Inspection Report Summary
The most recent inspection on February 4, 2025, identified deficiencies related to failure to identify and evaluate an injury of unknown origin and to ensure client safety in the locked Memory Care unit. Earlier inspections showed a mixed pattern, with prior deficiencies involving safety checks for high-risk clients, documentation issues, and administrative matters such as agreements and disclosures. The main themes across reports included client safety monitoring, injury evaluation, and regulatory compliance in documentation and care procedures. A complaint investigation in 2025 was substantiated regarding these safety concerns, while earlier complaints were not noted. The facility’s inspection history shows recurring issues with safety oversight, although some renewal inspections in recent years found no deficiencies.
Deficiencies (last 6 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a June 2022 inspection.
Census over time
| Name | Title | Context |
|---|---|---|
| Elizabeth T Heiney | SNC | Report submitted by Elizabeth T Heiney SNC. |
| Ellen Casey | ED | Personnel contacted during the inspection. |
| Roseline Lynch | SALSA | Personnel contacted during the inspection. |
| Description |
|---|
| Failure to identify and evaluate an injury of unknown origin and ensure client safety in the locked Memory Care unit. |
| Name | Title | Context |
|---|---|---|
| Elizabeth Heiney | Supervising Nurse Consultant | Author of the initial letter and contact for plan of correction |
| Rosaline Lynch | Director of Wellness and Supervisor of Assisted Living Services Agency | Submitted the plan of correction response |
| LPN #4 | Manager of the Memory Care Unit, interviewed regarding client injury | |
| LPN #1 | Provided statements about client observations and injury | |
| Aide #1 | Provided statements about client safety checks | |
| LPN #2 | Provided statements about client observations | |
| Aide #3 | Provided statements about client observations and bruising |
| Name | Title | Context |
|---|---|---|
| Ellen Casey | Executive | Personnel contacted during inspection |
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | RN Nurse Consultant | Report submitted by |
| Ron Bucci | Ex Director | Personnel contacted during inspection |
| Michelle DelValle | SALSA | Personnel contacted during inspection |
| Name | Title | Context |
|---|---|---|
| Michael J. Smith | Nurse Consultant | Report submitted by |
| Ron Bucci | Ex Director | Personnel contacted during inspection |
| Michelle DelValle | SALSA | Personnel contacted during inspection |
| Description |
|---|
| Failure of ALSA staff to provide necessary safety checks every two hours for a client at high risk for falls, resulting in a fall with injury and inadequate documentation of safety checks. |
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed the violation notice and correspondence from the Facility Licensing and Investigations Section. |
| Michelle DelValle | Director of Wellness and Supervisor of Assisted Living Services Agency | Signed the Plan of Correction response letter. |
| Name | Title | Context |
|---|---|---|
| Jane Wilson | RN | Personnel contacted during inspection |
| Description |
|---|
| Failure to develop a written agreement between the ALSA and the home care agency to delineate responsibilities and ensure continuity of care. |
| Failure to ensure ALSA special care unit disclosures were signed by the clients' responsible parties. |
| Name | Title | Context |
|---|---|---|
| Loan Nguyen | Supervising Nurse Consultant | Signed the notice of violations and correspondence related to the inspection |
| Michelle DelValle | Director of Wellness and Supervisor of Assisted Living Services Agency | Signed the Plan of Correction response letter |
| Name | Title | Context |
|---|---|---|
| Ron Bucci | ED | Personnel contacted during inspection |
| Rosalina Riccagni | RN | Personnel contacted during inspection |
| Sosa | Personnel contacted during inspection |
| Description |
|---|
| Failed to ensure personnel files met requirements including documentation of medical physical exams, TB testing, orientation, and clinical competency evaluations. |
| Medication administration errors including failure to timely administer medications and notify appropriate parties of missed doses. |
| Name | Title | Context |
|---|---|---|
| Rosaline Banguela | Supervisor of Assisted Living Services Agency | Named in relation to personnel file deficiencies and plan of correction |
| Loan Nguyen | Supervising Nurse Consultant | Report submitted by and approval of license granted |
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