Incident investigation·April 8, 2026

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to conduct a Case Management. LPA met with Director of Sales, Megan Silverman, and explained the purpose of today's visit. The facility self reported an incident on documenting on the afternoon of 03/23/2026 it was identified that on 03/22/2026 that the Assisted Living residents did not receive their 5:00pm medication. Staff 1, the Med Tech assigned to Memory Care completed cross over and the medication count for the Assisted Living with the AM shift Assisted Living Med Tech but Staff 1 failed to complete the med pass or report to supervisory staff about the need for assistance. On the afternoon of 03/23/2026 it was identified that on 03/23/2026 that the Memory Care residents did not receive their morning medication. Saff 2, the Med Tech assigned to Assisted Living, completed cross over and the medication count for Memory Care with the Noc shift Med Tech but failed to complete the med pass or escalate the need for assistance past the Manager on Duty. An immediate audit was initiated to identify all affected residents and medications. At this time, there have been no adverse outcomes identified, and all affected residents are being closely monitored. The facility terminated staff involved in the medication error incident, immediately notified all resident families of incident and also of staffing changes. The following deficiencies are being cited Per Title 22 Regulations, exit interview conducted with Director of Sales, Megan Silverman, and a copy of this report provided.