Deficiency Records for Ivy Hill Post Acute Nursing and Rehabilitation LLC
Updated as of July 01, 2022
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? |
|---|---|---|---|---|
| Establish policies and procedures for volunteers. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Meet other general requirements. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-10-28 | 2021-12-27 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-09-28 | 2021-11-15 | 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 | 2021-09-28 | 2021-11-15 | N |
| Respond appropriately to all alleged violations. | Health | 2021-09-28 | 2021-11-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-28 | 2021-11-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-09-28 | 2021-11-15 | 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 | 2021-09-28 | 2021-11-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2021-09-28 | 2021-11-15 | 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 | 2021-09-28 | 2021-11-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-28 | 2021-11-15 | 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 | 2021-09-28 | 2021-11-15 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2021-09-28 | 2021-11-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-28 | 2021-11-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-01 | 2021-10-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-01 | 2021-10-15 | Y |
| 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 |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 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 |
| 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 |
| 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 requirements for the installation and maintenance of electrical systems. | 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 |
| 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 |
