Deficiency Records for Ivy Hill Post Acute Nursing and Rehabilitation LLC
Updated as of April 01, 2024
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? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-08-17 | 2023-09-12 | N |
| 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 | 2023-08-17 | 2023-09-12 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-17 | 2023-09-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-17 | 2023-09-12 | 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 | 2023-08-17 | 2023-09-12 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-17 | 2023-09-12 | 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 | 2023-08-17 | 2023-09-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-09-12 | N |
| Dispose of garbage and refuse properly. | Health | 2023-08-17 | 2023-09-12 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-08-17 | 2023-09-12 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-08-17 | 2023-09-12 | 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 | 2023-08-17 | 2023-09-12 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-28 | 2023-09-12 | N |
| Meet other general requirements. | Fire Safety | 2023-08-28 | 2023-09-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-28 | 2023-09-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-28 | 2023-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-28 | 2023-09-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-28 | 2023-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-28 | 2023-09-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-07-27 | 2023-08-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-27 | 2023-08-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-01 | 2023-03-28 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-03-01 | 2023-03-28 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-15 | 2022-11-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-09-15 | 2022-11-08 | 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 | 2022-09-15 | 2022-11-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-15 | 2022-11-08 | N |
| Respond appropriately to all alleged violations. | Health | 2022-09-15 | 2022-11-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-15 | 2022-11-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-15 | 2022-11-08 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-09-15 | 2022-11-08 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-09-15 | 2022-11-08 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-09-15 | 2022-11-08 | N |
| Provide appropriate foot care. | Health | 2022-09-15 | 2022-11-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-11-08 | N |
| 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 | 2022-09-15 | 2022-11-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-15 | 2022-11-08 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-09-15 | 2022-11-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-09-15 | 2022-11-08 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-09-15 | 2022-11-08 | N |
| Provide or arrange emergency care by a doctor 24 hours a day. | Health | 2022-09-15 | 2022-11-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-15 | 2022-11-08 | 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 | 2022-09-15 | 2022-11-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-15 | 2022-11-08 | 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 | 2022-09-15 | 2022-11-08 | N |
| Provide or obtain dental services for each resident. | Health | 2022-09-15 | 2022-11-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-15 | 2022-11-08 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-15 | 2022-11-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Meet other general requirements. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Use approved construction type or materials. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Meet other general requirements. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-26 | 2022-11-08 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2022-08-23 | 2022-10-11 | Y |
| 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 | 2022-08-23 | 2022-10-11 | Y |
| 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 |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-11-01 | Not Fixed | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-11-01 | Not Fixed | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-11-01 | Not Fixed | 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 | 2023-04-25 | Not Fixed | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-04-25 | Not Fixed | Y |
