The most recent inspection on December 9, 2025, found no deficiencies during the recertification visit for the Assisted Living Program for People with Dementia. Earlier inspections showed a pattern of compliance, with no regulatory insufficiencies cited in the February 22, 2024, recertification visit or the May 4, 2022, complaint investigation, which found no issues. The initial licensing inspection in July 2021 identified several deficiencies related to staff background checks, tenant evaluations, documentation, service plan signatures and updates, and door alarm systems. No fines, enforcement actions, or license suspensions were listed in the available reports. The facility appears to have addressed earlier deficiencies and demonstrated improvement over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit, indicating compliance with certification rules for the facility.
Report Facts
Number of tenants without cognitive impairment: 2Number of tenants with cognitive impairment: 9Total census: 11
Investigation of Complaint #101059-C and Incident #101152-I at the Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint and incident.
Complaint Details
Investigation of Complaint #101059-C and Incident #101152-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 1Number of tenants with cognitive disorder: 13Total Census: 14
Inspection Report Original LicensingCensus: 12Deficiencies: 7Jul 19, 2021
Visit Reason
Initial certification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Findings
The inspection identified multiple regulatory insufficiencies including failure to complete required criminal history background checks prior to employment, failure to complete tenant evaluations within 30 days of occupancy and as needed with significant change, failure to maintain proper tenant documentation including nurses' notes, failure to have signed service plans prior to occupancy, failure to update service plans timely, and failure to have an operating door alarm system connected to each exit door in the dementia-specific program.
Deficiencies (7)
Description
Failed to complete a criminal history background check completed by the Department of Public Safety prior to employment for 1 of 5 staff reviewed.
Failed to complete cognitive, health and functional evaluations within 30 days of occupancy for 3 of 3 tenants reviewed.
Failed to complete cognitive, health and functional evaluations as needed with significant change for 2 of 3 tenants reviewed.
Failed to document nurses' notes by exception for 2 of 3 tenants reviewed.
Failed to ensure service plans signed by tenant or legal representative prior to signing occupancy agreement and taking occupancy for 3 of 3 tenants reviewed.
Failed to update service plans within 30 days of occupancy and as needed with significant change for 3 of 3 tenants reviewed.
Failed to have an operating door alarm system connected to each exit door in the dementia-specific program, potentially affecting all tenants (census of 12).