Ivory Wellness Center

In the surveyor’s words

From the most serious findings on record at Ivory Wellness Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jan 22, 2024

  Based on the review of clinical records, observations, facility policies and interview with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for Resident R27 with documented history of behavioral issues and suicidal ideation to prevent resident access to potentially hazardous materials. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within 2-3 feet close to the resident which placed Resident R27 and the other residents at risk for serious harm and resulted in immediate jeopardy situation. One of 25 residents reviewed. […]

• Immediate jeopardy, isolatedF689Jan 22, 2024

  Based on the review of clinical records, observations, facility policies and interview with staff, it was determined that the facility failed to ensure that resident's environments were free of accident hazards, and failed to ensure that hazardous materials were not accessible to residents in one nursing unit. This failure resulted in Resident R27 with documented history of behavioral issues and suicidal ideation obtained a twin blade disposable razor and was observed swinging the razor in the dining room while residents were within ,d+[DATE] feet close to the resident. […]

• Immediate jeopardy, isolatedF600Mar 28, 2023

  Based on interviews with residents and staff, review of clinical records, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure residents are free from physical and sexual abuse which resulted in actual harm to Resident R43. This failure resulted in an immediate jeopardy situation for Resident R43 who was sexually abused and Resident R30 who was hit and verbally abused by Resident R74 for three of 22 residents reviewed. […]

• Actual harm, isolatedF600Jul 30, 2024

  Based on review of clinical records, staff and resident interviews, and review of facility documentation, it was determined that the facility failed to ensure that a resident was free of neglect resulting in actual harm to Resident R1 who fell out of bed, required transfer to the hospital via emergency medical services and sustained five sutures to the forehead for one of four resident reviewed. (Resident R1). Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar disorder (mental health condition marked by intense mood changes),… […]

• Actual harm, isolatedF689Jul 30, 2024

  Based on review of clinical records, resident and staff interviews, and review of facility documentation, it was determined that the facility failed to ensure that Resident R1 received adequate assistance during bed mobility which resulted in actual harm to Resident R1 who fell out of bed, required transfer to the hospital via emergency medical services and sustained five sutures on the forehead. (Resident R1) Findings include: Review of Resident R1's clinical record revealed that the resident was admitted to the facility on [DATE], with the diagnoses of cerebral infarction (stroke) affecting left sided weakness, deep vein thrombosis (blood clot), high blood pressure, lack of coordination, anxiety disorder, bipolar disorder (mental health condition marked by intense mood changes),… […]