Inspection Report Summary
The most recent inspection on November 6, 2024, identified deficiencies related to the facility’s policy on pendant call response times and timely staff responses to client calls for assistance. Earlier inspections showed additional issues with updating service plans to reflect changes in client conditions and documentation and safety monitoring protocols, particularly during client isolation for COVID-19. Prior complaint investigations mostly found no violations, though a substantiated case in 2018 noted failures to update service plans and address client injuries and risks. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history shows ongoing challenges with documentation and timely client care responses, with some recent efforts to address these through plans of correction.
Deficiencies (last 4 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a July 2024 inspection.
Census over time
| Description |
|---|
| Failure to develop a comprehensive policy for pendant call response times and failure to provide timely responses to client calls for assistance. |
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Signed letter and contact person for response regarding complaint #41704. |
| Doris Quagliani | Interim Executive Director | Named as recipient and interviewed regarding pendant call policy. |
| Description |
|---|
| Failure to update the service plan with a change in condition for a client receiving assisted living services. |
| Failure of assisted living services agency aides to follow proper documentation and safety monitoring protocols during client isolation for COVID-19. |
| Name | Title | Context |
|---|---|---|
| Elizabeth T. Heiney | Supervising Nurse Consultant | Author of the plan of correction letter |
| Name | Title | Context |
|---|---|---|
| Julia O'Sullivan | ED | Personnel contacted during inspection |
| Jackie Noccioli | Acting SALSA | Personnel contacted during inspection |
| Karen Donato | RNC | Report submitted by |
| Elizabeth T. Tobey | Supervisor | Approval for issuance of license granted by |
| Name | Title | Context |
|---|---|---|
| Julia O'Sullivan | Executive Director | Self-reported the lightning strike incident and identified ongoing communication plans |
| Tony Rojos | Director | Obtained 100 air conditioners for client apartments |
| David Colongilo | VP of Operations | Identified possibility of chiller being fixed as of 07/09/24 |
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Nurse Consultant | Report submitted by |
| Julia O'Sullivan | Ex. Director | Personnel contacted during inspection |
| Pat Zimmermann | RN, SALSA | Personnel contacted during inspection |
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | RN Nurse Consultant | Report submitted by and signature on inspection report |
| Julia O'Sullivan | Executive Director | Personnel contacted during inspection |
| Pat Zimmermann | RN SALSA | Personnel contacted during inspection |
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Nurse Consultant | Report submitted by |
| Julia O’Sullivan | Executive Director | Personnel contacted during inspection |
| Sheryl Bilyard | SALSA | Personnel contacted during inspection |
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Nurse Consultant | Report submitted by and involved in the inspection |
| Julia O'Sullivan | Ex Director | Personnel contacted during the inspection |
| Sheryl Bilyard | SALSA | Personnel contacted during the inspection |
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Nurse Consultant | Report submitted by and involved in inspection |
| Julia O'Sullivan | Ex Director | Personnel contacted during inspection |
| Sheryl Bilyard | SALSA | Personnel contacted during inspection |
| Name | Title | Context |
|---|---|---|
| Sheryl Bilyard | SMUA | Personnel contacted during the inspection |
| Julia O'Sullivan | Executive Director | Personnel contacted during the inspection |
| Description |
|---|
| Failed to update client service plan to reflect injuries and interventions for Clients #1 and #3 with injuries of unknown origin. |
| Failed to identify updates to reflect changes in Client #1's condition and interventions to address functional decline, risk for falls, and bruises. |
| Failed to identify written instructions to aides addressing Client #1's functional decline, risk for falls, and bruises. |
| Failed to identify further statements from involved ALSA staff after inquiry from surveyor. |
| Failed to address instructions for ALSA aides to reflect Client #1's change in condition with interventions to address injuries of unknown origin. |
| Name | Title | Context |
|---|---|---|
| Donna Jones | Supervisor of Assisted Living Services Agency | Personnel contacted during the inspection and named in the report. |
| Loan Nguyen | Supervising Nurse Consultant | Named as the approving supervisor for issuance of license and recipient of plan of correction. |
| Joyce Farber | Resident Care Specialist | Author of the plan of correction letter responding to the alleged violations. |
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