Routine inspection·May 12, 2026

Licensing Program Analyst (LPA) Alberto Lopez made an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Madeleine "Maddie" Sievert, . The purpose of the visit was explained. The following (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The facility has an Infection Control Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility serves residents 60 years and older, and a Hospice Waiver for thirty (30) residents is approved. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 06/01/2026. A surety bond is not applicable. Facility does not handle resident's money. Staffing: There appears to be always sufficient staffing in the facility, with night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records/Staff Training: Staff have criminal record clearance, current First-Aid training, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed four (4) staff files with no issues observed. Administrator Madeleine Sievert certificate expires on 06/18/2027 Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, Ombudsman, and let us know poster near the resident mail room (continued on 809C) (continued from 809) Residents Rights-Information: Residents are provided with telephone and internet at the facility. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. Residents with Special Health Needs: Facility has recommended documents on residents with home health services and have ongoing communication with home health agencies. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. On site is away from the area. Plan is reviewed and updated as needed. Due to lack of time, LPA will return another day to complete annual inspection. No deficiencies observed during today's visit. Exit interview and copy of report provided to Administrator.