Incident investigation·October 28, 2024

Licensing Program Analyst (LPAs) Manalo and Clancy-Czuleger arrived unannounced to conduct a case management visit in response to the Unusual Incident Report (UIR) submitted by the facility. LPA's met with Leslie Ibo, Health and Wellness Director and Ryan Turner Executive Director and explained the purpose of the visit. Resident (R1) had passed away on 10/17/2024. On October 20, 2024, Health and Wellness Director (S1) started the process of medication destruction, when it was observed that an unused bottle of narcotics medications was missing. Medtech’s and nurses started to look for the medication. All medication carts and overflow cabinets were searched and still could not find the medications. An internal investigation was conducted, medtech’s and nurses was interviewed. The incident was reported to Fremont Police with the incident event number is P24125430. In-service with wellness team started on 10/22/2024 with the following topics: narcotic count, documentation, medication error, medication destructions and other topics. Regional Health Services Director and General Manager was notified regarding the incident. Our community started to have two staff signing off for the narcotics, nurses will audit narcotics weekly. No deficiency cited. Exit interview conducted and copy of this report provided .