A list of the most recent deficiencies for Ivy at Great Falls. 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? |
|---|---|---|---|---|
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2023-10-12 | 2023-11-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-10-12 | 2023-11-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-12 | 2023-11-26 | 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 | 2023-10-12 | 2023-11-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-12 | 2023-11-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-10-12 | 2023-11-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-12 | 2023-11-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-12 | 2023-11-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-12 | 2023-11-26 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-12 | 2023-11-26 | 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 | 2023-10-12 | 2023-11-26 | 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 | 2023-10-12 | 2023-11-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-12 | 2023-11-26 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-10-12 | 2023-11-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-12 | 2023-11-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-10-12 | 2023-11-26 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2023-10-12 | 2023-11-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-12 | 2023-11-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-10-12 | 2023-11-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-12 | 2023-11-26 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-17 | 2023-11-09 | 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 | 2023-10-17 | 2023-11-09 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-10-17 | 2023-11-09 | 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 | 2023-10-17 | 2023-11-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-17 | 2023-11-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-04-13 | 2023-05-15 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-04-13 | 2023-05-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-13 | 2023-05-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-13 | 2023-05-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-13 | 2023-05-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-13 | 2023-05-15 | 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 | 2023-04-13 | 2023-05-15 | N |
| Provide activities to meet all resident's needs. | Health | 2023-04-13 | 2023-05-15 | 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 | 2023-04-13 | 2023-05-15 | 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 | 2023-04-13 | 2023-05-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-13 | 2023-05-15 | 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 | 2023-04-13 | 2023-05-15 | 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 | 2023-04-13 | 2023-05-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-13 | 2023-05-15 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-04-13 | 2023-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-13 | 2023-05-15 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-18 | 2023-05-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-11 | 2023-02-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-13 | 2022-11-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-10-13 | 2022-11-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-13 | 2022-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-13 | 2022-11-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-10-13 | 2022-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-13 | 2022-11-22 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-10-13 | 2022-11-22 | N |
| Respond appropriately to all alleged violations. | Health | 2022-10-13 | 2022-11-22 | Y |
| 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 | 2022-10-13 | 2022-11-22 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Establish methods for sharing information. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-04 | 2022-11-18 | 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 | 2022-10-04 | 2022-11-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-04 | 2022-11-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-03 | 2022-08-31 | N |
| Report COVID19 data to residents and families. | Health | 2022-08-03 | 2022-08-31 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-03 | 2022-04-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-03 | 2022-04-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-03-03 | 2022-04-21 | Y |
| Meet other general requirements. | Fire Safety | 2021-12-15 | 2022-01-27 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-15 | 2022-01-27 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-12-15 | 2022-01-27 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-12-15 | 2022-01-27 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-09 | 2022-01-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-09 | 2022-01-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-09 | 2022-01-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-09 | 2022-01-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-09 | 2022-01-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-09 | 2022-01-07 | Y |
| 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 | 2021-12-09 | 2022-01-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-09 | 2022-01-07 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-09 | 2022-01-07 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-09 | 2022-01-07 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-12-09 | 2022-01-07 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-09 | 2022-01-07 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-12-09 | 2022-01-07 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-12-09 | 2022-01-07 | Y |
| 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 | 2021-12-09 | 2022-01-07 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-09 | 2022-01-07 | Y |
