Inspection Reports for
The Ivy at Wellington

The complaint alleged that the facility failed to meet the needs of Resident #1. The complaint was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.

The investigation found that the resident in question resided in the Independent Living portion of the facility, which is not under the Department's licensing requirements. Therefore, the allegation that the facility failed to meet the resident's needs was deemed unfounded and dismissed.

The complaint investigation was substantiated for allegations that staff did not provide safe transportation and resident sustained injury due to staff neglect. The allegation that staff did not seek medical attention in a timely manner was unfounded.

The investigation substantiated that staff failed to provide safe transportation, resulting in a resident being hit on the head by unsecured walkers in the facility van. Another complaint about delayed medical attention was found to be unfounded as the resident initially refused hospital evaluation but later sought care.

The complaint alleged the facility did not ensure a resident was accorded reasonable accommodations related to painting the resident's sunroom. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation found that the sunroom had not been painted due to concerns from the resident's responsible party about paint toxins. The facility provided a VOC levels report which satisfied the responsible party. There was insufficient evidence to prove or refute the allegation; therefore, the complaint was deemed unsubstantiated.

The complaint investigation addressed multiple allegations: 1) Facility did not safeguard medications, 2) Facility staff are not trained in medication administration, 3) Facility allowing unskilled staff to perform injections, and 4) Facility staff falsifies documents. The medication-related allegations were deemed unfounded, meaning false or without reasonable basis. The injection and falsification allegations were deemed unsubstantiated due to insufficient evidence.

The investigation found that the allegations regarding medication safeguarding and staff training were unfounded, as medications were properly secured and staff were adequately trained. The allegation of unskilled staff performing injections was unsubstantiated, with no evidence staff performed injections. The allegation of staff falsifying documents was also unsubstantiated due to conflicting information and lack of evidence. No citations were issued during this visit.

The complaint alleged that the facility did not safeguard a resident's personal items. The allegation was unsubstantiated due to lack of preponderance of evidence.

The investigation found that the locker assigned to the resident did not have a lock and contained items not belonging to the resident. However, the resident had not accessed the locker for four years and did not provide an inventory of items. Due to insufficient evidence, the allegation was deemed unsubstantiated.

The complaint investigation was triggered by allegations that lack of supervision resulted in resident on resident sexual abuse and that the facility allowed a resident to violate the gun policy. The investigation included interviews, record reviews, and inspections. The allegations were found to be unfounded.

The investigation found no corroborating evidence to support the allegations. The facility staff and administration had no reason to suspect abuse, and the facility enforced its gun policy once aware of the violation. The allegations were determined to be unfounded.

The complaint investigation was unsubstantiated. Allegations included staff tampering with resident belongings, failure to follow the monthly menu, and serving poor quality food. Interviews with staff and residents, as well as observations, did not support these allegations.

The investigation included interviews, facility file and menu reviews, and physical plant tours. The allegations were found to be unsubstantiated due to lack of preponderance of evidence to prove or refute the claims. Residents and staff interviews indicated no consistent issues with food quality or menu adherence, and no evidence of tampering with personal belongings was confirmed.

The inspection found no deficiencies in the areas inspected. The facility was observed to be well maintained with adequate food supply, proper medication storage, safe physical environment including pool fencing and fire safety equipment, and complete resident and staff records.

The complaint alleged that the facility did not release Resident 1's records to the responsible party. Staff interviews indicated no knowledge of denial of records, and record review showed documentation was present. Due to conflicting information, the allegation was unsubstantiated.

The investigation found conflicting information from staff interviews and record reviews, and was unable to determine if the facility failed to release resident records. Therefore, the allegation was unsubstantiated.

The amended report findings were discussed with facility staff including the Health Services Director and Executive Director. An exit interview was conducted and copies of the report and amended findings were provided.

The complaint was substantiated. The allegations that the facility administered unauthorized medications and did not provide medications as prescribed were found valid based on records and interviews.

The investigation substantiated the allegations that the facility administered unauthorized medications to Resident 1 and failed to provide prescribed medications from 12/29/2023 to 02/09/2024. The facility also failed to meet reporting requirements related to these medication issues.

The complaint alleged that a resident sustained multiple unexplained bruises while in care. The allegation was unsubstantiated due to lack of evidence.

The investigation included interviews with staff and the resident, a tour of the resident's bedroom, and a review of records. The resident was being treated for edema and cardiovascular disease, which could explain bruising. No bruising was observed during the visit, and there was insufficient evidence to substantiate the allegation. The complaint was deemed unsubstantiated.

The complaint was investigated and deemed unfounded, meaning the allegation was false, could not have happened, and/or was without a reasonable basis.

The investigation found that the allegation was unfounded. Resident records and interviews indicated the resident was independent except for bathing assistance, and the facility had made appropriate assessments and care adjustments following the resident's hospitalization.

The complaint alleged that staff were not following infection control requirements. After investigation, the allegation was deemed unsubstantiated due to lack of preponderance of evidence.

The investigation included interviews, observations, and document reviews which found that the facility had infection control precautions in place, including mask usage, cleaning protocols, PPE availability, and notification procedures. Despite the allegations, there was insufficient evidence to substantiate the claim, and the complaint was deemed unsubstantiated.

The inspection found no deficiencies in the areas inspected. The facility was observed to be well-maintained with adequate staffing, proper medication storage, safe physical environment, and compliance with health and safety regulations.

The complaint was unsubstantiated. The investigation included interviews with 7 staff and residents regarding call button response times and 3 staff interviews plus 4 resident interviews regarding bathing. The average call response time was between twelve to twenty three minutes based on pendant tracking reports. No evidence was found to prove or refute the allegations.

The investigation found that staff responded to call buttons within thirteen to fifteen minutes on average, with interviews from staff and residents not corroborating the allegations. Bathing schedules were tracked and refusals documented, with residents reporting no concerns. The allegations were deemed unsubstantiated due to lack of preponderance of evidence.

The visit was complaint-related, triggered by a self-reported incident of a medication error involving Resident #1. The medication error was substantiated as the licensee failed to ensure proper assistance with self-administered medications.

The inspection found that Resident #1 received a medication error but had no adverse reactions. The facility staff took corrective actions including retraining the Medication Technician involved, who later resigned. Deficiencies were cited related to failure to assist with self-administered medications.

The inspection found the facility in compliance with regulatory requirements, including adequate resident accommodations, operational appliances, safety systems, and emergency supplies. The facility is ready to be licensed pending final review and approval.

The applicant/administrator demonstrated understanding of facility operation, admission policies, staffing requirements and training, restrictive/prohibited health conditions, and general provisions as confirmed by the CAB analyst during the COMP II interview.