Deficiency Records for Ivy Hill Post Acute Nursing and Rehabilitation LLC
Updated as of January 01, 2021
This is not the most recent data for Ivy Hill Post Acute Nursing and Rehabilitation LLC. For the most recent information, click here.
A list of the most recent deficiencies for Ivy Hill Post Acute Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-10-19 | 2020-11-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-10-19 | 2020-11-15 | Y |
| 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 | 2019-12-05 | 2020-01-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-10-15 | 2019-11-15 | Y |
| Be properly staffed | Fire Safety | 2019-06-26 | 2019-09-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-06-26 | 2019-09-24 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-26 | 2019-08-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-06-26 | 2019-08-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-06-26 | 2019-08-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-26 | 2019-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-26 | 2019-08-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-26 | 2019-08-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-06-26 | 2019-08-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-26 | 2019-08-22 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-06-26 | 2019-08-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-06-26 | 2019-08-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-26 | 2019-08-22 | 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 | 2019-06-26 | 2019-08-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-03-14 | 2019-05-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-22 | 2019-03-08 | Y |
| Use approved construction type or materials. | Fire Safety | 2018-07-25 | 2018-10-19 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-07-25 | 2018-10-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-07-25 | 2018-10-19 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Meet other general requirements. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-07-25 | 2018-09-23 | N |
| Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2018-07-30 | 2018-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-30 | 2018-09-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-30 | 2018-09-20 | N |
| Use approved construction type or materials. | Fire Safety | 2017-06-26 | 2017-08-15 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2017-06-26 | 2017-08-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-26 | 2017-08-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-06-26 | 2017-08-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-06-26 | 2017-08-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-06-26 | 2017-08-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-06-26 | 2017-08-15 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-06-09 | 2017-07-22 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-06-09 | 2017-07-22 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-06-09 | 2017-07-22 | N |
