Deficiency Records for Ivy Creek Healthcare and Wellness Centre
Updated as of April 01, 2024
A list of the most recent deficiencies for Ivy Creek Healthcare and Wellness Centre. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-01-24 | 2024-02-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-24 | 2024-02-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-16 | 2023-12-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-29 | 2023-09-25 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2021-05-26 | 2021-07-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-26 | 2021-07-13 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2021-05-26 | 2021-07-13 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-26 | 2021-07-13 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-05-26 | 2021-07-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-05-26 | 2021-07-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-05-26 | 2021-07-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-26 | 2021-07-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-26 | 2021-07-13 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-05-26 | 2021-07-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-05-28 | 2021-07-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-05-28 | 2021-07-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-28 | 2021-07-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-05-28 | 2021-07-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-28 | 2021-07-01 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-05-28 | 2021-07-01 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-05-28 | 2021-07-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-01 | 2019-12-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-01 | 2019-12-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-01 | 2019-12-04 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide appropriate foot care. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-11-01 | 2019-12-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-01 | 2019-12-04 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-01 | 2019-12-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-01 | 2019-12-04 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-11-01 | 2019-12-04 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-11-01 | 2019-12-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-01 | 2019-12-04 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-11-06 | 2019-12-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-11-06 | 2019-12-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-06 | 2019-12-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-06 | 2019-12-02 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2019-11-06 | 2019-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-06 | 2019-12-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-11-20 | 2018-12-27 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-11-20 | 2018-12-27 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-11-20 | 2018-12-27 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-11-20 | 2018-12-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-11-20 | 2018-12-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-20 | 2018-12-27 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-11-08 | 2018-12-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-11-08 | 2018-12-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-11-08 | 2018-12-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-11-08 | 2018-12-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-11-08 | 2018-12-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-08 | 2018-12-14 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-11-08 | 2018-12-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-08 | 2018-12-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-11-08 | 2018-12-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-11-08 | 2018-12-14 | N |
