Ivy Creek Wellness & Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Feb 10, 2022

  Based on observations, interviews, facility document review, and facility policy review, the facility failed to ensure staff entering the facility, located in a high COVID-19 transmission county, were screened for signs and symptoms of COVID-19; and staff failed to report signs/symptoms of COVID-19. The facility also failed to ensure all staff wore appropriate personal protective equipment in the facility and when providing care to residents. This deficient practice had the potential to spread COVID-19 to the 45 residents in the facility, staff, and visitors, leading to serious illness and/or death; and occurred during the COVID-19 pandemic. […]

• Immediate jeopardy, isolatedF610Dec 29, 2023

  Based on interview and record review, the facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or misappropriation of property were thoroughly investigated in order to prevent further potential abuse, neglect, exploitation or misappropriation while the investigation was in progress for one (Resident #1) of five residents reviewed for abuse and neglect, in that: The facility failed to investigate after Resident #1 was diagnosed with a Fentanyl overdose on 12/25/23. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. […]

• Immediate jeopardy, isolatedF656Dec 29, 2023

  Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plans, in that: The facility failed to care plan Resident #1's history of illegal drug abuse. On 12/25/23, Resident #1 went unresponsive and was diagnosed with a Fentanyl overdose in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. […]

• Immediate jeopardy, isolatedF689Dec 29, 2023

  Based on observation, interview, and record review, the facility failed to ensure each resident recived adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for accidents and hazards, in that: The facility failed to supervise or prevent access to illegal drugs for Resident #1, knowing he had a history of drug use. On 12/25/23, Resident #1 went unresponsive and was diagnosed with a Fentanyl overdose in the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/28/23 at 2:47 PM. […]

• Immediate jeopardy, isolatedF600Apr 29, 2023

  Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 of 8 (Resident # 1 residents reviewed for abuse. The facility failed to ensure Resident # 1 was not assaulted by Resident # 4 on [DATE]. Resident #1 was hospitalized on [DATE] and died from the injuries sustained on [DATE]. Resident # 1 had a history or wandering in residents rooms and Resident # 4 had a history of aggressive behaviors towards other residents and staff. An IJ was identified on [DATE]. The IJ began on [DATE] and removed on [DATE]. The facility took action to remove the IJ before the survey began. […]