Deficiency Records for Ivy Woods Healthcare and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Ivy Woods Healthcare and Rehabilitation 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-06 | 2023-03-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-06 | 2023-03-20 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-06 | 2023-03-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-23 | 2023-03-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-23 | 2023-03-20 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-10-06 | 2022-11-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-06 | 2022-11-01 | 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 | 2022-10-06 | 2022-11-01 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-10-06 | 2022-11-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-10-06 | 2022-11-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-04 | 2022-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-04 | 2022-11-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-10-04 | 2022-11-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-04 | 2022-11-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-04 | 2022-11-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-01 | 2022-10-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-28 | 2022-05-10 | 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 | 2021-12-08 | 2021-12-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-05 | 2021-08-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-11 | 2021-06-15 | Y |
| 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 | 2021-05-11 | 2021-06-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-05-11 | 2021-06-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-05-11 | 2021-06-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-11 | 2021-06-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-11 | 2021-06-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-11 | 2021-06-15 | Y |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-05-11 | 2021-06-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-11 | 2021-06-15 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-05-11 | 2021-06-15 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-03-08 | 2021-04-09 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-10-24 | 2019-11-26 | 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 | 2019-10-24 | 2019-11-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-24 | 2019-11-26 | 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 | 2019-10-24 | 2019-11-26 | 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 | 2019-10-24 | 2019-11-26 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-24 | 2019-11-26 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-10-24 | 2019-11-26 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-10-24 | 2019-11-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-21 | 2019-11-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-10-21 | 2019-11-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2019-10-21 | 2019-11-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-21 | 2019-11-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-21 | 2019-11-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-10-21 | 2019-11-26 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-10-21 | 2019-11-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-21 | 2019-11-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-21 | 2019-11-26 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-29 | 2018-09-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-29 | 2018-09-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-29 | 2018-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-28 | 2018-09-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-28 | 2018-09-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-08-28 | 2018-09-25 | N |
