Inspection Reports for
The Ivy at Ellington Assisted Living and Memory Care

The visit was complaint-driven, identified as Complaint #37724. The complaint was investigated through clinical record reviews, interviews, and security camera observations. No practitioner referrals were anticipated at this time.

The investigation identified violations related to failure to maintain complete client records, inadequate nursing assessments, and failure to ensure hourly safety checks by aides. Specifically, Client #1's records showed missing reassessments and safety checks, and the agency failed to perform a follow-up RN assessment after a client fall.

The visit was complaint-related, triggered by concerns about the care of a client who fell and sustained injuries including two cervical fractures. The complaint was substantiated based on the findings of failure to follow fall policy and conduct proper investigations.

The facility failed to ensure oversight of nursing and ALSA aide care rendered to a client, failed to follow the agency's fall policy, failed to conduct a comprehensive investigation subsequent to a client's fall, and failed to review the client service plan as often as the client's condition required. The investigation revealed multiple failures in clinical record reviews, staff interviews, and agency documentation.

Complaint #29788 triggered the investigation. The complaint involved allegations of physical abuse to Client #1, substantiated by bruising and behavioral issues. The investigation found the agency did not comply with abuse reporting and investigation policies.

The investigation identified violations related to failure to promptly investigate allegations of physical abuse involving Client #1 in the memory care unit. The agency failed to follow its policy for abuse investigation, including failure to report bruises timely, incomplete documentation, and lack of suspension or prompt investigation of the alleged abuser.

The Assisted Living Services Agency (ALSA) registered nurse failed to document a risk assessment for two of three clients in the survey sample, leading to a clinical decision that the clients did not require isolation or quarantine after returning from the hospital or physician's office. The Supervisor of ALSA did not place either client under quarantine or complete a risk assessment including escort risk, transportation risk, and waiting room risk prior to determining quarantine was unnecessary.