Inspection Report Summary
The most recent inspection on October 15, 2025, identified deficiencies related to supervision of aides, safety checks, personnel record maintenance, prevention of unwelcome contact, and family council notifications. Earlier inspections showed a substantiated complaint investigation in June 2025 that confirmed violations involving the Alzheimer's special care unit and infection control requirements. The main themes across reports involved staff supervision, safety protocols, documentation, and resident interactions. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The pattern suggests ongoing challenges in maintaining certain regulatory standards without clear improvement or worsening over time.
Deficiencies (last 1 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
| Description |
|---|
| Failure to ensure completion of 120-day supervision of ALSA aides and proper documentation of aide performance and resident satisfaction. |
| Failure to ensure completion of hourly safety checks per Client #1's service plan and lack of a policy for safety checks in the memory care unit. |
| Failure to ensure personnel records contained annual reviews signed by employees upon completion. |
| Failure to maintain professional standards of conduct to prevent unwelcome contact by staff member for a resident with cognitive decline, including an incident of inappropriate touching. |
| Failure to periodically notify families about the ability to have family councils and low response to family council formation efforts. |
| Name | Title | Context |
|---|---|---|
| Clare Scully | Executive Director | Personnel contacted and submitted Plan of Correction |
| Erle Gerangaya | SALSA, RN | Personnel contacted during inspection |
| Jennifer Green | RNC | Report submitted by |
| Judy Birtwistle | SNC, Supervising Nurse Consultant | Approval for issuance of license granted by |
| Name | Title | Context |
|---|---|---|
| Clare Scully | Executive Director | Personnel contacted during the inspection |
| Erle Gerangaya | SALSA | Personnel contacted during the inspection |
| Megan Edson-Sawyer | Nurse Consultant | Signature of FLIS Staff and report submitter |
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