The Ellington

In the surveyor’s words

From the most serious findings on record at The Ellington, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 4, 2024

  Based on record reviews, observations, and interviews, the facility failed to implement care plan interventions and provide adequate supervision to ensure a cognitively impaired resident, who had a history of wandering did not elope for 1 (Resident #1) out of 3 sampled resident (Resident #1, #2, and #3). This deficient practice resulted in an Immediate Jeopardy on 08/23/2024 at 6:51 p.m. when Resident #1, a severely cognitively impaired resident, was unsupervised and eloped from the facility. On 08/23/2024 beginning at 5:10 p.m., Resident #1 was observed by multiple staff members repeatedly attempting to open several doors throughout the facility before exiting the facility's front entrance door undetected by staff at 6:51 p.m. […]

• Actual harm, isolatedF689Apr 16, 2024

  Based on interviews, observations, and record reviews, the facility failed to ensure a resident was free from accidents hazards during a chair to bed transfer for 1 (#1) of 4 (#1, #2, #3, and #R1) sampled residents. This deficient practice resulted in actual harm for Resident #1 on 03/25/2024 at 5:37 p.m. when S5CNA (Certified Nursing Assistant) transferred the resident from chair to bed without assistance of another person and without the use of a mechanical lifter as required by his plan of care. On 03/26/2024 at 10:30 a.m., S3ADONWC observed Resident #1's right lower leg as discolored and painful upon movement. X-ray of the resident's right lower leg, dated 03/26/2024, revealed a tibia (shin bone) fracture. […]

• Actual harm, isolatedF689Sep 8, 2022

  Based on record reviews and interviews the facility failed to ensure a resident was free from accidents hazards during a lift transfer for 1 (#5) of 2 (#3, #5) residents who required two-person transfer with a mechanical (Hoyer) lift, of a total of 5 (#1, #2, #3, #4, and #5) sampled residents. This deficient practice resulted in an actual harm for Resident #5 on 7/6/2022 when S4CNA transferred the resident from a chair to the bed without assistance of another person nor utilizing the mechanical lift, according to the resident's care plan. Resident #5 sustained a fracture to her Left shoulder during the transfer. On 7/7/2022, an x-ray revealed that Resident #5 had an Oblique displaced angulated fracture of the proximal humerus. […]

• Actual harm, isolatedF689Apr 20, 2022

  Based on observations, record review and interview, the facility failed to provide supervision to prevent an avoidable accident for 1 (#4) of 5 (#1, #2, #4, #5, #R1) residents investigated for falls in a final sample of 6 residents by: 1. failing to ensure Resident #4 received 2 person assistance for bed mobility; and 2. failing to ensure roll control bolsters were tightly fastened to Resident #4's bed before providing care. This deficient practice resulted in actual harm on 4/3/2022 when S6CNA provided Resident #4's incontinence care without two-person assistance and without ensuring the roll control bolsters (device attached to Resident #4's bed to prevent falls) were properly secured. […]

• No harm, potential for more than minimal, patternF689Jul 10, 2024

  Based on observations, interviews and record reviews, the facility failed to ensure resident's remained free from accidents for 1 (Resident #1) of 3 (Resident #1, Resident #2, Resident #3) investigated for falls. The facility failed to ensure: 1. night staff got resident out of bed during last rounds, and 2. the resident's wheel chair alarm was properly working. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses that included, but not limited to Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety, Repeated Falls, Cognitive Communication Deficit, and Unsteadiness on Feet. […]