A list of the most recent deficiencies for Ivy Court. 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 care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-22 | 2022-01-17 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-22 | 2022-01-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-10-22 | 2022-01-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-22 | 2022-01-17 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-10-22 | 2022-01-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-22 | 2022-01-17 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-10-22 | 2022-01-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-22 | 2022-01-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-22 | 2022-01-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-22 | 2022-01-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-22 | 2022-01-17 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Use approved construction type or materials. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-05-07 | 2021-08-16 | 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 | 2021-05-07 | 2021-08-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-05-07 | 2021-08-16 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2020-03-06 | 2020-04-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-03-06 | 2020-04-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-03-06 | 2020-04-29 | N |
| Respond appropriately to all alleged violations. | Health | 2020-03-06 | 2020-04-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-06 | 2020-04-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-03-06 | 2020-04-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-06 | 2020-04-29 | 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 | 2020-03-06 | 2020-04-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-06 | 2020-04-29 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-03-06 | 2020-04-29 | N |
| Post nurse staffing information every day. | Health | 2020-03-06 | 2020-04-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-06 | 2020-04-29 | N |
| Ensure that residents are free from significant medication errors. | Health | 2020-03-06 | 2020-04-29 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2020-03-06 | 2020-04-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-03-06 | 2020-04-29 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2020-03-06 | 2020-04-29 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-03-06 | 2020-04-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-03-06 | 2020-04-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-06 | 2020-04-29 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-02-25 | 2020-04-23 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-02-25 | 2020-04-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-02-25 | 2020-04-23 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-02-25 | 2020-03-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-25 | 2020-03-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-25 | 2020-03-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-25 | 2020-03-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-25 | 2020-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-25 | 2020-02-27 | 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 | 2018-11-09 | 2019-04-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-09 | 2019-04-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-09 | 2019-04-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-11-09 | 2019-03-04 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-11-09 | 2019-03-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-11-09 | 2019-03-04 | N |
| Respond appropriately to all alleged violations. | Health | 2018-11-09 | 2019-03-04 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-11-09 | 2019-03-04 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-11-09 | 2019-03-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-11-09 | 2019-03-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-09 | 2019-03-04 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-11-09 | 2019-03-04 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-11-09 | 2019-03-04 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2018-11-09 | 2019-03-04 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-10-23 | 2018-12-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-10-23 | 2018-12-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-10-23 | 2018-12-20 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-23 | 2018-12-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-10-23 | 2018-12-20 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-10-23 | 2018-12-20 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-10-23 | 2018-12-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-10-23 | 2018-12-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-10-23 | 2018-12-20 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-11-09 | 2018-12-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-09 | 2018-12-14 | N |
| Post nurse staffing information every day. | Health | 2018-11-09 | 2018-12-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-11-09 | 2018-12-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-11-09 | 2018-12-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2018-10-23 | 2018-11-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-10-23 | 2018-11-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-10-23 | 2018-11-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-23 | 2018-11-13 | N |
