Ivy Woods Healthcare Center.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review and staff and resident interview, the facility failed to provide documentation of informed consent prior to the administration of psychotropic medications. This affected one (#17) of five residents reviewed for unnecessary medications. The facility census was 89.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure the comprehensive care plans included the use of bed rails. This affected two (#20 and #43) of two sampled residents reviewed for bed rail use. The facility census was 89.

Inspectors wroteBased on medical record review, observation, staff and resident interview, and facility policy review, the facility failed to assess the use of bed rails for two (#20 and #43) of two residents sampled for use of bed rails. In addition, the facility failed to ensure bed rails were maintained. This affected one (#43) of two residents sampled for bed rails. The facility census was 89.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure the medication error rate was less than five percent. There were two medication errors out of 26 opportunities for error with a calculated medication error rate of 7.69 percent. This affected one (#01) of five residents reviewed during medication administration. The facility census was 89.

Inspectors wroteBased on medical record review, staff interview, review of the Long Term Care Pharmacist Recommendation, and policy review, the facility failed to ensure discontinuation of physician orders were transcribed in the medical record. This affected one (#32) of five residents reviewed for Medication Regimen Review (MRR). The facility census was 89.

Inspectors wroteBased on medical record review, observation, staff interview, review of staff training transcripts, and facility policy review, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was worn for one (#05) of two residents sampled for Enhanced Barrier Precautions (EBP). In addition the facility failed to clean and store nebulizer equipment after use. This affected two (#17 and #20) of four residents sampled for infection control. The facility census was 89.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to follow proper techniques while providing incontinence care. The affected one (#16) of the three residents reviewed for incontinence. The facility census was 90.

Inspectors wroteBased on record review, staff interview, facility fall investigation review, and facility policy review, the facility failed to ensure appropriate care was provided to a resident to avoid a preventable fall and the facility failed provided to thoroughly investigate a resident's fall and implement interventions to prevent a similar incident. This affected one (#10) out of three residents (#10,#84, #85) reviewed for falls. The facility census was 85. Findings Include: Review of medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, vascular dementia malignant neoplasm of rectum, diabetes mellitus, hypertension, aphasia, insomnia, and epilepsy. Review of physician's orders dated 08/22/23 for Resident #10, revealed the resident was to be transferred via Hoyer lift for all transfers. [...]

Inspectors wroteBased on record review, staff interview, review of facility fall investigation, review of facility policy, the facility failed to timely and adequately address a resident's complaints of pain following a fall. This affected one (#10) out of three residents reviewed for pain. The facility census was 85. Findings Include: Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease, vascular dementia malignant neoplasm of rectum, diabetes mellitus, hypertension, aphasia, insomnia, and epilepsy. Review of the physician's orders dated 12/17/21 for Resident #10, revealed the resident was to be monitored for pain twice day (each shift) and Tylenol (pain relief) 650 milligrams (mgs) every four hours as needed (PRN) for pain. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, observations, staff interviews, review of resident's diet lists, and review of facility policy, the facility failed to provide menus as planned by a Registered Dietitian (RD). This affected 13 Residents (#11, #62, #61, #60, #17, #12, #22, #35, #14, #78, #40, #69, and #06) of the 13 residents observed in the main dining room. The facility also failed to provide appropriate substitutions to residents. This affected four residents (70, # 53, #38 and #07) of the four residents identified by the facility as receiving puree diets. The facility census was 90. Findings Include: 1. Observation of the initial dining service in the main dining room on 10/04/23 from 12:00 P.M. through 12:30 P.M. revealed all 13 residents (#11, #62, #61, #60, #17, #12, #22, #35, #14, #78, #40, #69 and #06) received a four ounce (one-half cup) serving of salad. [...]

Inspectors wroteBased on record review, observation and staff interview, the facility failed to store, prepare, distribute, and serve foods in accordance with professional standards for food service safety. This had the potential to affect 89 residents who received food from the kitchen. The facility census was 90.

Inspectors wroteBased on observation and interview, the facility failed to maintain essential kitchen equipment in a safe and sanitary condition. This affected all 89 residents who received meals from the kitchen. The facility total census was 90.

Inspectors wroteBased on record review, observation, resident interview, and review of facility policy and documents the facility failed to ensure residents were treated with dignity and respect. This affected two residents (#28 and #81) of the 18 residents sampled. The facility census was 90 residents.

Inspectors wroteBased on record review, observation, resident interview, and staff interview the facility failed to ensure residents had appropriate bedding and mobility devices to accommodate resident needs. This affected one resident (#140) of 18 residents sampled. The facility census was 90 residents.

Inspectors wroteBased on record review, staff interview, and review of the facility policy the facility failed to ensure residents had their advanced directives /code status noted in the medical record. This affected two residents (#28 and #21) of the four residents sampled for advanced directives. The facility census was 90 residents.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure staff honored the residents' right to privacy by failing to knock prior to entering the resident's room and the resident's bathroom. This affected two residents (#09 and #140) of 18 residents sampled. The facility census was 90 residents.

Inspectors wroteBased on record review, observation, resident interview, and staff interview the facility failed to ensure resident room furnishings were in good repair and properly functional. This affected two residents (#18 and #06) of 18 residents sampled. The facility census was 90 residents.

Inspectors wroteBased on record review, observation, resident interview, review of the facility's Self-Reported Incidents (SRIs) and review of facility policy and documents the facility failed to ensure the facility's abuse policy was implemented when allegations of abuse were initiated by residents. This affected one resident (#28) of the one resident reviewed for abuse. The facility census was 90 residents.

Inspectors wroteBased on record review, observation, resident interview, review of facility's Self-Reported Incident (SRI) and review of facility policy and documents the facility failed to prevent further potential abuse while an abuse allegation investigation was in progress. This affected one resident (#28) of one resident reviewed for abuse. The facility census was 90 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Ombudsman was notified when residents were discharged to the hospital. This affected three residents (#36, #70, and #85) out of three residents reviewed for discharges. The facility census was 90.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure residents' fingernails were timed and clean. This affected one resident (#239) of three residents reviewed for activities of daily living (ADLs). The facility census was 90.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure a timely physician response to the monthly pharmacist drug regimen reviews. This affected one resident (#28) of five residents reviewed for medications. The facility census was 90 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure laboratory (labs) tests were completed in a timely manner as ordered by the physician. This affected one resident (#28) of 18 residents sampled. The facility census was 90 residents.

Inspectors wroteBased on medical review, observation, resident interview, and staff interview, and review of the facility policy the facility failed to ensure residents received routine dental services. This affected one resident (#28) of 18 residents sampled. The facility census was 90.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure food was stored and prepared in a clean environment, failed to ensure food items were dated and labeled as to the day they were opened, and failed to discard expired food items. This involved all 78 residents in the facility who received food from the kitchen.

Inspectors wroteBased upon record review, observation, staff interview, and review of facility policy, the facility failed to provide a dignified resident dining experience. This affected one (Resident #56) of 18 residents sampled. The census was 78.

Inspectors wroteBased upon record review, staff interview, and review of facility policy, the facility failed to accurately document the code status for one (Resident #56) of 18 residents sampled. The census was 78.

Inspectors wroteBased upon record review, observation, resident interview, and staff interview, the facility failed to maintain a homelike environment by storing wheelchairs and geri chairs in the room of one (#5) of 18 residents sampled. The census was 78.

Inspectors wroteBased on record review, observation, resident interview, and staff interview, the facility failed to ensure a Wander Guard restraining device was not used in the absence of wandering behaviors for one (#45) of two residents reviewed for restraints. The facility census was 78.

Inspectors wroteBased upon record review, observation, and staff interview, the facility failed to accurately code the presence of side rail usage on the bed of one (#38) of two residents reviewed for restraints. The census was 78.

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to develop a plan to reflect the discharge goals for one (#45) of two residents reviewed for discharge. The facility census was 78.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to assess the need for the use of bilateral half side rails on the bed of one (Resident #38) of two residents reviewed for restraints. The census was 78.

Inspectors wroteBased on record review, staff interview, and review of the facility policy, the facility failed to attempt gradual dose reduction (GDR) or document clinical contraindications to GDR for an antipsychotic medication, and failed to document behaviors necessitating the need for the use of an antipsychotic medication for one (Resident #5) of six residents reviewed for unnecessary medications. The census was 78.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure respiratory equipment was cleaned for one (Resident #38) of two residents reviewed for respiratory care. The census was 78.