A list of the most recent deficiencies for Ivy at Deer Lodge. 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? |
|---|---|---|---|---|
| Address subsistence needs for staff and patients. | Fire Safety | 2023-11-13 | 2023-12-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-11-13 | 2023-12-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-11-13 | 2023-12-27 | 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 | 2023-11-13 | 2023-12-27 | 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 | 2023-11-13 | 2023-12-27 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-13 | 2023-12-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-13 | 2023-12-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-13 | 2023-12-27 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-11-13 | 2023-12-27 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-11-13 | 2023-12-27 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-11-13 | 2023-12-27 | 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 | 2023-11-08 | 2023-12-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-08 | 2023-12-10 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-08 | 2023-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-11-08 | 2023-12-10 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-11-08 | 2023-12-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-08 | 2023-12-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-08 | 2023-12-10 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-11-08 | 2023-12-10 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-11-08 | 2023-12-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-08 | 2023-12-10 | 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 | 2023-08-02 | 2023-09-07 | Y |
| 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 | 2023-08-02 | 2023-09-07 | Y |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2023-08-02 | 2023-09-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-02 | 2023-09-06 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2023-08-02 | 2023-09-06 | Y |
| 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 | 2022-09-19 | 2022-11-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-09-19 | 2022-11-01 | 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 | 2022-09-19 | 2022-11-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-19 | 2022-11-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-19 | 2022-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-19 | 2022-11-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-19 | 2022-11-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-19 | 2022-11-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-19 | 2022-11-01 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-15 | 2022-10-14 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-09-15 | 2022-10-14 | 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 | 2022-09-15 | 2022-10-14 | 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 | 2022-09-15 | 2022-10-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-15 | 2022-10-14 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-09-15 | 2022-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-15 | 2022-10-14 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-09-15 | 2022-10-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-15 | 2022-10-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-25 | 2022-02-11 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-11-10 | 2021-12-07 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2021-11-10 | 2021-12-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-11-10 | 2021-12-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-10 | 2021-12-07 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-10 | 2021-12-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-14 | 2021-11-02 | Y |
| 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 | 2021-08-26 | 2021-10-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-08-26 | 2021-10-06 | 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 | 2021-08-26 | 2021-10-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-26 | 2021-10-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-08-26 | 2021-10-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-26 | 2021-10-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-26 | 2021-10-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-08-26 | 2021-10-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-26 | 2021-10-06 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-19 | 2021-10-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-19 | 2021-09-09 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-08-19 | 2021-09-09 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-19 | 2021-09-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-19 | 2021-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-09-09 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-08-19 | 2021-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-19 | 2021-09-09 | N |
