Inspection Reports for
The Ellington

The facility was found deficient in notifying the state's Long-Term Care Ombudsman of resident discharges, ensuring accurate Minimum Data Set (MDS) assessments, implementing physician orders for heel protectors, and reviewing and revising care plans appropriately.

The investigation was complaint-driven, focusing on failure to conduct fall risk assessments after falls and failure to assess and treat a resident's right leg injury. The complaints were substantiated with findings of minimal harm and few residents affected.

The facility failed to ensure nursing services met professional standards by not conducting fall risk assessments after each fall for Resident #3 and inaccurately assessing fall risk status. The facility also failed to assess and document care for Resident #4 after reports of bruising, swelling, and pain to the right leg, resulting in a missed fracture diagnosis.

The complaint investigation was substantiated. The Immediate Jeopardy was identified due to Resident #1 eloping from the facility undetected on 08/23/2024. The facility was notified on 09/04/2024, and the Immediate Jeopardy was removed the same day after the facility implemented an acceptable Plan of Removal.

The facility failed to implement care plan interventions and provide adequate supervision to prevent Resident #1, a cognitively impaired resident with a history of wandering, from eloping. Staff did not redirect or monitor the resident despite multiple exit-seeking behaviors, and the elopement alarm system was ineffective due to low volume and lack of staff response. The resident eloped undetected at 6:51 p.m. on 08/23/2024 and was found approximately 300 feet away.

The investigation was triggered by complaints about Resident #1's repeated falls and failure of staff to assist him properly during night rounds. The complaint was substantiated as the facility did not follow care plan interventions and the wheelchair alarm was non-functional.

The facility failed to ensure that Resident #1 was properly assisted during night rounds and that the resident's wheelchair alarm was functioning. Multiple falls occurred due to inadequate supervision and a non-functioning wheelchair alarm without batteries.

The facility was found deficient in multiple areas including failure to maintain clean bed linens, failure to follow physician orders for TED hose application, improper storage of oxygen equipment, leaving medications at the bedside, improper food labeling and storage, and incomplete documentation of treatment administration records.

The facility failed to ensure that Resident #2's person-centered plan of care was implemented for monitoring adverse reactions to Plavix and Aspirin. Documentation of monitoring for adverse reactions was not found in the Medication Administration Record or Treatment Administration Record for March, April, and May 2024.

A finding of neglect was substantiated as the aide failed to follow the resident's care plan during transfer. The resident sustained fractures to both lower legs. The staff member was suspended, counseled, retrained, and placed on probation. The facility started a Quality Assessment and Improvement Project and monitoring of transfers.

The facility failed to ensure a resident was transferred safely according to the care plan, resulting in fractures to the resident's legs. The staff member responsible was suspended, retrained, and placed on probation, and the facility implemented corrective actions including monitoring transfers.

Resident #2's responsible party filed a grievance after reviewing video footage showing the resident pressed the call bell at 1:34 a.m. on 12/05/2023 but did not receive assistance for approximately 30 minutes before attempting to get out of bed and falling. The call system was confirmed to be malfunctioning on Halls B and C during this time.

The facility failed to ensure Resident #2 had a working call light and received prompt response when assistance was requested. The resident call system was malfunctioning on Halls B and C from December 4 through December 19, 2023, contributing to the resident's fall and delayed assistance.

The facility had multiple deficiencies including inaccurate Minimum Data Set assessments, incomplete PASARR screening for mental disorders, failure to implement care plans as ordered, failure to meet resident food preferences, and inadequate infection prevention practices.

The complaint investigation substantiated that the facility did not notify the physician in a timely manner about Resident #2's low blood pressure on 03/24/2023. Interviews with nursing staff and the medical doctor confirmed the failure to follow protocols and notify the physician promptly.

The facility failed to notify the physician promptly about Resident #2's low blood pressure readings on 03/24/2023, despite care plans requiring notification of significant abnormalities. The resident's condition deteriorated, requiring hospital transfer for critical care due to metabolic crisis, dehydration, and sepsis.