Facility Evaluation Report

On 05/13/2026, Licensing Program Analysts (LPAs) M. Medina and M. Garza arrived at the facility for an unannounced case management visit. LPAs met with Wellness Director, Elizabeth Vasku to conduct facility tour of the facility inside and out. A health and safety check was conducted on residents in care. Residents observed in common areas and in rooms. LPAs spoke with Administrator, Brittany Kavanaugh via telephone to advise of case management.

This case management is being conducted for an incident report received by the Department on 4/15/26 for an incident occurring with R1 on 4/13/26. Incident report indicated that R1 was complaining of chest pain and EMS was contacted. Upon arrival R1 declined EMS services and transport to hospital.

During visit LPAs requested and reviewed documentation (Resident roster, medical assessment for R1, preplacement appraisal, emergency and identification information, admission agreement, and discharge paperwork) and completed interviews. Review of medical assessments for R1 indicates that R1 has a pacemaker. Interview with R1's grandson indicated R1 is independent and able to make medical decision for themselves and sees their cardiologist regularly (every 3 months).

Exit interview completed with Wellness Director, Elizabeth, Activities Director, Taylor and Administrator, Brittany via telephone.