Inspection Report Summary
The most recent inspection on June 20, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a mixed record with some deficiencies related mainly to client safety and service plan updates, as well as medication management issues identified in prior complaint investigations. Inspectors cited failures to update service plans after incidents of falls and elopement, and earlier reports noted medication misappropriation by a staff member that led to termination. Complaint investigations were mostly unsubstantiated except for the substantiated medication issue in 2021. The facility’s inspection history shows some improvement with no deficiencies found in the latest visit following earlier citations.
Deficiencies (last 5 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a April 2024 inspection.
Census over time
| Name | Title | Context |
|---|---|---|
| Jessica Brown | Executive Director | Personnel contacted during the inspection. |
| Michael J. Smith | RN | Report submitted by. |
| Name | Title | Context |
|---|---|---|
| Jessica Brown | ED | Personnel contacted during inspection |
| Corrina Vendetto | SALSA | Personnel contacted during inspection |
| Paige Menditto | Reg. Dir. Resident Care | Personnel contacted during inspection |
| Elizabeth T Heiney | SNC-FLIS | Report submitted by |
| Name | Title | Context |
|---|---|---|
| Jessica Brown | ED | Personnel contacted during inspection |
| Corrina Vendetto | SALSA | Personnel contacted during inspection |
| Paige Menditto | Reg. Dir. Resident Care | Personnel contacted during inspection |
| Elizabeth Heiney | SNC-FLIS | Nurse Consultant and report submitter |
| Name | Title | Context |
|---|---|---|
| Bonnie Pollard-Johnson | Executive Director | Personnel contacted during the inspection. |
| Megan Edson-Sawyer | Survey Team Leader | Named as Survey Team Leader and Nurse Consultant. |
| Elizabeth Heiney | Supervisor | Named as Supervising Nurse Consultant/Health Program Supervisor. |
| Description |
|---|
| The ALSA failed to ensure clients' safety and failed to update service plans and assessments with changes in clients' conditions, including failure to identify and revise interventions after incidents of falls and elopement for Client #1 and Client #2. |
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Signed letter and contact for plan of correction response |
| Bonnie Pollard-Johnson | Executive Director | Named in relation to failure to identify additional elopement evaluations and revise service plans |
| Description |
|---|
| Failure to protect the client's property related to misappropriation of medication for two clients. |
| Name | Title | Context |
|---|---|---|
| Cheryl Davis | Public Health Services Manager | Signed the report and is the contact for questions regarding the violation |
| RN #1 | Identified as the staff member who misappropriated medication and was terminated | |
| Pill Finder | RN designee who identified pills during the investigation |
| Name | Title | Context |
|---|---|---|
| Bonnie Pollard Johnson | Executive Director | Personnel contacted during inspection |
| Senetra Wright | Acting SABST | Personnel contacted during inspection |
| Laura Boggio | RN Nurse Consultant | FLIS Staff conducting inspection and report submission |
| Name | Title | Context |
|---|---|---|
| Bonnie Pollard Johnson | Executive Director | Personnel contacted during inspection |
| Sandra Wright | Acting SA/SA Designee | Personnel contacted during inspection |
| Name | Title | Context |
|---|---|---|
| Tashawn Leahy | ALSA | Personnel contacted during inspection |
| Bonnie Pollard-Johnson | Personnel contacted during inspection | |
| Joyce Stuben | Regional | Personnel contacted during inspection |
| Loan D Nguyen | Supervisor | Approval for issuance of license granted by |
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