Ivy Creek Healthcare & Wellness Centre

In the surveyor’s words

From the most serious findings on record at Ivy Creek Healthcare & Wellness Centre, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF550May 21, 2026

  Based on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of two residents (Resident 54 and 104) reviewed for dignity, in accordance with the facility's policy when: 1. Facility staff did not address Resident 54 by the resident's preferred name and used the term [NAME] on 5/18/2026.2. Facility staff did not address Resident 58 by the resident's preferred name and used the term Mama on 5/19/2026. These deficient practices had the potential to affect Residents 54 and 58 senses of self-worth and self-esteem which could result in problems with emotional and mental well-being. Findings:1. […]

• No harm, potential for more than minimal, patternF921May 21, 2026

  Based on observation, interview and record review, the facility did not ensure a homelike environment was established for 34 of 47 rooms (Rooms A, B, C, D, E, F, G, H, I, J, K, L, M, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG and HH) by failing to ensure the rooms were free from peeled wallpaper, missing paint on the walls and/or had functional drawers. These deficient practices can negatively affect the comfort and psychosocial wellbeing of the residents residing in the 34 rooms.Findings:During an interview on 5/20/2026 at 2:46 PM with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated a homelike environment should be provided for residents and if paint or wallpaper is missing from the walls in the residents' rooms, it should be fixed. […]

• No harm, potential for more than minimal, patternF698Apr 10, 2025

  Based on observation, interview, and record review, the facility failed to provide two (2) of three (3) sampled residents (Residents 37 and 43) on dialysis (a lifesaving treatment for residents with kidney failure) treatment, a safe and appropriate care in accordance with the facility's policy by failing to ensure: 1a. Resident 37's fluid intake was restricted to 1200 milliliters (ml, unit of volume) per day as indicated on the physician's orders and care plan. 1b. A current Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) meeting was conducted for Resident 37's fluid restriction noncompliance. 2. […]

• No harm, potential for more than minimal, patternF755Apr 10, 2025

  Based on observation, interview and record review, the facility failed to administer medications as indicated on facility policy for three (3) of four (4) sampled residents (Resident 245, 4 and 11), by failing to administer: 1. Resident 245's cyclobenzaprine (a muscle relaxer that treats muscle spasms) between 7 AM and 9 AM. 2. Resident 4's bethanechol (medication that stimulates the bladder to urinate), metoprolol (medication that lowers blood pressure), verquvo (medication that reduces risks of death or hospitalization with heart failure), eliquis (medication that reduces blood clotting), entresto (medication that reduces stress on the heart and strengthens the heart's pumping action) between 8 AM and 10 AM. 3. […]

• No harm, potential for more than minimal, patternF759Apr 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Eight (8) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications/accepted professional standards and principles) out of 26 opportunities (observed administered medications) for error, which yielded a facility medication error rate of 30.77% for three (3) of four (4) sampled residents (Residents 245, 4 and 11) observed during medication administration (med pass). The medication errors were as follows: 1. […]