Ivy Creek Healthcare & Wellness Centre

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment of the Minimum Data Set (MDS, a resident assessment tool) for one of five sampled residents (Resident 11) reviewed for unnecessary medication reflect the resident's use of antipsychotic (AP, drug that works by altering brain chemistry to help reduce psychotic symptoms like hallucinations [an experience which a person sees, hears, feels, or smells something that does not exist], delusions [fixed false beliefs], and disordered thinking) medication on the Antipsychotic Medication Review (a structured, interprofessional evaluation of a resident's antipsychotic drug therapy to assess effectiveness, monitor side effects, and determine the need for continued use, dose reduction, or withdrawal) and its gradual dose reduction (GDR, a stepwise tapering of a dose to determine if symptoms, conditions, or [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 Screening (initial screening completed prior to admission to a nursing facility to identify individuals who have mental disorder [mental illness] or intellectual disability [ID, an individual with a level of retardation]) accurately for one (1) of two (2) sampled residents (Resident 43), reviewed for PASARR. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) to address one (1) of 21 resident's (Resident 43) anxiety (mental disorder involves persistent and excessive worry that can interfere with daily activities). This failure had the potential for Resident 43 to receive care that was not personalized to meet the resident's specific needs for anxiety, which could negatively affect her overall wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) were provided for two (2) of 2 sampled residents (Residents 4 and 72) reviewed for ADL care area by failing to ensure:1. Resident 4's fingernails on both hands were kept clean.2. Resident 72 received oral care as needed to prevent the resident's lips from becoming chapped (a condition where the lips become dry, cracked, and peeling). These failures had the potential for Residents 4 and 72 to develop skin breakdown and infection, which would negatively affect Resident 4 and 72's wellbeing. Findings 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) for two (2) of six (6) sampled residents (Residents 4, and 31) reviewed for unnecessary medications (any drug when used without adequate monitoring, and without adequate indication for use) and insulin use as indicated on the residents' care plan by failing to monitor: 1. Resident 4 for signs and symptoms (s/s) of hypoglycemia (an abnormally low level of sugar [glucose] in the blood) and hyperglycemia (a condition where the blood glucose [sugar] levels are abnormally high), while on Lantus Solostar (Insulin Glargine [Lantus, a type of long-acting insulin]) and Novolin R ( Regular human Insulin, a short-acting insulin) from 4/30/2026 to 5/21/2026. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of three (3) sampled residents (Residents 4 and 10) reviewed for tube feeding (enteral nutrition, delivers liquid nutrition through a flexible tube that goes in through the nose or directly into the stomach or small intestine) in accordance with the facility's policy and procedure when: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functional call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) for one (1) of four (4) sampled residents (Resident 58) reviewed for environment as indicated in the facility's policy and procedure. This deficient practice had the potential not to meet Resident 58's needs, which could negatively affect the resident's overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to address the recurrent behavior fluctuations of manic mood (mental state of an extreme highs or depressive lows) of verbally aggressive towards staff/others and diminished interest/pleasure in usual Activities of Daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily), for (1) of two (2) sampled residents (Resident 2) while on Depakote (drug used to calm overactive nerves in the brain). This deficient practice resulted in Resident 1 being hit on the left leg by Resident 2's right hand and had the potential to place Resident 1 at risk for physical and psychosocial harm.

Inspectors wroteBased 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. Resident 43's fluid intake was restricted to 1000 ml per day as indicated on the physician's order and care plan. [...]

Inspectors wroteBased 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. Resident 11's amlodipine (medication to lower blood pressure) and clopidogrel (medication that prevents blood platelets from sticking together) between 8 AM and 10 AM. [...]

Inspectors wroteBased 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. Resident 245's cyclobenzaprine (a muscle relaxer that treats muscle spasms) was not administered between 7 AM and 9 AM. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (3) of 3 dumpsters (a movable waste container designed to be brought and taken away) were closed and not overflowing, in accordance with the facility's Policy and Procedure (P&P) titled, Waste Management. This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) and may cause disease and other health issues to residents, staff, and the community.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to obtain an accurate water temperature reading and ensure the water used to wash two loads of soiled linens in two (2) of 2 washing machines had the correct temperature in accordance with the facility policy. This deficient practice had the potential to compromise infection control measures to eliminate disease causing bacteria, germs, and viruses on linens which could get residents sick and potentially spread infection in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote respect and dignity for one (1) of 1 sampled resident (Resident 56) by not providing privacy during brief change. This deficient practice had the potential for Resident 56 to experience loss of dignity, self-esteem, and affect resident's psychosocial well-being.

Inspectors wrote2. During a review of Resident 245's admission Record, the admission Record indicated resident 245 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), gastro esophageal reflux disease (GERD - chronic digestive disease where the contents of the stomach refluxes and irritates the esophagus) and fusion of thoracic spine (a surgical procedure where two or more bones in the mid-back are joined together to eliminate movement between them). During a review of Resident 245's MDS, dated [DATE], the MDS indicated Resident 245 was moderately impaired with cognitive skills for daily decision making. [...]

Inspectors wroteBased interview and record review, the facility failed to ensure the dental care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) was reviewed and revised for one (1) of 19 residents (Resident 28) after the completion of the Minimum Data Set (MDS - a resident assessment tool) on 2/19/2025 and based on the assessed needs of the resident as indicated in the facility's policy. This failure had the potential for Resident 28 to receive inappropriate care and/or inadequate services, negatively affecting Resident 28's well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply Geri sleeves (protective sleeves that prevent tearing, bruising, and abrasions of the skin) for one (1) of two (2) sampled residents (Resident 4) as indicated on the physician's order. This failure had the potential for Resident 4 to acquire additional skin tears (traumatic wounds caused by friction when the upper layer of the skin becomes torn from the underlying layers) to the arms and a lack of services to attain or maintain his highest practicable physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the site of blood pressure measurement for one of 19 sampled residents (Resident 20), for consistent monitoring and clinical interpretation. This deficient practice had the potential to affect the accuracy of clinical assessments and medical management of Resident 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a visible and audible alarm activated by a call button) for one of 19 of sampled residents (Resident 3) was within reach as indicated on care plan and facility's policy. This failure had the potential to result in the inability for Resident 3 to obtain necessary care and services which could result to harm/injury to the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe, clean, comfortable sanitary and home like environment for one (1) of (3) three sampled residents (Resident 56) for the environment care area by failing to ensure the linen bin was not overflowing in Room A. This deficient practice caused an unsanitary environment and had a potential for residents to be placed at risk for serious illness and/ or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four (4) of 47 resident bedrooms measure at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms. Rooms 24, 26, 28, and 44 measured less than 80 sq. ft. per resident. This deficient practice had the potential to cause the residents in these rooms not to have enough room for activities of daily living and hinder staff from providing care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document the administration of the two (2) doses of intravenous (IV, directly into the blood stream) antibiotics (medicines that treat bacterial infections by killing or stopping the growth of bacteria0 medication on to the Medication Administration Record (MAR) for one (1) of five (5) sampled residents (Resident 4) in accordance with the Medication Administration policy. This deficient practice had the potential to result in the doubling up of medications (taking the dose twice).

Inspectors wroteBased on observation and interview, the facility failed to provide a communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) for two (2) of three (3) sampled residents (Residents 1 and 2) that was readily accessible with the language the residents were able to understand in accordance with the facility's policy. This failure had the potential for Residents 1 and 2 to experience a delay in receiving appropriate care and treatment and feeling lonely and isolated due to the staff not being able to properly communicate with the residents.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) on 1/23/2025 for one (1) of three (3) sampled residents (Residents 1) within two (2) hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement. This deficient practice had the potential to compromise or impede the protection of Resident 1, which could affect the resident's emotional and mental wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a homelike environment for three (3) of four (4) sampled residents (Residents 19, 81, and 20) for the environment care area by: 1. and 2. Failing to provide Residents 19 and 81 a room without unfinished and peeling paint on the walls and unmaintained baseboards (wooden or plastic board covering the lowest part of a wall). 2. Leaving a plastic cup of frozen beverage, owned by staff, on top of Resident 20's hand sanitizer dispenser. These deficient practices have the potential for an unsafe and unsanitary resident's environment which had the potential to negatively affect the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy to ensure licensed nurses administer oxygen to two (2) of 2 sampled residents (Resident 143 and 85) for Respiratory Care area, as indicated on the care plan. This deficient practice had the potential for Residents 143 and 85 not to receive the appropriate respiratory care and services, which can affect the residents' overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food were done under sanitary conditions by failing to ensure: 1. One red fruit Jello was labeled with use by date and expiration date. 2. Apple sauce tray cups were labeled with a use by date. 3. [NAME] noodles and garlic bag were labeled with received, use by, and expiration date. 4. Expired cilantro bag was not mixed in with carrots in same container. 5. Chorizo container labeled as Chorizo, contained a bacon and not a chorizo. These deficient practices have the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever, which could lead to hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced dignity and respect in full recognition of the resident's individuality for two (2) of 19 sampled residents (Resident 11 and 37). The facility staff was observed standing above the resident's eye level while assisting the resident during a meal. This deficient practice had the potential to affect Resident 11's and 37's self-esteem and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to reasonably accommodate the needs of three (3) of 19 sampled residents (Resident 37, 73, and 3) by failing to have residents call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach. This deficient practice had the potential for the residents not to be able to call the staff for assistance, which could result to not receiving or delayed needed care or services necessary for the residents' well-being.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) of the resident's medical records by not closing the unattended computer screen for one (1) of 19 sampled residents (Resident 11). This deficient practice violated Resident 11's right for privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) signed and certified the Minimum Data Set (MDS, standardized assessment and care screening tool)/ Care Area Assessment (CAA, provides guidance to focus on key issues identified in the comprehensive MDS) for one (1) of two (2) sampled residents (Resident 84), for Resident Assessment Care Area, in accordance with the facility's policy. This deficient practice had the potential to result in an incomplete assessment and inaccurate depiction of resident specific issues affecting the development of an individualized care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan for one (1) of two (2) sampled residents (Resident 18) to ensure the head of bed (HOB) was elevated while resident was on oxygen. This deficient practice had the potential to result in complications from hypoxia (lack of sufficient oxygen in the body) and can lead to shortness of breath, rapid breathing, confusion, and loss of consciousness, and irregular heartbeat.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 17) for the activities of daily living (ADL) care area, who was unable to carry out ADL received the necessary services to maintain good personal hygiene. This deficient practice resulted in Resident 17 having white crust on the eyelids and brownish stains around the mouth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 19 sampled residents (Residents 3 and 30) received treatment and care in accordance with the physician's order, care plan, and professional standards of practice by failing to: 1. Ensure facility staff applied Resident 3's abdominal binder (a wide compression belt that wraps around the abdomen) to prevent the gastrostomy tube (g-tube, a flexible tube surgically inserted through the wall of the abdomen directly into the stomach for feeding, fluid, and medication administration) dislodgement as ordered by the physician. This deficient practice had the potential to result in Resident 3 pulling her g-tube and suffer complications and hospitalization. 2. Reassess and monitor Resident 30's right big toe as indicated in the resident's care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a coordination of care between facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for one (1) of 1 sampled resident (Resident 79), for hospice care area, by failing to ensure Hospice nursing/ visitation notes were maintained in the resident's medical record, in accordance with the hospice policy. This deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to Resident 79.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enforce its policy and procedure on infection control by : 1. Certified Nursing Assistant 6 (CNA 6) did not perform hand hygiene after doffing (remove) dirty gloves and donning (put on) clean gloves during resident care. 2. CNA 7 picked up resident's nasal cannula tubing (device used to deliver supplemental oxygen from the tube to nose) off the floor and connecting it to the oxygen concentrator (a device that concentrates oxygen by removing nitrogen giving a supply of 95% oxygen) from the floor and attached it to the resident's oxygen concentrator. 3. Failing to disinfect the laundry washers after every use. These deficient practices have the potential to transmit infectious microorganisms and increase the risk of infection for the residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain equipment in the kitchen in safe operating condition when the kitchen burners did not ignite when [NAME] turned knob on 4/9/24. This failure had the potential to cause the staff to burn their hands while igniting burners, which could result to hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four (4) of 47 resident bedrooms measure at least 80 square feet (sq. ft.) per resident in multiple resident bedrooms. Rooms 24, 26, 28, and 44 measured less than 80 sq. ft. per resident. This deficient practice had the potential to cause the residents in these rooms not to have enough room for activities of daily living and hinder staff from providing care to the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control (methods used to prevent, control, or stop the spread of infections) precautions by having expired alcohol hand sanitizer bottles available and used throughout the facility. This failure had the potential to result in the spread of bacteria, viruses and pathogens (harmful microorganisms) to residents, visitors and staff while increasing the risk of infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility supplies for resident care and treatment, including Personal protective equipment (PPE- equipment worn to minimize exposure and spread of illnesses) and gastrostomy tube (GT - a tube that is surgically inserted into the resident's stomach to allow access for food fluids and medications) feedings (nutritious and caloric supplements) were stored in a safe and sanitary environment. This failure had the potential for staff to use contaminated (the presence of an infectious agent on or inside) supplies during the care and treatments provided to the residents and increasing the possible spread of bacteria, viruses, and pathogens (harmful microorganisms).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement intervention to prevent falls (multiple factors that increases an older person's chance of falling) for two out of three sampled residents (Resident 1 2) by failing to place fall risk identifiers for Resident 1 and 2 in accordance with the facility's policy and procedure. This failure had the potential to result in Resident 1 and Resident 2 being at risk for falling and possibly sustaining a serious bodily injury.