Inspection Report
Renewal
Census: 14
Deficiencies: 0
Dec 9, 2025
Visit Reason
Recertification visit conducted 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 for the Assisted Living Program for People with Dementia.
Report Facts
Number of tenants without cognitive impairment: 1
Number of tenants with cognitive impairment: 13
Total census: 14
Inspection Report
Renewal
Census: 11
Deficiencies: 0
Feb 22, 2024
Visit Reason
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: 2
Number of tenants with cognitive impairment: 9
Total census: 11
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 0
May 4, 2022
Visit Reason
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: 1
Number of tenants with cognitive disorder: 13
Total Census: 14
Inspection Report
Original Licensing
Census: 12
Deficiencies: 7
Jul 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). |
Report Facts
Census: 12
Staff reviewed: 5
Tenants reviewed: 3
Documented refusals: 61
Falls: 12
Falls with pain complaints: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in finding for failure to complete DPS criminal history background check prior to employment | |
| Nurse Manager | Interviewed and confirmed multiple findings related to tenant evaluations, documentation, and service plans | |
| Director | Interviewed and confirmed finding related to background checks and door alarm system |
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