Aegis Living at Ravenna

The facility had four violations related to fire safety documentation and maintenance: sprinkler testing records, means of egress obstructions, emergency generator maintenance documentation (weekly inspections, monthly load testing, and battery tests), and incomplete fire drill records for all shifts and quarters. Two violations were corrected on-site during the inspection (sprinkler testing and egress obstruction), demonstrating responsive action. The facility requires comprehensive documentation improvements for life safety systems but showed immediate corrective capability for physical violations, with a follow-up inspection scheduled within 37 days.

The facility failed its fourth consecutive fire and life safety re-inspection on 04/23/2025, indicating a pattern of systemic non-compliance with Office of the State Fire Marshal requirements affecting 65 residents. Multiple failed re-inspections demonstrate serious fire safety deficiencies that create substantial risk to resident safety in emergency situations. The facility's response has been inadequate, as evidenced by repeated failures to correct identified issues despite multiple opportunities, suggesting insufficient corrective action or remediation efforts. Citations were issued for failure to ensure OSFM compliance.

This residential care facility has demonstrated a persistent pattern of severe fire safety and life safety violations spanning eight months across five inspections (August 2024 through April 2025). Critical deficiencies include missing documentation for fire drills, sprinkler system testing, fire alarm testing, emergency lighting tests, smoke/CO detector testing, and fire wall inspections—all fundamental life safety systems. Additional violations included a missing ceiling tile compromising smoke barriers, potential elevator fire risk from burnt hydraulic oil smell, missing CO detector in gas appliance area, unsecured compressed gas cylinder, and storage blocking generator clearance. The facility's response has been inadequate, as evidenced by identical violations cited repeatedly across all five inspections with 'Disapproved' status at each visit, demonstrating failure to implement corrective actions despite multiple opportunities and escalating reinspection schedules.

The inspection identified two moderate violations: unsigned Negotiated Service Agreements for 4 of 9 sampled residents, placing them at risk for not receiving agreed-upon care, and improper food storage temperatures (46-50°F instead of required 41°F or below), creating food-borne illness risk. The facility promptly acknowledged both deficiencies and submitted corrective action plans with specific completion dates. A follow-up inspection on 03/31/2025 confirmed all deficiencies were corrected and the facility met licensing requirements, demonstrating effective remediation and compliance restoration.

The facility had multiple procedural violations affecting operational compliance but not immediate resident safety: incomplete background checks for 3 staff members, expired tuberculosis testing for 2 employees, failure to post recent inspection reports, unsecured resident medical records in common areas, and non-functioning ventilation in housekeeping closets with maintenance issues. The facility's response was adequate but reactive, with staff acknowledging deficiencies during the inspection and committing to corrections, though the violations indicate systemic gaps in monitoring compliance processes. No evidence of resident harm occurred, but the pattern of administrative oversights across multiple regulatory areas demonstrates insufficient internal quality assurance systems. The facility took immediate corrective action when issues were identified but lacked proactive compliance monitoring to prevent these lapses initially.

The May 2023 inspection found 12 violations, primarily related to missing documentation for required safety inspections and maintenance (fire drills, hood cleaning, fire door inspections, damper testing, emergency systems testing) and operational issues including multiple fire doors propped open throughout the facility. The facility demonstrated a good response by addressing all violations within the 3-month timeframe, as evidenced by the August 2023 follow-up inspection showing full compliance with approved status. While the violations were serious from a documentation and fire safety perspective, they were largely correctable procedural deficiencies rather than immediate life-safety threats, and the facility's timely remediation demonstrated adequate commitment to compliance and resident safety.

The facility had a moderate violation involving a caregiver working with an expired license, discovered during an investigation of unexplained bruising on a resident. The facility conducted a timely investigation into the bruising allegations which did not substantiate abuse or neglect, determining the injuries were likely from transfers by family, self-infliction, or recent falls. The facility's response was good overall, with a proper investigation completed and residents reporting they felt safe, though the expired license issue represents a compliance gap in credential verification processes.