Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ivy Woods Healthcare Center. during CMS and state inspections, most recent first.
MDS assessments were inaccurate for multiple residents. One resident’s tobacco use was documented in the chart, but the MDS coded no current tobacco use. Another resident’s wound records showed multiple pressure injuries on admission, yet the MDS mis-coded a Stage 2 pressure ulcer. A resident receiving dialysis was not coded for dialysis or hemodialysis on the MDS, and another resident with a PASRR Level II finding for serious mental illness was coded no for PASRR. Staff interviews confirmed the coding errors and that the MDSs were completed and signed off with these inaccuracies.
A resident with major depressive disorder and intact cognition received sertraline and PRN trazodone, but the record contained no documentation of informed consent or discussion of risks, benefits, and alternatives before the psychotropic medications were started or continued. Staff, including the MRC, RDCO, LPN, CMRN, DON, MD, and ED, were unable to identify where the consent was documented, and the resident did not recall a medication review.
Care plans for two residents did not include the use of bed rails or grab bars even though both had active orders, informed consent documents, and observed bed canes attached to the top of the bed. One resident had intact cognition with assistance needs for bed mobility and transfers, while the other had severe cognitive impairment and required substantial assistance. Multiple staff, including an MDS LPN, CMRN, and DON, stated that bed rails or grab bars should be care planned.
Bed Rail Use Not Properly Assessed or Maintained: The facility failed to complete required bed rail assessments for two residents and failed to maintain a bed cane for one resident. One resident with intact cognition had bilateral bed canes ordered and observed in place, but the left cane was repeatedly found loose and leaning outward; the resident said they did not use the bars and tried not to use the loose one. Another resident with severe cognitive impairment also had bilateral bed canes ordered, but the record lacked an assessment of side rails, positioning/grab bars, canes, related risks, or alternatives tried. Staff and the DON stated the bed safety evaluation form did not address bed rails, and the facility policy required assessment, consent, and documentation for bed rail use.
Medication Error Rate Exceeded Allowed Threshold: An LPN administered incorrect doses of vitamin C and senna to a resident with hemiplegia, COPD, vascular dementia, and constipation. The resident had moderate cognitive impairment, and the facility’s observed medication error rate was 7.69%, above the required threshold of less than 5%. The DON stated medications should be given as ordered and that the expected error rate was below 5%.
Failure to transcribe discontinued medication orders: A resident with vascular dementia and moderate cognitive impairment had an LTC pharmacist review that recommended discontinuing several vitamins and supplements. The MD agreed to discontinue the listed medications, but the MAR and physician order summary still showed thiamine as active and being administered, and the DON confirmed the order had not been discontinued in the record.
The facility failed to follow EBP and nebulizer care practices for two residents. An LPN provided G-tube care for a resident on EBP without wearing a gown, despite the resident’s feeding tube and door signage indicating PPE requirements. In addition, nebulizer equipment for two residents with COPD was left connected, not rinsed, not bagged, and visibly soiled with dried debris, even though staff and policy stated the equipment should be cleaned, dried, and stored after use.
A facility failed to follow proper incontinence care techniques for a resident with bladder and bowel incontinence. The resident, with diagnoses including diabetes and dementia, required extensive assistance with ADLs. During care, an STNA was observed cleaning the resident from back to front, contrary to the facility's policy of wiping from front to back. The STNA admitted to using the incorrect technique, citing difficulty in performing the correct method.
MDS assessments were coded inaccurately for tobacco use, pressure ulcers, dialysis, and PASRR status
Penalty
Summary
The facility failed to ensure that MDS assessments were accurate for four residents reviewed for MDS accuracy. The report states that the facility did not correctly code resident information in multiple sections of the MDS, and staff interviews confirmed that the assessments were completed using review of records and then signed off, but the coding errors remained in the submitted assessments. For one resident admitted with hypertension, the admission MDS indicated no current tobacco use even though the smoking assessment documented that the resident used three to five cigarettes daily, was aware of the risks, and was independent for smoking. The MDS LPN stated she missed the smoking assessment and that Section J1300 was incorrectly coded. The RAI manual section cited in the report required tobacco use to be coded as yes when the resident or another source indicated tobacco use during the look-back period. For another resident admitted with severe protein-calorie malnutrition and pressure ulcers, the wound assessment documented multiple wounds on admission, including a Stage 2 pressure ulcer, a Stage 4 pressure ulcer, and several deep tissue injuries. The admission MDS coded one Stage 2 pressure ulcer as not present on admission, while also indicating other wounds were present on admission. The MDS LPN reviewed Section M and stated the coding for the number of Stage 2 pressure ulcers present upon admission was incorrect. The cited RAI manual instructions required the number of Stage 2 pressure ulcers first noted at admission or reentry to be entered in Section M0300B2. For a resident with chronic kidney disease stage 4 and a care plan showing dialysis therapy, the 5-day MDS did not check dialysis or hemodialysis in Section O0110J1 and O0110J2. The MDS LPN stated the resident was not on dialysis initially but later returned from the hospital on dialysis, and dialysis was not captured because she did not have dialysis run sheets to verify treatment. For another resident with depression, bipolar disorder, and anxiety disorder, the PASRR Level II outcome showed serious mental illness and specialized services, but the modified admission MDS coded PASRR as no. The SSD stated she completed the PASRR section, acknowledged the resident had a Level II PASRR, and said it should have been captured on the MDS. The cited RAI manual required PASRR to be coded yes when Level II screening determined the resident had serious mental illness and/or ID/DD or a related condition.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to provide documentation of informed consent before administering psychotropic medications to Resident #17. Resident #17 was admitted with a diagnosis of major depressive disorder, recurrent and mild, and had a BIMS score of 15 on the quarterly MDS, indicating intact cognition. The care plan identified the resident as at risk for altered mood and behavior related to depression and anxiety, with interventions to monitor mood and behavior changes, administer medications as ordered, and provide emotional support and reassurance. The physician order recap showed sertraline 25 mg daily, later increased to 50 mg daily, and trazodone 25 mg at night as needed. The MAR showed the resident received sertraline and trazodone as ordered. Review of the record found no evidence of informed consent or documentation of discussion of risks, benefits, and alternatives with the resident or representative before initiation or continuation of these medications. During interviews, the MRC, RDCO, LPN, CMRN, DON, MD, and ED were unable to identify where the consent was documented, and the resident stated they did not recall staff reviewing medications and were unsure what medications they took.
Care Plans Omitted Bed Rail Use for Two Residents
Penalty
Summary
The facility failed to ensure the comprehensive care plans included the use of bed rails for two residents, Resident #43 and Resident #20. Both residents had bed canes or grab bars attached to the top of the bed, active physician orders for bilateral grab bars to enhance mobility, and informed consent documents addressing bed rail or assist bar use. However, each resident’s care plan report did not include the use of side rails or assistive grab bars. Resident #43 was admitted with diagnoses including unspecified convulsions, acute respiratory failure with hypoxia, and unspecified dementia without behavioral disturbance. The annual MDS showed a BIMS score of 15, indicating intact cognition, and documented that the resident needed setup or clean-up assistance with bed mobility, sitting, standing, and transfers. Observations on multiple dates showed two bed canes attached at the top of the bed. The resident’s informed consent recommended both right and left bedrails to promote independence with bed mobility and transfers, but the document was not signed by a nurse. The care plan revised in September 2025 did not include the bed rails or grab bars. Resident #20 was admitted and readmitted with diagnoses including hypertensive heart disease with heart failure, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, COPD, vascular dementia, and epilepsy. The MDS showed a BIMS score of 3, indicating severe cognitive impairment, and documented substantial to maximal assistance with rolling and partial to moderate assistance with standing and transferring. Observations on multiple dates showed two bed canes positioned at the top of the bed. The resident’s informed consent recommended both right and left bed rail position bars to promote independence with bed mobility and transfers, but the care plan revised in November 2025 did not include the use of side rails or assistive grab bars. Staff interviews confirmed that bed rails or grab bars should have been included on the care plan for both residents.
Bed Rail Use Not Properly Assessed or Maintained
Penalty
Summary
The facility failed to assess the use of bed rails for two residents, and it failed to ensure bed rails were maintained for one of those residents. The report states that the facility’s Bed Safety Evaluation did not include an assessment for side rails, positioning/grab bars, or canes, the risk of side rail use, or alternatives attempted and why they failed. The facility policy titled, Safe Use of Bed Rails, required assessment of cognition and therapeutic need, review of prior interventions, and documentation of physician order, consent, education, and care plan for bed rail use. Resident #43 was admitted with diagnoses including unspecified convulsions, acute respiratory failure with hypoxia, and unspecified dementia without behavioral disturbance. The resident’s MDS showed a BIMS score of 15 and indicated intact cognition, with setup or clean-up assistance needed for several bed mobility and transfer tasks. The physician order summary included an order for bilateral grab bars to the bed to enhance mobility and transfers every shift. Observations on multiple dates showed two bed canes attached at the top of the bed, and the left cane was loose and leaning outward away from the mattress, creating a gap between the cane and the mattress. The resident stated they did not use the bars and tried not to use the loose one. Resident #43’s Bed Safety Evaluation stated the resident was capable of decision-making, could use the call light, had not demonstrated poor bed mobility or difficulty sitting on the side of the bed, and was able to transfer independently from bed; it did not mention any type of side rails. The informed consent form recommended both right and left bedrails, but it was signed by the resident and not by a nurse. Staff interviews showed CNA #01 believed the bed cane was beneficial but did not realize it was loose, LPN #03 stated the bed safety evaluation did not address bed rails, and the DON stated therapy usually completed the assessment for bedrails. The DON verified the evaluation did not include an assessment for positioning bars and stated the resident’s positioning bars were used for repositioning. Resident #20 was admitted and later readmitted with diagnoses including hypertensive heart disease with heart failure, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, COPD, vascular dementia, and epilepsy. The MDS showed a BIMS score of 3, indicating severe cognitive impairment, and documented substantial/maximal assistance with rolling in bed and partial/moderate assistance with standing and transferring. The physician order summary included an order for bilateral grab bars to the bed to enhance mobility and repositioning every shift for safety. Observations showed two bed canes positioned at the top of the bed and not loose. The Bed Safety Evaluation noted poor bed mobility and left-sided weakness requiring a bed mobility device, but it did not mention any type of side rails. The informed consent form recommended both right and left bedrail position bars and was signed by the resident representative and two nurses. Nursing progress notes from January 2025 through January 2026 did not mention grab bars, bed canes, bed bars, side rails, or similar devices, and the record did not include an assessment for side rails, positioning/grab bars, or canes, the risk of side rail use, or alternatives attempted and why they failed.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to keep the medication error rate below five percent. During medication administration observation, there were two medication errors out of 26 opportunities for error, resulting in a calculated error rate of 7.69 percent. This affected one resident reviewed during medication administration out of five residents reviewed, with the facility census at 89. Resident #01 was admitted with diagnoses including hemiplegia following cerebral infarction, COPD, vascular dementia, and constipation. The resident’s annual MDS showed a BIMS score of 10, indicating moderate cognitive impairment. During a medication administration observation, an LPN gave vitamin C 500 mg instead of the ordered ascorbic acid 250 mg, and gave Senna Plus 50/8.6 mg instead of the ordered senna 8.6 mg. The LPN later acknowledged the vitamin C dose was incorrect and identified the Senna Plus bottle as the medication administered. The DON stated nurses were expected to administer medications as ordered and that the medication error rate should be less than 5 percent. The facility policy stated medications are to be administered only as prescribed and that the five rights include the right resident, right time, right medicine, right dose, and right route.
Failure to Transcribe Discontinued Medication Orders
Penalty
Summary
The facility failed to ensure that discontinued physician orders were transcribed in the medical record for one resident reviewed for Medication Regimen Review. Resident #32 was admitted with vascular dementia and other behavioral disturbance, and the admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment. The resident’s LTC pharmacist recommendation dated 12/18/2025 identified active orders for folic acid, a multivitamin, thiamine, and cholecalciferol, and recommended evaluating those medications for discontinuation to reduce medication burden and the risk of adverse effects. The Medical Director responded on 01/02/2026 to discontinue all medications listed by the pharmacy consultant, and both the Medical Director and DON stated they expected the orders to be updated in the system. However, the Physician Order Summary Report and the January 2026 MAR still showed thiamine mononitrate 100 mg daily as an active and administered order with no end date. During interview, the DON verified the thiamine had not been discontinued and stated the order update had not been completed.
PPE Not Used for EBP and Nebulizer Equipment Left Uncleaned
Penalty
Summary
The facility failed to ensure appropriate PPE was worn for a resident on Enhanced Barrier Precautions (EBP). Resident #05 was admitted with diagnoses including gastrostomy status, systemic lupus erythematosus, and other paralytic syndrome following cerebral infarction, and had severe cognitive impairment with a BIMS score of six. The resident’s care plan and physician orders identified EBP for the resident’s feeding tube, and the EBP sign on the door directed staff to wear gloves and a gown for high-contact care and device care involving a feeding tube. During observation, an LPN entered the resident’s room to discontinue continuous tube feeding, washed hands, and donned gloves, but did not don a gown. The LPN flushed the G-tube, stopped the feeding pump, disconnected the feeding tube from the G-tube, checked placement, and replaced the cap on the G-tube port. The LPN later stated they only wore a gown if bodily fluids or drainage were present and did not realize a gown should have been worn when G-tube care was performed. The MD, DON, and ED each stated staff were expected to use a mask, gloves, and a gown for residents on EBP, and the facility policy identified gowns and gloves as required PPE for EBP involving feeding tubes. The facility also failed to clean and store nebulizer equipment appropriately for two residents. One resident with COPD and CHF had a nebulizer machine on the nightstand with the mask and medication cannister still connected, not rinsed, and not stored in a bag, with dried debris visible on the mask; a used mask was also left on the nightstand. Another resident with COPD and CHF had a nebulizer machine on the nightstand with the mouthpiece and medication cannister still connected and not stored in a bag, and the same condition was observed repeatedly over several days, including dried debris inside the mask and the mouthpiece touching the surface. Staff interviews stated nebulizers should be rinsed, dried, and stored in a plastic bag after use, and if discontinued, the equipment should be removed and disinfected. The facility policy stated nebulizer treatments should be rinsed with sterile water and allowed to air dry, or discarded after therapy if applicable.
Improper Incontinence Care Technique
Penalty
Summary
The facility failed to follow proper techniques while providing incontinence care for Resident #16, who was admitted with diagnoses including diabetes, dementia, anxiety, and dysphagia. The resident's care plan indicated bladder and bowel incontinence, with interventions to check for incontinence and clean the perineum appropriately. However, during an observation of incontinence care, a State Testing Nursing Assistant (STNA) was seen cleaning the resident from back to front with stool, contrary to the facility's policy which requires wiping from front to back. The STNA acknowledged the incorrect technique but stated it was too difficult to perform the correct way. This deficiency was identified during an investigation under Complaint Number OH00154279.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harrison Pavilion Care Center | 0.8 mi | ★★★★★ | 24 | 0 |
| Edith Lane Of Cincinnati | 1.1 mi | ★★★★★ | 4 | 0 |
| Aventura At West Park | 1.5 mi | ★★★★★ | 5 | 0 |
| Clifton Healthcare Center | 2.6 mi | ★★★★★ | 13 | 0 |
| Seven Acres Senior Living At Clifton | 2.8 mi | ★★★★★ | 1 | 0 |
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