Inspection Report Summary
The most recent inspection on July 21, 2025, identified a deficiency related to the failure to establish a family council in the dementia special care unit as required by state law. Earlier inspections showed mostly compliance, with no violations found during monitoring visits in late 2023, although a complaint investigation then noted a failure to ensure client safety and timely reporting of an abuse allegation, which was ultimately unsubstantiated. The main themes of deficiencies involved administrative oversight in dementia care and adherence to abuse reporting policies. Complaint investigations were generally unsubstantiated, and no fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The inspection history shows some isolated issues but no clear pattern of worsening or repeated deficiencies over time.
Deficiencies (last 2 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a July 2025 inspection.
Census over time
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Karen Donato | RNC | Report submitted by |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Named as the contact for questions and instructions related to the plan of correction |
Inspection Report
Monitoring| Name | Title | Context |
|---|---|---|
| Jessica Carlson | SALSA | Personnel contacted during the inspection. |
| Sabrina Consiglio | Executive Director | Personnel contacted during the inspection. |
Inspection Report
Plan of Correction| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Signed letter and contact for instructions related to plan of correction |
Inspection Report
Monitoring| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Survey Team Leader | Named as survey team leader for the inspection |
| Liz Heiney | Supervisor | Named as supervisor for the inspection |
| Sabrina Consiglio | Executive Director | Personnel contacted during inspection |
| Jessica Carlson | RN | Personnel contacted during inspection |
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