Ivy at Deer Lodge

In the surveyor’s words

From the most serious findings on record at Ivy at Deer Lodge, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Nov 10, 2021

  Based on observations, interviews, and record reviews, the facility staff failed to uphold and follow policies and procedures related to the prevention of the spread of Covid-19, which included the failure to effectively train and monitor all staff on donning/doffing PPE and hand hygiene during the provision of resident care and services, for 10 (#s 3, 4, 5, 8, 13, 14, 15, 16, 17, 18); failed to implement infection control signage for a resident on isolation precautions, for staff/visitor awareness, for 1 (#8), of 10 resident's rooms observed on 200 hall; staff failed to sanitize and wash their hands during passing and setting up meal trays for 4 (#s 5, 8, 13, 14); residents were not encouraged to wear masks while out of their rooms, in open areas of the facility, to include the dining… […]

• Immediate jeopardy, patternF686Nov 25, 2024

  Based on observation, interview, and record review, facility failed to identify, assess, document, measure, obtain, and follow physician orders for wound care for 3 (#s 2, 3, and 4) of 6 sampled residents. The facility failed to identify changes in the resident's skin status, which occurred over a short period of time, and failed to address wound changes timely for the provision of medical assistance or needed interventions. The facility failed to have a wound management system in place that provided the necessary oversight for care and treatment of wounds, based on professional standards of practice. […]

• Immediate jeopardy, isolatedF600Nov 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were free of neglect for 3 (#s 2, 3, and 4) of 6 sampled residents. The facility failed to have systems in place for wound care, which resulted in three Immediate Jeopardy deficiencies being identified. Resident outcomes included: a. Resident #2 showed progressive worsening of pressure ulcers from a Stage II (blisters) worsening to Unstageable in ten days, and the resident was admitted to the hospital for the worsening wounds with foul odor, increased assistance with ADLs, and edema. b. Resident #3 showed progressive worsening of pressure ulcers and was placed on hospice, following a hospital stay with sepsis, and passed away at the facility, upon returning. c. […]

• Immediate jeopardy, isolatedF697Nov 25, 2024

  Based on interview and record review, the facility failed to assess, document, treat, and monitor pain for 1 (#4) of 6 sampled residents. Resident #4 had severe pain during pressure ulcer dressing changes and turning and repositioning, which caused the resident to refuse care and dressing changes. Resident #4 expressed to the staff the pain regimen he had in place had not worked in relieving his pain during dressing changes and cares, resulting in increased skin breakdown. Resident #4 was transferred to the hospital on 11/9/24, and he passed away on 11/10/24. The facility failed to provide adequate pain management in a timely and effective manner to meet the resident's pain needs. […]

• Immediate jeopardy, isolatedF678Nov 10, 2021

  Based on interview and record review, the facility failed to ensure the staff initiated CPR and failed to alert EMS for 2 (#s 9 and 19) of 8 sampled residents who were a full code at the time of death. IMMEDIATE JEOPARDY On [DATE] at 2:34 p.m., the facility Administrator, DON, Infection Preventionist, VP of Clinical Services and Clinical Director were notified that an Immediate Jeopardy existed in the area of F678 Cardiopulmonary Resuscitation. Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy lowered to a G. The facility did not submit an acceptable plan to remove the immediacy prior to the end of the survey. […]