Incident investigation·February 25, 2026

Licensing Program Analyst (LPA) Sparkle Day conducted this Case Management regarding an incident dated 2/10/26. Licensee Reported that R#1 missed several medications due to the facility ran out of the medications. It was reported that Resident #1 (R#1) missed eight (8) different medications from 4 to 8 days. During today's visit Licensing Program Analyst spoke with Dawn Smith, Executive Director and Rosetta Hines, Resident Service Director who were consistent in their statements that R#1 was managing their own medication according to physician report dated 5/15/2024. LPA reviewed the file of R#1 and observed an physician report indicating R#1 was able to manage and administer their own medication without assistance. The facility did have a list of the medications of R#1 upon admission but had no way of knowing if medications were missed. Due to this incident the facility has sent R#1 to the hospital for re assessment and R#1 is now on the medication management plan with the facility where ALL medications are now handled and administered by a Medication Tech at the facility. Licensing Day found that the incident report was not complete with ALL necessary information required. LPA Advised Executive Director of the Reporting Requirements per Title 22 No deficiency was cited today Exit interview conducted with Executive Director, Dawn Smith