Health inspection·September 3, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document and inventory medications brought in by the family, following a hospital discharge. The facility did not identify if the medication label matched the current physician's orders, resulting in a medication error for one of three residents (Resident 1), when reviewed for Pharmacy Services. This failure resulted in Resident 1 receiving a three milligram (mg) dose instead of 1.5 mg dose, as ordered by the physician. Findings:An unannounced visit was made to the facility on 9/3/25, after a complaint was filed regarding a medication error.Resident 1 was admitted to the facility on [DATE], with diagnoses which included kidney transplant, per the facility's Resident Face Sheet.Resident 1's medical record was reviewed on 9/3/25:According to the physician's order, dated 8/3/25,.Give tacrolimus (medication to prevent organ rejection), 0.5 milligrams (mg) amt: 3 capsules to = 1.5 mg oral (by mouth) every 12 hours (8 am and 8 pm) s/p Renal (kidney) Transplant: Nursing Do Not Refill: FM (family) to Supply.According to admission progress notes, dated 8/3/25 at 3:45 P.M., Licensed Nurse 6 (LN 6) documented, Patent was admitted from the hospital. There was no documentation of what medication the family provided, how many bottles, or what the dosage was.According to the social worker note, dated 8/7/25, Resident 1 was moved from the south hall to the west hall, once a private room was available in the facility. According to the nursing progress note dated 8/7/25 at 8:57 P.M., LN 6 documented, LN 4 brought to this writer's attention, patient was given 3 mg of tacrolimus instead of 1.5 mg, MD (doctor) notified with new orders for labs in the A.M., DON (director of nursing), (name) pharmacy, and patient aware of med issue.According to the nursing progress notes dated 8/8/25 at 7:38 A.M., Discussed tacrolimus incident with resident. Bottle of tacrolimus 0.5 mg caps was found and is now on the west cart on her new hallway. Resident would like the wrong dose destroyed.On 9/3/2025, The DON and LN 6 were unavailable for interviews.An interview was conducted with the Assistant Director of Nursing (ADON), on 9/3/25 at 10:55 A.M. The ADON stated he was aware the DON was investigating a medication error involving Resident 1, that the family had brought in. The ADON stated the medication was given to staff when admitted from the hospital. The ADON was unaware if staff inspected the medication labels or inventoried the number of medications before adding to their medication cart. The ADON could not find any documented evidence or inventory of the medications the family supplied to the facility. An interview was conducted with LN 1 on 9/3/25 at 11:31 A.M., regarding Resident 1, who was no longer in the facility. LN 1 stated she was not working on 8/7/25, in the South hall, but was aware of the incident when she returned to work on 8/8/25. LN 1 stated she was very familiar with Resident 1 and had administered Resident 1's medication in the South hallway since her admission. On the morning of 8/8/25, Resident 1 approached LN 1 in the South hallway and asked to see her medication bottle and label on the South hall med cart for tacrolimus. LN 1 stated she removed the medication bottle and showed the resident the label which was listed as, one capsule equals 0.5 mg, give 3 capsules for a total of 1.5 Page 1 of 3 555424 555424 09/03/2025 The Dorothy & Joseph Goldberg Healthcare Center 211 Saxony Road Encinitas, CA 92024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few mg. LN 1 stated Resident 1 informed her she was given 3 capsules of 1 mg dose each, equaling a total dose of three milligrams, the previous night in the [NAME] hall. LN 1 stated they must have removed the wrong bottle from the South cart when the medications were moved to the [NAME] hall. LN 1 was unable to say how many bottles of tacrolimus were originally on her cart. LN 1 stated the medication nurses should have reconciled the label on the bottles when first brought in by the family with the current physician's order.An interview was conducted with the facility's contracting pharmacist (CP 1) on 9/3/25 at 11:56 A.M. CP 1 stated Resident 1 provided her own tacrolimus to the facility and the medication was not supplied by the facility's pharmacy. CP 1 stated that sometimes residents supply their own medication, because it is not covered by their medical insurance. CP 1 stated since the pharmacy did not supply the medication, they did not provide oversite, unless the facility asks. CP 1 stated she had no documented evidence the facility asked them to review or provide oversight for the tacrolimus. CP 1 stated a one-time double dose of tacrolimus would not cause any harm or side effects. CP 1 stated the nurses should always verify the medication brought in by someone else, matching the physician's order. CP 1 stated if multiple bottles were brought in, only one bottle should have been on the medication cart and the others removed and stored for when the resident was discharged An interview was conducted with LN 4 on 9/4/25 at 3:58 P.M. LN 4 stated she was working in the west hall on the evening of 8/7/25, and Resident 1 was already settled into her new room. LN 4 stated Resident 1's medications were already on the [NAME] hall med cart, and she proceeded to give the resident her 8 P.M. dose of tacrolimus. LN 4 stated the order read tacrolimus 0.5 mg per capsule, give three capsules for a [NAME] of 1.5 mg. LN 4 stated the medication bottle read 1 mg per capsule, give three capsules for a total of 3 mg. LN 4 stated she was confused, because she knew she could not break a capsule in half to provide the 1.5 mg total dose. LN 4 stated she approached LN 5 in the South hall, who was familiar with Resident 1. LN 4 stated she showed LN 5 the bottle label, and LN 5 grabbed the medication bottle from her saying, This is the right dose. LN 4 stated she watched, as LN 5 walked into Resident 1's room and administered three tablets of the 1 mg capsules. LN 4 stated she was confused and concerned, so after LN 5 returned to the South hall, she approached the nurse in charge (LN 6) to inform her of what had happened.An interview was conducted with the DON on 9/8/25 at 1:35 P.M. The DON stated she had investigated the medication incident involving Resident 1. The DON stated LN 5 and LN 6 worked on the evening shift.An interview was conducted with LN 5 on 9/8/25 at 3:39 P.M., the DON was present. LN 5 stated she was very familiar with Resident 1, since she previously had been on LN 5's hallway (South hall). LN 5 recalled LN 4 coming up to her on the evening of 8/7/25, asking for help. LN 5 stated she did not have any specific memory of the medication or the dose. LN 5 stated she was aware the family brought the medication in, and she recalled giving the resident three capsules. LN 5 stated she could not recall looking at the label, or if the capsules were 0.5 mg or 1 mg. LN 5 stated she could not recall if she spoke with the resident once in the room administering the capsules or if the resident said anything to her. An interview was conducted with LN 6, on 9/8/25 at 3:50 P.M., with the DON being present. LN 6 stated on the evening of 8/7/25, LN 4 approached her, saying she thought there had been a medication error. LN 6 recalled looking at the medication label for tacrolimus, which indicated the capsules were 1 mg each, not 0.5 mg. LN 6 stated she immediately notified the physician, pharmacy, and DON, because she believed there had been a medication error.An interview was conducted with the DON on 9/8/25 at 4 P.M. The DON stated she was unable to prove how many bottles of tacrolimus medications were brought in by the family. The DON stated she had no documented evidence what the medication labels read, the dosage, the expiration date, or the amount of capsules per bottle. The DON stated the medication bottles were never inventoried by 555424 Page 2 of 3 555424 09/03/2025 The Dorothy & Joseph Goldberg Healthcare Center 211 Saxony Road Encinitas, CA 92024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff. The DON stated during her investigation, she was unable to determine who removed Resident 1's medication from the South hall medication cart and put it in the [NAME] hall medication cart.On 9/10/25, Resident 1's hospital medical records were received. Resident 1 was admitted on [DATE] to the hospital. The hospital physician's order, dated 7/31/25, tacrolimus 1.5 mg capsule, twice a day, end 8/2/25. An additional order was written by the physician on 8/3/25 on day of discharge, for tacrolimus 0.5 mg capsules, three capsules twice a day.The facility's policy related to handling medication admitted with residents was reviewed. According to the facility's policy, titled Handling Meds admitted with Residents, dated November 2017, A. MEDS TO BE VERIFIED: Legally, all meds admitted with a resident coming directly from an acute care hospital or skilled facility may be accepted for use without verification from the pharmacist or the residents' attending physician . The med nurse, however, must examine and check for proper packaging and labeling. Attached Assessment for need of medication verification form may be used to determine whether these medication(s) require pharmacist/physician verification. Refer to the labeling section below for further information .The facility's policy related to administering medication was reviewed. According to the facility's policy, titled Administering Medication, dated April 2019, .The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medication. 555424 Page 3 of 3