A list of the most recent deficiencies for Ivy Woods Healthcare Center.. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-16 | 2023-12-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-16 | 2023-12-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-05 | 2023-12-06 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-05 | 2023-12-06 | 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 | 2023-10-05 | 2023-12-06 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-10-05 | 2023-12-06 | 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 | 2023-10-05 | 2023-12-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-10-05 | 2023-12-06 | N |
| Respond appropriately to all alleged violations. | Health | 2023-10-05 | 2023-12-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-05 | 2023-12-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-05 | 2023-12-06 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-05 | 2023-12-06 | 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 | 2023-10-05 | 2023-12-06 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-10-05 | 2023-12-06 | N |
| Provide or obtain dental services for each resident. | Health | 2023-10-05 | 2023-12-06 | N |
| 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 | 2023-10-05 | 2023-12-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-05 | 2023-12-06 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-05 | 2023-12-06 | N |
| Keep all essential equipment working safely. | Health | 2023-10-05 | 2023-12-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-10-02 | 2023-12-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-02 | 2023-12-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-02 | 2023-12-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-02 | 2023-12-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-02 | 2023-12-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-02 | 2023-12-06 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-02-16 | 2022-03-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-15 | 2021-04-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-20 | 2020-03-31 | 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 | 2020-02-20 | 2020-03-31 | 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 | 2020-02-20 | 2020-03-31 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-02-20 | 2020-03-31 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-20 | 2020-03-31 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2020-02-20 | 2020-03-31 | 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 | 2020-02-20 | 2020-03-31 | 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 | 2020-02-20 | 2020-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-20 | 2020-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-02-20 | 2020-03-31 | 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 | 2020-02-20 | 2020-03-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-02-20 | 2020-03-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-02-20 | 2020-03-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-01-10 | 2019-02-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-10 | 2019-02-08 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2019-01-10 | 2019-02-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-01-10 | 2019-02-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-10 | 2019-02-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-10 | 2019-02-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-10 | 2019-02-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-10 | 2019-02-08 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-01-10 | 2019-02-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-10 | 2019-02-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-01-10 | 2019-02-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-01-10 | 2019-02-08 | N |
