Ivy Hill Post Acute Nursing & Rehabilitation LLC

In the surveyor’s words

From the most serious findings on record at Ivy Hill Post Acute Nursing & Rehabilitation LLC, in the surveyor’s own words.

• Actual harm, isolatedF690Apr 25, 2023

  Based on clinical record review and family and staff interviews, it was determined that the facility failed to obtain a urinary study in a timely manner for a resident with an indwelling urinary catheter and experiencing bleeding from the urinary catheter for one of five residents reviewed. (Resident R1). This failure resulted in actual harm to Resident R1 who was transferred to the hospital, diagnosed with a urinary track infection, anemia and required two units of PRBC (packed red blood cells). […]

• No harm, potential for more than minimal, widespreadF812Aug 17, 2023

  Based on observations and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Findings include: A tour of the Food Service Department was conducted on August 14, 2023, at 9:45 a.m. with Employee E7, Food Service Director (FSD), revealed the following concerns: Observation in the hallway between dietary and the receiving area was dirty, the floor was dusty with trash including dirty gloves. Observations in the dry storage are revealed a baseboard that was peeling off the wall, the floor under the shelves was dusty and dirty with empty cups on the floor under the shelving. […]

• No harm, potential for more than minimal, patternF577Mar 12, 2026

  Based on a review of the observations, and an interview with residents and staff, it was determined that the facility failed to ensure that the most recent Department of Health Survey results were readily accessible to residents and visitors in three of three nursing floors.Findings include: On 03/10/2026 at 10:42 a.m., a Resident Council meeting was conducted with five alert and oriented residents (R46, R174, R93, R119, and R131). During the meeting, residents reported that the facility does have a sign at the front desk stating, Survey results are available upon request, but the survey binder itself is not readily accessible and must be requested. […]

• No harm, potential for more than minimal, patternF584Mar 12, 2026

  Based on observations, interviews with residents and staff, it was determined that the facility failed to provide a clean linen, safe, comfortable, and homelike environment in two of the three nursing units observed (3th and 2nd floor Nursing Units).Findings include: On 03/09/2026 at 9:00 a.m., the front door was observed to stick to the floor, preventing it from opening and closing properly. The facility's receptionist, Employee E7, confirmed the door was broken and required force to operate. On 03/09/2026 at 10:08 a.m., an interview was conducted with Resident R110. The resident reported that the facility does not have enough clean linens and towels available. During the observation, a brown spot was noted on the wall near the railing outside of room [ROOM NUMBER]. […]

• No harm, potential for more than minimal, patternF584Mar 28, 2025

  Based on observation and resident and staff interviews, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, comfortable, and homelike environment for three of three nursing units observed (first floor, second floor, third floor). Findings include: On March 24, 2025, at 12:57 p.m., Unit Manager Employee E19 confirmed that Resident R37 in room [ROOM NUMBER]-2 did not have access to a locked drawer at his bedside to store his personal belongings. Resident R37 had filed a grievance on January 3, 2025, regarding the missing $80, which was not reimbursed, and had been promised a locked drawer to secure his personal items. Observation on March 25, 2025 at 11:44 a.m. […]