Inspection Report Summary
The most recent inspection on October 26, 2023, found substantiated violations during a complaint investigation. Earlier inspections showed a pattern of deficiencies related mainly to infection control, including a failure to employ a part-time Infection Preventionist as required by state law. Complaint investigations prior to this were mostly unsubstantiated, with one in March 2023 finding no violations. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates ongoing challenges with infection prevention, with no clear improvement trend evident.
Deficiencies (last 2 years)
Deficiencies are regulatory violations found during state inspections.
Deficiencies per year
Census
Based on a September 2023 inspection.
Census over time
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Karen Donato | RNC | Report submitted by |
| Theresa Williams | ED | Personnel contacted |
| Debbie Bartosiewicz | SALSA (Regional) | Personnel contacted |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Theresa Williams | Executive Director | Personnel contacted during the inspection |
| Milissa Burnett | SALSA | Personnel contacted during the inspection |
| Megan Edson-Sawyer | Nursing Consultant and Survey Team Leader | Signature of FLIS Staff and report submitter |
| Elizabeth Heiney | Supervisor | Supervisor approving issuance of license |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Theresa Williams | Executive Director | Named as responsible for ensuring compliance with the plan of correction |
| Elizabeth Heiney | Supervising Nurse Consultant | Author of the inspection report and contact for plan of correction |
Inspection Report
Complaint Investigation| Name | Title | Context |
|---|---|---|
| Theresa Williams | Executive Director | Personnel contacted during inspection |
| Melissa Burnette | SALSA | Personnel contacted during inspection |
Inspection Report
Renewal| Name | Title | Context |
|---|---|---|
| Theresa Williams | Administrator | Personnel contacted during the inspection |
| Maryla Underwood | SALSA | Personnel contacted during the inspection |
| Laura Boggio | Survey Team Leader | Signature of FLIS Staff and report submitter |
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