A list of the most recent deficiencies for The Ivy at Gastonia LLC. 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? |
|---|---|---|---|---|
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-01 | 2023-10-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-01 | 2023-08-22 | 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 | 2023-06-01 | 2023-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-01 | 2023-08-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-01 | 2023-08-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-06-01 | 2023-08-22 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2023-06-01 | 2023-08-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-01 | 2023-08-22 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-05-02 | 2023-05-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-02 | 2023-05-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-02 | 2023-05-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-05-02 | 2023-05-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-02 | 2023-05-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-05-02 | 2023-05-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-23 | 2022-07-16 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-23 | 2022-07-16 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-23 | 2022-07-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-23 | 2022-07-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-23 | 2022-07-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-06-23 | 2022-07-16 | Y |
| 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 | 2022-06-23 | 2022-07-16 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-06-23 | 2022-07-16 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2022-06-23 | 2022-07-16 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-06-23 | 2022-07-16 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-23 | 2022-07-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-23 | 2022-07-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-23 | 2022-07-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-24 | 2022-07-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-24 | 2022-07-16 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-24 | 2022-07-16 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-24 | 2022-07-16 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-18 | 2021-09-04 | 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 | 2021-07-14 | 2021-09-01 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-07-14 | 2021-09-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-14 | 2021-09-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-07-14 | 2021-09-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-14 | 2021-09-01 | N |
| Post nurse staffing information every day. | Health | 2021-07-14 | 2021-09-01 | 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 | 2021-07-14 | 2021-09-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-14 | 2021-09-01 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-14 | 2021-09-01 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-04-22 | 2021-05-29 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-04-22 | 2021-05-29 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-04-22 | 2021-05-29 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-22 | 2021-05-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-22 | 2021-05-29 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-22 | 2021-05-29 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-03-03 | 2021-04-23 | 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 | 2020-03-03 | 2021-04-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-03 | 2021-04-23 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2020-03-03 | 2021-04-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-03 | 2021-04-23 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-02-07 | 2020-02-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-02-07 | 2020-02-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-07 | 2020-02-28 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-07 | 2020-02-28 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2020-02-07 | 2020-02-28 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2020-02-07 | 2020-02-28 | 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 | 2020-02-07 | 2020-02-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-02-07 | 2020-02-28 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-07 | 2020-02-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-02-07 | 2020-02-28 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2020-02-07 | 2020-02-28 | N |
