appropriate interventions has been evaluated C. The ISP has been reviewed and / or updated. D. Fall Risk assessment completed after 3 Falls in 30 days. 2. A progress note will be completed to document any falls, including weather an injury occurred or not, and to reflect all required notifications. 7413/2025 Monitoring Plan: 1. Adminstrator will Audit Residents with falls ISP 2x 7/3/2025 weekly to verify documentation accuracy, intervention, This will include documentation in progress note, boat athe’ Vink (olu/ 26 2. Findings from these audits will be corrected and discussed during weekly Manager meetings to evaluate compliance, identify patterns or recurring concerns, and determine any additional staff training or procedural changes that may be needed. : Education: 1. Director of Nursing and Program Manager attended the Virtual Training on incidents & ISP’s 7/3/2025 2. All staff were in serviced by DON on fall prevention, and notifications. A4755 DATE OF COMPLIANCE 7103/2025 | The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.

PRINTED: 02/27/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED eC B. WING 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 RAVENWOOD TERRACE-ASSISTED LIVING BY AMER (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A2256 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas Shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class II. Based on observation and interview on , 2/26/25 this facility fails to ensure hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. Facility census was | fourty (40). This deficiency affects twenty -one _ (21) of twenty-one (21) residentsin the Ravenwood building. Observation on 2/26/25 in the Ravenwood building found the hallway closets used for Storage and/or water heaters missing trim around attic access, allowing an open gap between the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM sid 6GKK11 If continuation sheet 1 of 5 arth Werer I 7/a0a% Ly Hb Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER RAVENWOOD TERRACE-ASSISTED LIVING BY AMER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) PRINTED: 02/27/2025 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED 02/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 19 CSR 30-86.022(10)(A) Hazardous Area Requirements Protection from Hazards. (A) In assisted living facilities and residential care facilities licensed on or after November 13, 1980, for more than twelve (12) beds, hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. In facilities equipped with a complete fire alarm system, the one- (1-) hour fire separation is required only for furnace or boiler rooms. Hazardous areas equipped with a complete sprinkler system are not required to have this one- (1-) hour fire separation. Doors to hazardous areas shall be self-closing and shall be kept closed unless an electromagnetic hold-open device is used which is interconnected with the fire alarm system. When the sprinkler option is chosen, the areas shall be separated from other spaces by smoke-resistant partitions and doors. The doors shall be self-closing or automatic-closing. Facilities formerly licensed as residential care facility | or Il, and existing prior to November 13, 1980, shall be exempt from this requirement. II This regulation is not met as evidenced by: Class Il. Based on observation and interview on , 2/26/25 this facility fails to ensure hazardous areas shall be separated by construction of at least a one- (1-) hour fire-resistant rating. Facility census was fourty (40). This deficiency affects twenty -one (21) of twenty-one (21) residentsin the Ravenwood building. Observation on 2/26/25 in the Ravenwood building found the hallway closets used for storage and/or water heaters missing trim around attic access, allowing an open gap between the Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 6GKK11 If continuation sheet 1 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER RAVENWOOD TERRACE-ASSISTED LIVING BY AMER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 1 attic and closet. During the interview on 2/26/25 at 12:00 P.M. with the maintenance director, he stated he would get the trim rehung to cover the openings. 19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of Protection from Hazards. (B) The storage of unnecessary combustible materials in any part of a building in which a licensed facility is located is prohibited. I/II This regulation is not met as evidenced by: Class II Based on observation and interview on 2/26/25, the facility failed to ensure protection from hazards by storing unnecessary combustible materials in any part of the building. The facility census was forty (40). This affected nineteen (19) of the nineteen (19) residents in the Arbors building.. Observation in the Arbors building found a bed frame and mattress being stored in resident room 14 bathroom. During an interview on 2/26/25 at 12:00 P.M with the maintenance director, he stated he was not aware the bed was in there and would get it removed. 19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements Trash and Rubbish Disposal. (A) Only metal or UL- or FM-fire-resistant rated Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 6GKK11 PRINTED: 02/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 2 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 RAVENWOOD TERRACE-ASSISTED LIVING BY AMER PRINTED: 02/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/26/2025 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE Continued From page 2 wastebaskets shall be used for trash. Il This regulation is not met as evidenced by: Class II Based on observation and interview on 2/26/25 the facility failed to use only metal or UL- or FM-fire-resistant rated wastebaskets. The facility census was forty (40) and this affected nineteen (19) of nineteen (19) residents in the Arbors building. Observation during the inspection of the Arbors building found a mesh metal trash can in resident room 5 and unapproved plastic trash cans in resident rooms 15 and 16. During an interview on 2/26/25 at 12:00 P.M. with the maintenance director, he stated he would get them all replaced with approved trash cans. 19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected In facilities that are constructed or have plans approved after July 1, 2005, electrical wiring shall be installed and maintained in accordance with the requirements of the National Electrical Code, 1999 edition, National Fire Protection Association, Inc., incorporated by reference, in this rule and available by mail at One Batterymarch Park, Quincy, MA 02269, and local codes. This rule does not incorporate any subsequent amendments or additions to the materials incorporated by reference. Facilities built between September 28, 1979 and July 1, 2005 shall be maintained in accordance with the requirements of the National Electrical Code, which was in effect at the time of the original plan approval and Missouri Department of Health and Senior Services STATE FORM oeee 6GKK11 DEFICIENCY) If continuation sheet 3 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER RAVENWOOD TERRACE-ASSISTED LIVING BY AMER (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) Continued From page 3 local codes. This rule does not incorporate any subsequent amendments or additions. In facilities built prior to September 28, 1979, electrical wiring shall be maintained in good repair and shall not present a safety hazard. All facilities shall have wiring inspected every two (2) years by a qualified electrician. II/III This regulation is not met as evidenced by: Class III Based on record review and interview on 2/26/25, the facility failed to have the buildings wiring inspected every two (2) years by a qualified electrician. The facility census for the main building was forty (40). This deficiency affects forty (40) of forty (40) residents. Record review for both The Arbors building and Ravenwood found that the last electrical certification was done February 21, 2023. During an interview on 2/26/25 at 12:00 P.M, the maintenance director stated he had them scheduled to come. 19 CSR 30-86.032(18) Extension Cords/Duplex Receptacles If extension cords are used, they must be Underwriters ' Laboratory (UL)-approved or shall comply with other recognized electrical appliance approval standards and sized to carry the current required for the appliance used. Only one (1) appliance shall be connected to one (1) extension cord and only two (2) appliances may be served by one (1) duplex receptacle. If extension cords are used, they shall not be placed under rugs, through doorways or located where they are Missouri Department of Health and Senior Services STATE FORM (X2) MULTIPLE CONSTRUCTION A. BUILDING: 6899 6GKK11 PRINTED: 02/27/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED 02/26/2025 STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 PROVIDER'S PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) If continuation sheet 4 of 5 PRINTED: 02/27/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) RAVENWOOD TERRACE-ASSISTED LIVING BY AMER Continued From page 4 subject to physical damage. II/Ill This regulation is not met as evidenced by: Class III Based on observation and interview on 2/26/25, the facility failed to insure that extension cords comply with electrical appliance approved standards. The facility census was forty (40). This deficiency potentially affected twenty-one (21) of the twenty-one (21) residents in the Ravenwood building. Observations during the inspection of the Ravenwood building found: Resident room 9 with two extension cords, One extension cord going to a power strip, as well as a mini fridge plugged into a power strip. Resident room 11 with a mini fridge plugged into a power strip. Resident room 16 with an unapproved extension cord. Resident room 19 with a mini fridge plugged into a power strip. Resident room 23 with a mini fridge plugged into a 6 way electrical adapter. During the exit interview on 2/26/25 with the maintenance director, he stated he would get them removed from the rooms and plug all mini fridge directly into the wall. Missouri Department of Health and Senior Services STATE FORM 6899 6GKK11 If continuation sheet 5 of 5 | PLAN OF CORRECTION Provi li orm suppiler Ravenwood Terrace by Americare Street Address, City, Zip: 1830 Ravenwood Drive Moberly Mo 65270 Date of Survey: 2/26/2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE The Facility Staff will ensure hazardous area shall be separated mas by construction of at least a one-(1-) hour fire-resistant rating. aueeee The alleged deficient practice has potential to affect all residents in Ravenwood building. Immediate correction as follows 1. Ravenwood building storage closet used for storage 4/11/2025 and/or water heater Missing trim around storage access is repaired closing the cap between attic and closet. The Adminstrator completed inspection of all Storage closets for evidence of open gaps between the attic and closets. 4/11/2025 2. None found The Adminstrator in-serviced ALL staff on this regulation. This included gaps in ceilings in all areas of building. = TUaeES Maintenance director will audit closets and other storage area 2x's weekly for duration of 8 weeks. 1x weekly on going. Admin 4/11/2025 will receive results of audits. All repair will be corrected immediately. — DATE OF COMPLIANCE 4/11/2025 The facility staff will ensure that unnecessary combustible A2257 ae! ; : : 4/11/2025 material is stored in a safe manor and in a proper location. The alleged deficient practice has the potential to affect all a ie 4/11/2025 occupants in the building. Corrective Action for the Identified Deficiency 1. The facility has immediately removed bed frame and mattress located in room 14 in Arbors building. 4/11/2025 2. Athrough inspection of the entire building was conducted to identify and eliminate unnecessa combustible material that pose fire hazards. None were found. 3. Staff has been instructed to report and remove any unnecessary combustible materials found in unauthorized storage areas. Measures to prevent recurrence 1. The Adminstrator sent letters to all families and responsible parties informing them of the deficiency and emphasizing the importance of not storing unnecessary items in residents’ rooms. 2. Storage rooms, residents’ areas and common space will be audit by Maintenance director 2x’s weekly for duration of 8 weeks. Than weekly on going. 4/11/2025 ] Adminstrator in serviced all staff on unnecessary storage of combustible material, this including location of storage and notifying residents family to pick up stored items. | —_~«ds DATE OF COMPLIANCE 4/11/2025 The facility staff will use mental UL-or FM-fire resistant rated A2286 wastebaskets for trash, to ensure compliance with fire safety standards (A2286 The alleged deficient practice has the potential to affect all occupants of building if trash is unproperly stored in 4/11/2025 wastebasket catches on fire. Corrective Action for the identified Deficiency 1. Arbors building room # 5 mesh metal trash can was removed from room. 2. Arbors resident room # 15 and 16 unapproved trash can was removed and replaced with approved wastebasket. 3. Acomprehensive inspection of Arbors and Ravenwood building was conducted to ensure no remaining nom- compliant waste baskets are in use. Measurers to prevent recurrence 1. The Adminstrator has informed all staff and residents families of the fire safety concern and the corrective action taken. Letters were mailed to family and responsible parties. 2. All staff in serviced on fire safety and importance of proper wastebaskets. 3. Audits will be conducted by Maintenance Director 1x’s weekly to ensure proper waste baskets are used in all areas of building this includes residents’ rooms. Wastebaskets that are found not approved standards will be removed immediately. 4. Results will be reported to administrator pe DATE OF COMPLIANCE 4/11/2024 4/11/2025 4/11/2025 The facility administrator will ensure to have the facility wiring inspection every 2 year by a qualified electrician. The alleged deficient practice has potential to affect all occupants if failed electrical wiring cause safety, and fire hazards to occupants of Arbors and Ravenwood building. Corrective Action for identified Deficiency 1. Ravenwood Terrace electrical wiring was inspection was completed by Mid-Missouri Electric on February 28 2025. 2. Arbors of Ravenwood Terrace electrical | wiring inspection was completed by Mid-Missouri on February 28 2025, Measure to prevent recurrence 1. Maintenance Director will Schedule electrical wiring inspection 8 weeks prior to time inspection is due to ensure inspection are completed by date due. 2. Maintenance Director was in serviced by Adminstrator on importance of all required inspection scheduling and completion of inspections in timely manner. 3. Adminstrator will audit all required inspection i2x monthly on going. 4. Adminstrator and Maintenance Director will review results of audit to ensure upcoming inspections are scheduled. 2/28/2025 |__| DATE OF COMPLIANCE 4/11/2025 | sd The facility will ensure that extension cords comply with electrical appliance approved standards. Alleged deficient practice affects all occupants of building by creating electrical hazards caused by un approved extension cords that don’t meet appliance electrical standards. Corrective Action for Identified Deficiency 1. Resident room # 9, extension cord and power strip were removed. Mini refrigerator was plugged into wall outlet. 2. Resident room # 11 power strip is removed, mini fridge is plugged into wall outlet. 3. Resident room # 16 extension cord was removed. 4. Resident room # 19 power strip was removed. Mini fridge is plugged into wall outlet. 5. Resident room # 23, 6-way electrical adapter is removed from room. Mini refrigerator is plugged into wall outlet. 6. Comprehensive inspection was done in both buildings this included storage closets other public area of building to ensure no other unapproved electrical cords are being used. 4/11/2025 urers to Prevent Recurrence The Adminstrator mailed letter to families and responsible parties electrical appliance cord standards A3219. 2. The Adminstrator and maintenance director in served all Staff of electrical cords and outlet extenders and approved power strips. 3. Adminstrator attended resident council to address the electrical appliance standards with residents in both buildings. 4. Maintenance will Audit residents’ rooms and other areas of building 2x weekly for a period of 4 weeks, then 1x weekly for 6 months. Maintenance director will report all findings to Adminstrator. 5. Electrical appliance during audit need to be removed immediately Meas 4, 4/11/2025 DATE OF COMPLIANCE 4/11/2025 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form. nt{e cet 317/20Q4H Uw Her

PRINTED: 01/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES {X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER A. BUILDING: COMPLETED C 16411D tthe rene 01/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) RAVENWOOD TERRACE-ASSISTED LIVING BY 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. HAN | This regulation is not met as evidenced by: Class II* Based on observation, interview, and record review, the facility failed to ensure urine odors in Resident #1's room were eliminated for one resident (Resident #1) of seven sampled residents. The facility census was 19. Review of Resident #1's face sheet showed the resident admitted to the facility on 10/5/23. | Review of the resident's physician's order sheet dated 10/5/23 showed the resident's diagnoses included fracture of the right femur (leg), and stroke. Review of the resident's individualized service plan dated 10/9/2023 showed the resident needed assistance with housekeeping including a weekly or more room cleaning, and the resident was totally dependent upon staff for housekeeping chores. Observation on 1/2/25 at 9:56 A.M. and 2:26 P.M., showed the following in Resident #1's room: _-The trash can located in the bathroom with a soiled adult diaper; -There was a strong odor of urine throughout the resident's room; -There was a strong odor of urine from the bedding on Resident #1's bed. During interview on 1/2/25 at 4:49 P.M. Housekeeper D said the following: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE TO STATE FORM 6899 S9ES11 If continuation sheet 1 of 5 fel GV PRINTED: 01/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED C 16411D B. WING 01/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) RAVENWOOD TERRACE-ASSISTED LIVING BY A3224 19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily Rooms shall be neat, orderly and cleaned daily. I/II This regulation is not met as evidenced by: Class II* Based on observation, interview, and record review, the facility failed to ensure urine odors in Resident #1's room were eliminated for one resident (Resident #1) of seven sampled residents. The facility census was 19. Review of Resident #1's face sheet showed the resident admitted to the facility on 10/5/23. Review of the resident's physician's order sheet dated 10/5/23 showed the resident's diagnoses included fracture of the right femur (leg), and stroke. Review of the resident's individualized service plan dated 10/9/2023 showed the resident needed assistance with housekeeping including a weekly or more room cleaning, and the resident was totally dependent upon staff for housekeeping chores. Observation on 1/2/25 at 9:56 A.M. and 2:26 P.M., showed the following in Resident #1's room: -The trash can located in the bathroom with a soiled adult diaper; -There was a strong odor of urine throughout the resident's room; -There was a strong odor of urine from the bedding on Resident #1's bed. During interview on 1/2/25 at 4:49 P.M. Housekeeper D said the following: Missouri Department of Health and Senior Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 S9ES11 If continuation sheet 1 of 5 PRINTED: 01/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED C 16411D B. WING 01/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) RAVENWOOD TERRACE-ASSISTED LIVING BY Continued From page 1 -He/She cleaned Resident #1's room every morning; -He/She and other staff reminded the resident to change his/her briefs prior to every meal; -The resident did not know when he/she was soiled; -The Maintenance staff had cleaned the carpet in Resident #1's one time a couple of weeks ago; -He/She used a lemon cleaner on the stained carpet on 11/2/22 and multiple other times to help with the odor. During interview on 1/3/25 at 3:33 P.M., the resident's family member said the following: -The facility contacted him/her the first of December in regard to the resident's refusal to shower; -They came for a visit shortly after the call from the facility; -There was a strong odor of urine that had permeated into the carpet and bedding on both beds in the room. During interviews on 1/2/25 at 1:52 P.M. and 3:00 P.M., the Director of Nursing said the following: -The resident refused to shower, urinates in his/her clothing and places the wet clothing on the carpet causing the carpet to become saturated with urine; -Housekeeping staff will shampoo the carpet frequently to try and eliminate the odor; -Staff remove the resident's clothing from the room and place it in the laundry room and wash it nightly to eliminate odor; -The Resident's bedding is washed daily and the plastic mattress cover is wiped down and disinfected every morning; - The Resident's wheelchair is taken into the shower every evening and washed and disinfected; Missouri Department of Health and Senior Services STATE FORM 6899 S9ES11 If continuation sheet 2 of 5 PRINTED: 01/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED C 16411D B. WING 01/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) RAVENWOOD TERRACE-ASSISTED LIVING BY Continued From page 2 -The facility staff has tried to address the carpet odors with little success. MO243155 *The higher classification merited due to the extent of the violation. 19 CSR 30-86.047(38) Assist to be Clean & Odor Free The facility shall encourage and assist each resident based on his or her individual preferences and needs to be clean and free of body and mouth odor. II This regulation is not met as evidenced by: Class II* Based on interview and record review, the facility failed to ensure one resident, (Resident #1) was groomed and free of odor for one of seven sampled residents. This had the potential to affect all residents. The census was 19. Review of Resident #1's medical record showed the resident admitted to the facility on 10/5/23. Diagnoses included fracture of the right femur (leg), and stroke. Review of the resident's individualized service plan dated 10/9/2023 showed the following: -Resident would shower two times weekly with staff assisting as needed with resident's back and legs. -Required some staff assistance with bowel/bladder, bathing and dressing. -Resident is alert and oriented and his/her own person; Missouri Department of Health and Senior Services STATE FORM 6899 S9ES11 If continuation sheet 3 of 5 PRINTED: 01/16/2025 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED C 16411D B. WING 01/02/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1830 RAVENWOOD MOBERLY, MO 65270 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) RAVENWOOD TERRACE-ASSISTED LIVING BY Continued From page 3 -Incontinent of urine. -The ISP did not address the resident's refusals to shower, or alternatives offered to showering. Review of the resident's shower log for December 2024 showed the resident was to be showered every Sunday and Wednesday. -On 12/1/24 12/3/24, 12/6/24, 12/8/24, 12/11/24, 12/14/24, 12/15/24, 12/22/24, 12/25/24, and 1/1/25 staff documented as refused; -Handwritten note located on the shower log dated 1/1/25 read, the resident requested shower after three on 1/1/25 and was not initialed; -Resident's shower sheets showed no documentation staff assisted the resident to shower from 12/1/24 through 1/1/25. The shower sheets only showed the resident's refusals to shower. Review of resident's progress note dated 12/29/24 showed the Resident refused to let staff change his/her clothes or bedding. There was no documentation staff offered or assisted the resident at a later time. Observation on 1/2/25 at 9:50 A.M. of Resident #1 showed the following: -The Resident's hair and beard were long and appeared unkempt: -The resident had a very pungent urine odor. During an interview on 1/2/25 at 3:00 P.M., Director of Nursing said the following: -She had seen Resident #1 in the shower a week prior, was unsure of the exact date; -He/She contacted Resident #1's family in early December due to the resident's constant refusal to shower; *The higher classification merited due to the Missouri Department of Health and Senior Services STATE FORM 6899 S9ES11 If continuation sheet 4 of 5 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 16411D WINS NAME OF PROVIDER OR SUPPLIER RAVENWOOD TERRACE-ASSISTED LIVING BY Lacey (X2) MULTIPLE CONSTRUCTION A. BUILDING: MOBERLY, MO 65270 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (x4) ID PREFIX TAG Continued From page 4 extent of the violation. MO243155 Missouri Department of Health and Senior Services STATE FORM 6899 CROSS-REFERENCED TO THE APPROPRIATE S9ES11 PRINTED: 01/16/2025 FORM APPROVED (X3) DATE SURVEY COMPLETED Cc 01/02/2025 STREET ADDRESS, CITY, STATE, ZIP CODE PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE (x5) COMPLETE DATE DEFICIENCY) If continuation sheet 5 of 5 PLAN OF CORRECTION Provider/Supplier Ravenwood Terrace Assisted Living Name: Street Address, ‘ 1830 Ravenwood Drive Moberly Mo 65270 City, Zip: Date of Survey: January 02 2025 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION COMPLETION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE A3224 The Facility will ensure Residents rooms are free from odors. 2-8-2024 The alleged deficient practice has the potential to affect all Residents rooms. Immediate correction as follows Resident # 1, Magic city Cleaning LLC cleaned and treated carpet for urine and odor. Resident # 1 bed mattress removed and replaced with new mattress and cover. Bathroom trash is free from soiled briefs. The Adminstrator Completed inspection of all residents’ rooms and common area for evidence of odors. 1. None found, The Adminstrator in-serviced ALL staff on this regulation. This included handling of soiled briefs, cleaning of carpets, and cleaning of mattress covers. Director of Nursing will audit residents’ room and bathroom for cleanliness, 5x’s weekly for durations of 6 weeks. 3x’'s weekly for 3 months. Admin will receive results of audits 5 weekly for 6 weeks and 3x’s weekly for 3 months. Rooms will be corrected at time of audit. To ensure cleanliness of room. CO Date of compliance 2-8-2025 CT A4779 The Facility staff will preform appropriate grooming and ensure residents are free from odor CT The alleged deficient practice has the potential to affect all Residents. a Immediate correction as follows: 1. Resident #1 received shower on 1/8/25, 1/14/25, 1/22/2025 Resident # 1 offered hair cut on 1-20-2025 — Resident stated will cut hair and beard on 4-2025 Resident # 1 hair and beard are free from odor. Resident wheel chair cleaned. The Director of Nursing preformed a audit on all residents to ensure they are groomed and free from odor. All residents are 2/8/2025 groomed and free from odor. Date of compliance 2-8-2024 a DON in serviced CMA , and direct care staff on proper documentation, refusal of care, and offering flexible shower and bath times. This Inservice included shaving. The Director of Nursing was in serviced by RNC regarding ISP including updating as need for residents needs as well as refusals. Notifications of PCP & family with hygiene and refusal of care. DON will audit Shower, hygiene and grooming to ensure residents are free from odors 5x's weekly. vane audits will be The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form. Jacl ace LVR.