Ivy At Wellington, The

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility failed to meet resident's needs.

On March 24, 2026, Licensing Program Analyst (LPA) Jessica Cho made an unnanounced visit for the purpose of continuing the investigation into the above allegation. LPA met with Assistant Executive Director (AED) Melanie Sigar and explained the reason for the visit. On November 20, 2023, the Department received the complaint initiated by LPA Jenifer Tirre on November 29, 2023. During the course of the investigation conducted by LPA Cho, LPA interviewed one staff/ witness and obtained copies of the following documentation for review: Resident/Staff Rosters, Residency Agreement, facility map, and written correspondence. It is alleged that Facility failed to meet the resident's needs concerning Resident #1 (R1). Based on record review, R1 resided in the Independent Living (IL) per the Residency and Service Agreement dated April 19, 2022. Page 7 of the agreement notes under section 9. "Not a Continuing Care or RCFE Contract," the agreement does not entitle resident to receive services in ththe state’s words, verbatim · CDSS document, Mar 24, 2026 · control 22-AS-20231120131411

Allegation investigated: Staff did not provide safet transportation to residents. Resident sustained an injury due to staff neglect.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegations. LPA spoke with Jerry Vadnais, Executive Director, and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, resident file review and interviews conducted. It is alleged staff did not provide safe transportation to residents and resident sustained an injury due to staff neglect, specifically to driver not securing resident walkers and walkers hitting resident (R1) on the head. Interview with staff stated that it was reported by R1 of the incident once they returned to the facility. Staff Continued on LIC9099-C Substantiatedthe state’s words, verbatim · CDSS document, Mar 10, 2026 · control 22-AS-20260108125813

Allegation investigated: Facility did not ensure resident was not accorded reasonable accommodations.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Gerry Vadnais, Executive Director and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, and interviews conducted. It is alleged that facility did not ensure resident was not accorded reasonable accommodations, specifically to resident (R1) sunroom being painted. LPA conducted a facility visit on October 29, 2025, and toured the facility and R1’s apartment. It was observed that R1’s sunroom had not been painted, or Continued on LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 17, 2025 · control 22-AS-20251024160735

Allegation investigated: Staff did not allow resident's medication to be delivered.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA spoke with Gerry Vadnais, Executive Director and explained the purpose of the visit. During the course of the investigation, interview was conducted with staff, a review of facility records was completed and copy of pertinent documents obtained. It is alleged that staff did not allow resident's (R1) medication to be delivered. Based on the information on file for facility R1 resides in the independent living side in building A. Building A census is independent residents and it is not covered under CCLD licensure for the facility. Licensure for the facility only covers building B. Therefore, the Department has determined the complaint to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. The Department has therefore dismissed the complaint. A copy of thisthe state’s words, verbatim · CDSS document, Nov 17, 2025 · control 22-AS-20251010153151

Allegation investigated: Facility did not safeguard medications Facility staff are not trained in medication administration

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegations received on January 29, 2024. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Gerry Vadnais. LPA explained the reason for the visit. This Department has investigated the complaint alleging that facility did not safeguard medications. Regarding the allegation the following was revealed: During the course of the interviews with individuals nine of nine individuals interviewed denied the allegations. During the initial visit on February 8, 2024, and subsequent visits on October 29, 2025, and November 14, 2025, LPA tour the facility and observed that the medications were locked inside the Medication Room. LPA also observed that the Medication Technicians (MTs) need a key to open the Medication carts. During the course of the interviews with residents, Resident 2 (R2) reported that the facility staff safeguard the medicationthe state’s words, verbatim · CDSS document, Nov 14, 2025 · control 22-AS-20240129065431

Allegation investigated: Faciltiy did not safeguard resident's personal items.

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude investigation into the above identified complaint allegation. LPA arrived at the facility and was greeted at the and granted entry. LPA spoke with Gerry Vadnais, Executive Director and explained the purpose of the visit. Findings are based upon this investigation which included tour of the facility, facility file review, and interviews conducted. It is alleged that facility did not safeguard resident’s personal items, specifically to items in an assigned residents (R1) locker. Interview with staff stated that when the license and the building were under the Continued on LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 21, 2025 · control 22-AS-20251006154342

Allegation investigated: Lack of supervision resulted in resident on resident sexual abuse. Facility is allowing resident to violate gun policy.

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Jessica Cho for the purpose of delivering findings for the investigation into the above identified complaint allegations. LPA met with Administrator (AD) Gerry Vadnais and explained the reason for today’s inspection. The investigation conducted by LPA Sean Haddad into the allegations that lack of supervision resulted in resident on resident sexual abuse and facility is allowing resident to violate gun policy revealed the following: During the course of the investigation, Department staff inspected the facility, interviewed AD, residents, staff, and witnesses, and obtained and reviewed copies of the resident roster, staff roster, Resident #1’s (R1) Admission Agreement, R1’s Physician’s Report dated November 17, 2021, R1’s Resident Appraisal dated March 17, 2022, R1’s Level of Care Assessment dated November 2, 2021, R1’s Mini-Mental State Examinations conducted on November 23, 2021, and March 17, 2022, R1’sthe state’s words, verbatim · CDSS document, Aug 21, 2025 · control 22-AS-20230831115602

Allegation investigated: -Staff tamper with resident's personal belongings -Staff are not following the monthly menu -Staff are serving a poor quality of food

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrive at facility was greeted and granted entry by staff. LPA spoke with Gerry Vadnais, Executive Director and explained the purpose of the visit. Findings are based upon this investigation which included facility file review, menus, room service menus, tour of the physical plant of the facility and interviews conducted. It is alleged that staff tamper with resident’s personal belongings. The interview with 2 of 2 staff stated that resident (R1) complained about an artificial plant in the exterior of their apartment in which the leaves were cut and/or removed. R1 never complained about a safe or missing batteries from it. Staff stated they weren’t Continued on LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 24, 2025 · control 22-AS-20250603091336

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: -Staff discarded residents' meals. -Staff disoensed medication to residents that was not prescribed.

Licensing Program Analyst (LPA) Ruth Martinez visited the facility to deliver findings for the investigation into the above identified complaint allegations. LPA arrived at facility and was greeted at the door and granted entry receptionist. LPA spoke with Gerry Vadnais, Executive Director and explained the purpose of the visit. After further investigation into this complaint and information received LPA determined that this complaint was written under the wrong facility license number. We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted with Executive Director and a copy of this LIC9099 report was left at facility. Unfoundedthe state’s words, verbatim · CDSS document, Apr 8, 2025 · control 22-AS-20250324102341

Allegation investigated: Facility did not release resident records to responsible party

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez regarding the allegation mentioned above for the purpose of delivering findings. LPA met with Executive Director (ED) Gerry Vadnais and explained the purpose of the inspection. It is alleged facility did not release Resident 1’s (R1’s) records to responsible party. During initial complaint investigation conducted on February 26, 2025, LPA conducted a record review of R1’s file and observed all documentation in question to be present, including physician orders and resident progress notes. During today’s visit, LPA interviewed two of two staff responsible for the release of resident records to their responsible party. During their interview, Staff 1 (S1) stated that that they had not personally received any request for release of any residents’ records, including R1. Per S1, in order for any resident’s responsible party to obtain records all that is required is a verbalthe state’s words, verbatim · CDSS document, Apr 8, 2025 · control 22-AS-20250131085015

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility administered unauthorized medications Facility staff did not provide medications as prescribed

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a complaint investigation. LPA Mendivil was greeted and granted entry into the facility by Executive Director Gerry Vadnais and explained the reason for the visit. The Department received a complaint on 01/02/2025 and the initial 10 day visit was conducted on 01/09/2025. During the visit LPA Mendivil interviewed staff and obtained copies of medication administration records from July 2023 to December 2024, physician reports, and doctors orders. Regarding the allegations facility administered unauthorized medications and facility did not provide medications as prescribed, the investigation revealed the following: It was alleged that Resident 1 (R1) was administered unauthorized medications. Substantiatedthe state’s words, verbatim · CDSS document, Jan 9, 2025 · control 22-AS-20250102131745

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident sustained multiple unexplained bruises while in care.

This unannounced visit conducted by Licensing Program Analysts (LPA) Ruth Martinez is being conducted to conclude this agency’s investigation into the complaint allegation mentioned above. During the course of the investigation the following was conducted: interviews were conducted with staff, interviews were conducted with resident, a tour of the resident’s bedroom was conducted, a review of resident records was completed and copy of pertinent documents obtained. It is alleged resident sustained multiple unexplained bruises while in care. Interviews were conducted with staff which indicated that resident (R1) was being treated for Edema of the lower leg and for her ASCVD (Atherosclerotic cardiovascular disease) by a home health agency. R1 was sent to hospital on October Continued on LIC9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 4, 2024 · control 22-AS-20241104110548

Allegation investigated: Staff do not provide adequate care and supervision for a resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility and interviewed staff and witness as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that staff do not provide adequate care and supervision for a resident, the investigation revealed the following: Resident 1 (R1) was hospitalized from 09/02/2024-09/09/2024 for weeping legs. Facility conducted an assessment upon return from the hospital with two changes from prior assessment dated 06/15/2024 which includes meal delivery and standby assistance with dressing until the resident recuperates. Resident's physician reports dated 04/23/2019 and 09/09/2024 are virtually the same indicating resident is able to leave the facility unassisted and receives methe state’s words, verbatim · CDSS document, Oct 1, 2024 · control 22-AS-20240904100619

Allegation investigated: Staff are not following infection control requirements

Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit to deliver findings on complaint investigation into the above allegations. LPA explained the reason for the visit with Senior Executive Director Gerry Vadnais. During the course of the investigation LPA toured facility with Health Service Director, conducted interviews with staff and residents, made visual observations and requested pertinent documentation such as Resident Roster, staff roster, notification letter, incident reports and copy of essential precautions. During investigation LPA conducted interviews with staff and residents. Staff interviews revealed that facility has infection control precautions put into place for Covid 19 such as masks available at reception desk & Health Services room for residents, Caregiving staff, Dining room staff & maintenance staff are required to wear masks when coming into contact with residents. Staff interviews also revealed that staff are cleaning surfaces daily in cthe state’s words, verbatim · CDSS document, Jun 25, 2024 · control 22-AS-20240618142643

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff do not answer residents' call buttons in a timely manner Staff do not ensure residents are bathed

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility for the complaint received on 10/27/23 and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted by executive director (ED) Gerry Vadnais. During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed. It was alleged that the staff do not answer resident's call buttons in a timely manner. LPA toured random resident rooms and tested the call buttons. LPA observed that staff responded between thirteen to fifteen minutes. LPA conducted a total of 7 interviews that consisted of staff and residents. All 7 interviews did not corroborate with the allegation by stating that although there is an average of a fifteen to twenty minute response period, the staff still responds to the call button. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 3, 2023 · control 22-AS-20231027144246