Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ravenwood Specialty Care during CMS and state inspections, most recent first.
A resident dependent on staff for oral care due to multiple medical conditions did not consistently receive required oral hygiene assistance, as shown by gaps in documentation and confirmed by interviews with the resident, family, and DON. Facility policy required such care, but it was not provided as specified in the care plan.
The facility failed to properly store and label food items and served meals on dirty dishes. Observations revealed undated and unlabeled food in the refrigerator and dirty dishes used during meal service. A resident reported frequently receiving dirty dishes. The CDM acknowledged the need for proper labeling and dishwashing procedures.
A resident's code status was inconsistently documented across physician orders, EHR, and Care Plan, leading to a deficiency. The resident, with intact cognition, had expressed a desire for CPR, but the Care Plan incorrectly listed a DNR status. Staff interviews confirmed the expectation for consistent documentation, which was not met, resulting in a failure to honor the resident's advanced directives.
A facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to a resident with moderately impaired cognition and multiple diagnoses, including cancer and heart failure. The resident transitioned from Medicare Part A skilled services to an intermediate care level, but the required SNF ABN was missing from their clinical record. The Social Worker responsible for reviewing the SNF ABN confirmed it was not provided, and the facility lacked a policy for Medicare-required notices.
A facility failed to update the PASRR for a resident with a new PTSD diagnosis. The resident had moderately impaired cognition and was diagnosed with anxiety, depression, psychotic disorder, and PTSD, receiving antipsychotic and depression medications. The PASRR did not reflect the PTSD diagnosis, and no new evaluation was completed. The Social Services Coordinator admitted the oversight, and the DON noted the absence of a specific PASRR policy.
The facility failed to ensure the use of two CNAs when operating a full-body mechanical lift for transferring residents, as required by their care plans. Two residents with functional limitations experienced transfers with only one aide, despite the policy requiring two. Staff interviews revealed inconsistencies in policy adherence, with some staff performing transfers alone due to staffing shortages. The DON was reportedly unaware of these incidents, although staff claimed to have informed her.
A resident with severely impaired cognition did not receive perineal care according to standards, as observed when two CNAs failed to perform hand hygiene, used the same wipe for multiple areas, and did not change gloves between tasks. Interviews revealed inconsistencies in staff understanding of the facility's perineal care policy, which requires cleaning from front to back and changing gloves when moving from dirty to clean tasks.
A resident with severe cognitive impairment was prescribed Risperdal without the facility obtaining informed consent. Although the resident's wife was informed of the new medication, the facility did not discuss the risks or obtain consent. Interviews confirmed the lack of informed consent, and the DON acknowledged the absence of a policy for psychotropic medications.
Failure to Provide Consistent Oral Care Assistance
Penalty
Summary
A deficiency was identified when a resident, who was assessed as having intact cognition but was dependent on staff for oral care and eating due to medical conditions including hypertension, stroke, hemiplegia, anxiety, and depression, did not consistently receive oral hygiene assistance as required. The resident's care plan specified maximum assistance with oral hygiene, but documentation for multiple days in February and March showed no record of oral care being provided. Interviews with the resident confirmed that oral care was inconsistently performed, depending on which staff were on duty, and the family expected oral care after every meal. The DON confirmed that the facility's expectation was for oral care to be provided twice daily, but acknowledged that this was not consistently done according to the documentation reviewed. Observation further revealed that the resident had missing teeth and experienced gum bleeding during oral care, although no pain was reported. The facility's policy required that residents unable to perform activities of daily living independently receive necessary assistance, including oral hygiene, in accordance with their care plan and assessed needs. The lack of consistent oral care and incomplete documentation indicated a failure to provide the required assistance for activities of daily living for this resident.
Food Storage and Dish Cleanliness Deficiencies
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as well as maintain cleanliness in dishware used for serving meals. During an observation in the drink area refrigerator, several items were found to be improperly stored, including an open, undated, and uncovered piece of cherry pie, an undated and unlabeled plate with a prior day's meal, and unlabeled and undated items in a clear plastic container. Additionally, two juice pitchers were found without labels or dates. The Certified Dietary Manager (CDM) acknowledged that staff should have covered, dated, and labeled these items according to facility policy. During a lunch meal service, staff served meals on dirty dishes containing dried food particles. Staff A served fish, hashbrown casserole, and mixed vegetables on dirty plates, while Staff B served tomato soup in dirty bowls. A resident reported receiving a bowl of soup with a dirty rim and mentioned that receiving dirty dishes was a frequent occurrence. An observation of the clean dish caddy revealed it was dirty, with dishes containing food particles. The CDM confirmed that dishes should be sent back through the dishwasher if not properly cleaned, as per the facility's sanitization policy.
Inconsistent Documentation of Advanced Directives
Penalty
Summary
The facility failed to maintain consistent documentation of a resident's code status across various records, leading to a deficiency in honoring the resident's advanced directives. The clinical record review revealed that Resident #101, who had intact cognition as indicated by a BIMS score of 14, had conflicting code status information. The physician orders and a signed CPR declaration form indicated the resident desired CPR, while the Care Plan incorrectly documented a DNR status. This inconsistency was not aligned with the facility's policy, which required consistent Plans of Care reflecting the resident's treatment preferences. Interviews with facility staff, including the Director of Nursing and a Registered Nurse, confirmed the expectation for consistent advanced directives across the resident's physician orders, EHR, and Care Plan. Despite this expectation, the Care Plan for Resident #101 inaccurately reflected a DNR status, contrary to the resident's expressed wishes for CPR. The Director of Nursing acknowledged the discrepancy, highlighting a failure in the facility's process to ensure accurate and consistent documentation of advanced directives.
Failure to Provide SNF ABN to Resident
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS 10055 to a resident, identified as Resident #372, who was under review. The resident had a Minimum Data Set (MDS) assessment indicating moderately impaired cognition and required supervision or assistance for various activities. The resident had multiple diagnoses, including cancer, coronary artery disease, heart failure, diabetes mellitus, stroke, wound infection, and non-Alzheimer's dementia. Despite the resident's transition from Medicare Part A skilled services to an intermediate care facility level of care, the clinical record lacked the required SNF ABN. The Social Worker, identified as Staff B, acknowledged responsibility for reviewing the SNF ABN and the Notice of Medicare Non-Coverage (NOMNC) with the resident or their responsible family member. However, Staff B confirmed that they did not provide the SNF ABN to Resident #372. The facility's administrator expected all required notifications to be completed as mandated, but the facility did not have a policy for providing Medicare-required notices. This oversight was identified during a review of the resident's clinical records and staff interviews.
Failure to Update PASRR for Resident with New PTSD Diagnosis
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a new mental health diagnosis. The resident, identified as having moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12, had diagnoses of anxiety, depression, psychotic disorder, and post-traumatic stress disorder (PTSD). Despite these diagnoses and the administration of antipsychotic and depression medications, the resident's Level 1 PASRR dated 11/20/23 did not include the PTSD diagnosis, and no subsequent PASRR was completed. The Social Services Coordinator acknowledged missing the PTSD diagnosis on the PASRR and the need for a new evaluation. The Director of Nursing reported that the facility did not have a specific policy for PASRR, instead following general regulations.
Failure to Use Two CNAs for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure the use of two certified nursing assistants (CNAs) when operating a full-body mechanical lift for transferring residents, as required by their care plans. This deficiency was identified for two residents, both of whom had functional limitations and required total staff assistance for transfers. Resident #12, with a history of cerebrovascular accident and intact cognition, reported that often only one staff member operated the lift, despite the care plan specifying the need for two. Similarly, Resident #34, who had diagnoses including stroke with hemiparesis and morbid obesity, also experienced transfers with only one aide, although she expressed feeling safer with two staff members present. Interviews with staff revealed inconsistencies in adhering to the policy requiring two staff members for lift operations. Some staff members admitted to performing transfers alone due to staffing shortages or difficulty finding assistance, despite knowing the policy and the risks involved. Staff members expressed varying levels of compliance, with some refusing to operate the lift alone, while others admitted to doing so when unable to find help. The Director of Nursing (DON) was reportedly unaware of these incidents, although staff claimed to have informed her about the issue. The facility lacked a specific policy for the use of full-body mechanical lifts, relying instead on the manufacturer's instructions, which suggested that two caregivers might be necessary depending on the situation. The DON emphasized the requirement for two staff members during transfers and expressed frustration upon learning that staff claimed to have reported the issue to her. Despite the lack of reported incidents or injuries, the deficiency highlights a failure to consistently follow established procedures for resident safety during transfers.
Failure to Follow Perineal Care Protocols
Penalty
Summary
The facility failed to provide clean perineal care according to standards of practice for one resident, identified as Resident #65, who had severely impaired cognition and required total staff assistance for toileting hygiene. During an observation, two Certified Nursing Assistants (CNAs), Staff C and Staff D, were seen performing perineal care on Resident #65 without following proper hygiene protocols. They did not perform hand hygiene before donning gloves, and Staff D used the same disposable wipe to clean multiple areas without changing or folding it. Additionally, Staff D did not change gloves or perform hand hygiene after handling soiled items and before touching clean supplies. Interviews with staff members revealed inconsistencies in understanding and implementing the facility's perineal care policy, which directs staff to clean from front to back using a one wipe, one swipe method, and to change gloves and perform hand hygiene when transitioning from dirty to clean tasks. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the expectations for perineal care, which were not met during the observed incident. The facility's policy, revised in February 2018, outlines specific steps for washing and drying the perineal area, which were not adhered to by the staff involved.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of a psychotropic medication, Risperdal, for a resident with severe cognitive impairment. The resident, who had diagnoses of diabetes, Alzheimer's disease, depression, and anxiety, was prescribed Risperdal 0.25 mg twice daily. Although the resident's wife was informed of the new medication order, the facility did not discuss the associated risks or obtain informed consent. Interviews with the resident's family and staff confirmed that the facility did not complete the informed consent process. Additionally, the Director of Nursing acknowledged the absence of a policy for psychotropic medications and confirmed that the facility did not obtain informed consent for the medication in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waterloo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Village Retirement | 0.4 mi | — | 4 | 0 |
| Harmony Waterloo | 0.9 mi | — | 17 | 1 |
| Northcrest Specialty Care | 3.9 mi | — | 7 | 0 |
| Harmony House Health Care Center | 3.9 mi | — | 11 | 0 |
| Pinnacle Specialty Care | 4.9 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.