Ivy Woods Healthcare Center.

In the surveyor’s words

From the most serious findings on record at Ivy Woods Healthcare Center., in the surveyor’s own words.

• Actual harm, isolatedF697Oct 5, 2023

  Based on record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to provide pain management interventions in accordance with the resident's care plan. This resulted in Actual Harm to Resident #139 who had traumatic burn wounds to her bilateral lower extremities and was not medicated for pain prior to wound care which resulted in the resident exhibiting signs of severe pain. This affected one resident (#139) of three residents reviewed for pain management. The facility census was 90 residents. Findings include: Review of the medical record for Resident #139 revealed an admitted [DATE] with diagnoses of cellulitis and open wounds of the lower legs. […]

• Actual harm, isolatedF689Apr 15, 2021

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, interviews, review of a self-reported incident (SRI), review of the hospital records, review of the facility investigation, review of personnel files, and policy review, the facility failed to ensure residents were appropriately transferred from the bed to the geriatric chair with a mechanical lift resulting in an avoidable fall. […]

• No harm, potential for more than minimal, widespreadF868Oct 5, 2023

  Based on record review and staff interview, the facility failed to have the Medical Director in attendance at the Quality Assurance and Performance Improvement (QAPI) meetings. This had potential to affect all 90 residents who resided in the facility. Findings include: Review of the QAPI quarterly meetings sign-in sheets dated 10/22/22, 01/15/23, 04/19/23 and 08/09/23, revealed no documented evidence the Medical Director attended the meetings. Interview with the Administrator on 10/05/23 at 2:32 P.M. verified the Medical Director did not attend the QAPI meetings on 10/22/22, 01/15/23, 04/19/23 and 08/09/23. The Administrator reported the Medical Director was required to attend all the QAPI Meetings as part of the required attendees.

• No harm, potential for more than minimal, widespreadF727Feb 16, 2022

  Based on record review and staff interview, the facility failed to staff a Registered Nurse (RN) at the facility eight hours a day, seven days a week. This had the potential to affect 60 of 60 residents. The facility census was 60. Findings include: Record review of staffing records for 02/05/22, 02/06/22 and 02/13/22 revealed there was no RN scheduled on those days and no RN worked those days. Interview on 02/15/22 at 1:45 P.M., with the Administer verified there were no RN's scheduled on 02/05/22, 02/06/22 and 02/13/22 and no RNs worked those days.

• No harm, potential for more than minimal, patternF641Jan 17, 2026

  Based on medical record review, staff interview, and review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual (RAI manual), the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate. This affected four (#52, #103, #46, and #92) of 19 residents reviewed for accuracy of the MDS assessment. The facility census was 89.Findings included:1. Review of the medical record revealed the facility admitted Resident #52 on 08/22/2025. Diagnosis included essential hypertension (high blood pressure). […]