Ivy Creek Wellness & Rehabilitation

Penalties

• Apr 16, 2025 — Fine ($140,085)
• Dec 29, 2023 — Fine ($8,954)

Inspection findings

1. Jul 1, 2026 Health · 3 findings
   • Not serious Scope/severity E Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     CMS health inspection

2. Feb 6, 2026 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0602 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from the wrongful use of the resident's belongings or money.

     Corrected Feb 9, 2026 · CMS health inspection

3. Jul 23, 2025 Health · 5 findings
   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Aug 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Aug 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Aug 15, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 15, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0926 Environmental Deficiencies

     Have policies on smoking.

     Corrected Aug 15, 2025 · CMS health inspection

4. Jun 13, 2024 Fire Safety · 30 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected May 14, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0020 Emergency Preparedness Deficiencies

     Establish policies and procedures including evacuation.

     Corrected May 14, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected May 5, 2025 · CMS fire safety

   • Not serious Scope/severity E

     F0576 Resident Rights Deficiencies

     Ensure residents have reasonable access to and privacy in their use of communication methods.

     Corrected Jul 8, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jul 3, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 3, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0919 Environmental Deficiencies

     Make sure that a working call system is available in each resident's bathroom and bathing area.

     Corrected Jul 5, 2024 · CMS health inspection

   • Serious Scope/severity L

     K0100 Construction Deficiencies

     Meet other general requirements.

     Corrected Jun 12, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Apr 17, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0225 Egress Deficiencies

     Have stairways and smokeproof enclosures used as exits that meet safety requirements.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0741 Miscellaneous Deficiencies

     Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0916 Gas, Vacuum, and Electrical Systems Deficiencies

     Have a battery powered remote alarm panel in a location accessible by operating personnel.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected May 31, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected May 31, 2025 · CMS fire safety

5. Dec 29, 2023 Health · 3 findings
   • Serious Scope/severity J Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jan 17, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jan 17, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 17, 2024 · CMS health inspection

6. May 10, 2023 Health · 3 findings
   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Jun 9, 2023 · CMS health inspection

   • Not serious Scope/severity C

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     CMS fire safety

Owners and managers (as published by CMS)

• BEASLEY, CAROLYN — adp of the snf, NOT APPLICABLE, since 01/15/2024
• BEASLEY, CAROLYN — operational/managerial control, NOT APPLICABLE, since 01/15/2024
• BYROM, DAVID — corporate director, NOT APPLICABLE, since 09/01/2014
• DAVIDOVICH, NIV — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 02/02/2026
• GARETZ, DAVID — operational/managerial control, NOT APPLICABLE, since 02/01/2026
• HAGINS, ELIZABETH — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 02/02/2026
• JIAN, PETER — adp of the snf, NOT APPLICABLE, since 01/02/2024
• JIAN, PETER — operational/managerial control, NOT APPLICABLE, since 01/02/2024
• KAPLAN, ESTHER — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 02/02/2026
• MINDLE, ADAM — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 02/02/2026
• STERNSHEIN, JENNIFER — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 02/02/2026
• 2501 MAPLE AVE TX LLC — adp of the snf, NOT APPLICABLE, since 02/01/2026
• CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY — 5% or greater direct ownership interest, 100%, since 01/02/2024
• ESDOV INVESTMENTS LLC — adp of the snf, NOT APPLICABLE, since 02/01/2026
• FIRST SWEETZER HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 02/01/2026
• IVY CREEK WELLNESS & REHABILITATION LLC — operational/managerial control, NOT APPLICABLE, since 02/01/2026
• LINZ TRUST — adp of the snf, NOT APPLICABLE, since 02/01/2026
• PIMENTO PROPERTY HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 02/01/2026
• RED STONE ADVISORS LLC — adp of the snf, NOT APPLICABLE, since 02/01/2026
• ROJO RE TRUST — adp of the snf, NOT APPLICABLE, since 02/01/2026