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

The inspection was conducted as a renewal licensing inspection and included review of a complaint investigation #37724.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection.

Complaint investigation #37724 was reviewed during this inspection.

An unannounced visit was conducted on February 16, 2024, to Ellington Assisted Living Services, LLC, for the purpose of conducting a complaint investigation.

The investigation identified violations related to failure to maintain complete client records, failure to ensure client safety, and failure to conduct timely nursing assessments. Specifically, Client #1 experienced a fall resulting in injury, and the agency failed to perform consistent hourly safety checks and follow-up nursing assessments as required.

Complaint #37724 triggered the investigation. The complaint involved concerns about client safety and nursing assessments related to Client #1, who suffered a fall and injury.

The inspection visit was conducted in response to complaint #35490 and included verification of Alzheimer's special care units or programs and compliance with infection prevention and control requirements.

No violations of the General Statutes of Connecticut and/or regulations were identified at the time of this inspection.

Complaint #35490 was investigated and found to have no violations.

The inspection visit was conducted as a complaint investigation related to Complaint #35003 regarding violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies.

Violations were identified at the time of the inspection as noted in the attached violation letter dated 2023-09-30.

Complaint #35003 was investigated and violations were substantiated as indicated by the attached violation letter dated 2023-09-30.

An unannounced visit was made to Ellington Assisted Living Services LLC on May 1, 2023, by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an investigation with additional information received through May 1, 2023.

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.

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 inspection was a licensing inspection for renewal purposes at The Ivy Ellington facility.

Violations of the General Statutes of Connecticut and/or regulations of Connecticut State Agencies were identified at the time of this inspection. A violation letter dated 6/13/22 was attached. The facility has a full-time Infection Prevention and Control Specialist.

An unannounced review was conducted at Ellington Assisted Living Services LLC on April 14, 2021, by the Department of Public Health to investigate allegations of physical abuse and compliance with state regulations.

The investigation found that the agency failed to promptly investigate allegations of physical abuse involving Client #1, including failure to report bruises and conduct a thorough investigation. Documentation and staff interviews revealed lapses in following agency policy for abuse reporting and investigation.

Complaint #29788 involved allegations of physical abuse to Client #1 in the memory care unit. The complaint was substantiated by findings of bruises and failure of staff to report and investigate as required by policy.

An unannounced visit was made to Ellington Assisted Living Services LLC on June 29, 2020 by a representative of the Facility Licensing and Investigations Section of the Department of Public Health for the purpose of conducting an inspection.

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.