Ivy Creek Wellness & Rehabilitation

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening condition of clinical complications for one of eight residents (Resident #1) reviewed for resident rights. The facility failed to notify Resident #1's FM when she refused meals on 6/20/2026, 6/21/2026, 6/22/2026, 6/23/2026, 6/24/2026, and 6/25/2026. This failure could place residents at risk of a decreased quality of life and risk of not having their responsible party represent them in medical and care decisions.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of eight (Resident #2) residents reviewed for reporting abuse and neglect. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 resident (Resident #2) of 3 residents reviewed for accidents and hazards The nursing facility failed to ensure there was appropriate supervision to prevent Resident #2 from going missing on 6/28/2026 for 30-40 minutes resulting in sunburn to his scalp, arms, legs and face. This failure could place residents at risk of serious injuries from falls, heat-related emergencies from heat exposure and injuries from traffic accidents.

Inspectors wroteBased on interview and record review, the facility failed to keep residents free from misappropriation of property for 2 of 6 residents (Resident #1 and Resident #2) reviewed for misappropriation in that: On 1/30/2025 the facility discovered Resident #1 had 60 tablets of 7.5/325 mg hydrocodone tablets missing On 2/2/2026, the facility discovered Resident #2 had 30 tablets of 10 mg hydrocodone missing This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and could result in worsening or exacerbation of chronic medical conditions, and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed on 07/22/2025 to ensure dietary CK 2 used proper hand hygienewore gloves while plating food for service on the line. The facility failed on 07/22/2025 to ensure CK 1 wore a beard net while preparing food for the residents. The facility failed on 07/22/2025 to ensure dietary CK 1 washed his hands or changed his gloves while preparing pureed food for the residents and in between tasks. The facility failed on 07/22/2025 to ensure dietary CK 1 cleaned and sanitized the food processer in between pureed food items. These failures could place residents at risk for food contamination and/or foodborne illness. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 4 of 4 residents (Residents #15, #25, #34, and #70) and 1 of 1 laundry carts reviewed for infection control. The facility failed on 07/21/2025 to ensure laundry staff handled and stored linens during transport in a manner to ensure cleanliness, protect from dust, and to prevent cross-contamination and the spread of infections. The facility failed on 07/22/2025 to ensure MA-A sanitized reusable equipment (BP cuff) between Residents #15, #25, #34, and #70. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with limited range of motion and limited mobility receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion and appropriate services, equipment, and assistance to maintain or improve mobility for 1 of 6 residents (Resident #22) reviewed for ROM and mobility, in that:The facility failed on 4/25/2025 to ensure Resident #22 continued to receive OT services that were signed off on by the MD on the resident's initial OT evaluation. This failure placed residents at risk of not maintaining their highest practicable physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 3 medication carts reviewed (East Cart, 1 [NAME] Back Cart). The facility failed to ensure narcotic logs on the East Cart and 1 [NAME] Back Cart were completely filled out and were not missing nurse signatures from 7/19/25-7/21/25. This failure could place residents at risk of drug outages due to drug diversions and poor inventory control which could result in the diminished health and well-being of residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their established policy regarding smoking, smoking areas, and smoking safety for 1 (Resident #49) of 8 residents reviewed for smoking. The facility failed to inform Resident #49 of the facility's smoking policy prior to 7/21/2025. The facility failed on 7/21/2025 to maintain a clean smoking area for staff and residents. These failures could result in unwanted fire hazards and pose safety risks to residents and staff.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 11 of 11 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend. This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure the kitchen staff cleaned and sanitized the blender in between pureed food items. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the transmission of communicable diseases and infections for 5 of 5 residents (Residents #27, #11, #20, #38 and #17) reviewed for infection control. 1. The facility failed to ensure CMA performed proper hand hygiene when passing medications. 2. The facility failed to ensure CMA sanitized equipment according to infection control guidelines. This failure could place residents at risk for development of communicable diseases and infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 2 resident (Resident #31) reviewed for quality of care. The facility failed to ensure Resident #31's wound care orders were followed daily. This failure could place residents at risk for worsening of wounds, development of infections, and possible loss of the highest practicable level of functioning.

Inspectors wroteBased on observation, interview and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 5 residents (Resident #40) reviewed for physical environment. The facility failed to ensure Resident #40 had a working call light in the room. This failure could place residents at risk of not being able to get assistance when needed.

Inspectors wroteBased 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. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased 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. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased 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. While the IJ was removed on 12/29/23 at 6:15 PM, the facility remained out of compliance at a severity of actual harm at a scope of isolated that is not Immediate Jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed residents at risk of a drug overdose, hospitalization, or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I Screening for residents diagnosed with mental illness were accurate and residents were provided with a PASRR Level II Screening for 1 of 2 resident (Resident #3) reviewed for PASARR coordination, by failing to ensure: 1. Resident # 3's PASARR Level I was completed accurately for Resident #3 who had active mental health diagnosis. This failure could place residents at risk for inappropriate placement in the nursing facility for long term care and at risk of not receiving appropriate care and services from the local authority, which could result in a possible decline in mental health