Inspection Reports for The Ivy at Wellington

This unannounced inspection was conducted to investigate complaints alleging lack of supervision resulting in resident on resident sexual abuse and that the facility was allowing a resident to violate the gun policy.

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 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 inspection was an unannounced complaint investigation visit triggered by allegations received on 2025-06-03 regarding staff tampering with resident's personal belongings, not following the monthly menu, and serving poor quality food.

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 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 visit was an unannounced annual required inspection conducted by Licensing Program Analyst Ruth Martinez to evaluate compliance with licensing requirements.

The inspection found no deficiencies in the areas inspected. The facility was observed to be well maintained with proper safety measures, adequate staffing documentation, and appropriate resident care and environment.

The visit was an unannounced complaint investigation triggered by allegations received on 2025-03-24 regarding staff discarding residents' meals and dispensing medication not prescribed.

The investigation determined that the complaint was filed under the wrong facility license number and found the allegations to be unfounded, meaning the allegations were false or without reasonable basis. The complaint was dismissed.

The complaint was investigated and found to be unfounded; the allegations were false or could not have happened.

An unannounced complaint investigation was conducted regarding an allegation that the facility did not release resident records to the responsible party.

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 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.

An unannounced visit was made by Licensing Program Analyst Andrea Mendivil to deliver an amended report due to technical difficulties in delivering findings earlier.

The amended report findings were discussed with facility staff including the Health Services Director and Executive Director, and an exit interview was conducted with facility staff.

An unannounced case management visit was conducted in conjunction with complaint control 22-AS-20250102131745 regarding allegations that a resident was administered unauthorized medications.

The investigation found that medication Oxybutynin was supposed to be tapered off and discontinued per the current physician's order received on 07/19/2023, but the medication continued to be administered until August 14, 2024, due to a failure to update the medication administration records and report the issue to the Department.

Complaint investigation related to unauthorized medication administration to Resident 1 (R1). The issue was substantiated based on interviews and record reviews.

This unannounced visit was conducted to investigate a complaint alleging that a resident sustained multiple unexplained bruises while in care.

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

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

An unannounced complaint investigation visit was conducted in response to an allegation that staff do not provide adequate care and supervision for a resident.

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

An unannounced complaint investigation visit was conducted in response to an allegation that staff were not following infection control requirements.

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 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 visit was an unannounced annual required inspection conducted by Licensing Program Analyst Ruth Martinez to evaluate compliance with state regulations.

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 inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-10-27 alleging that staff do not answer residents' call buttons in a timely manner and do not ensure residents are bathed.

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 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.

This unannounced Case Management – Incident inspection was conducted to follow up on a self-reported incident involving a medication error where Resident #1 received twice the prescribed dose of Oxycodone.

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 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.

Licensing Program Analyst Lydia Martinez conducted a pre-licensing inspection visit to evaluate the facility's readiness for initial licensing as a Residential Care Facility for the Elderly (RCFE) with a capacity of 305 residents.

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 visit was an office type evaluation involving the applicant/administrator's participation in COMP II to verify understanding of community care facility licensing laws and regulations.

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.

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