Incident investigation·July 31, 2024

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 07/31/2024 to conduct a case management visit and met with Executive Assistant, Ellaina Canady and explained the purpose of the visit. The facility submitted a completed Unusual Incident/Injury Report (LIC624) on/around 07/22/24 regarding 1 missing bottle out of 3 bottles of Oxycodone (narcotic) for resident, R1 (hospice care) during pm med count on 07/20/24. IR stated that, on 7/20/24 Med Manager notified ED that during PM narcotic count a bottle of oxycodone was missing for R1, Prior to 2pm count on 07/20/24, R1 had 3 bottles of oxycodone. Sacramento County Sheriff’s Department was notified on 07/22/24 regarding this incident. Facility also notified CCLD, R1s physician, responsible party, hospice agency and other agencies as required. Facility launched their internal investigation and did the through search for this missing medication. During today's visit LPA interviewed 2 staff members and requested documents related to incident which facility will send to LPA via email by 08/02/24. This case is under review and Department will follow up as warranted. No deficiencies were cited during today's visit. Exit interview conducted and copy of the report left at the facility.