Health inspection·August 14, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) was free from significant medication errors when Resident 1 received two medications (solatol- used to treat heart rhythm problems and apixaban- a blood thinner that reduces blood clotting), which were intended for another resident. This failure resulted in the potential to affect Resident 1's health and well-being and placed other residents at risk for medication errors.Findings:During a record review, the admission Record indicated Resident 1 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia (paralysis on one side of the body) following cerebral infarction (a stroke), and epilepsy (a seizure disorder). During a record review, the MDS (Minimum Data Set- an assessment tool) dated 5/19/25 indicated Resident 1 had a BIMS (Brief Interview for Mental Status- a tool to measure cognition) of 14, which indicated intact cognition. During a record review, the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses which included atrial fibrillation (irregular heart rhythm) and hypertension (high blood pressure). During a record review, the MDS (Minimum Data Set- an assessment tool) dated 6/17/25 indicated Resident 2 had a BIMS (Brief Interview for Mental Status- a tool to measure cognition) of 14, which indicated intact cognition. On 7/2/25 at 9:50 A.M., an interview was conducted with Resident 1. Resident 1 stated Resident 2 was his roommate. Resident 1 stated a few weeks ago, Licensed Nurse (LN) 1 accidentally gave him two of Resident 2's medications. Resident 1 stated, .my blood pressure got really low and I had to go to the hospital. On 7/2/25 at 11:21 A.M., an interview was conducted with Resident 2. Resident 2 stated on 3/27/25 around 5 P.M. while he was in his room, Licensed Nurse (LN) 1 brought medications into the room. Resident 2 stated LN 1 brought two medication cups, with pills in each cup. Resident 2 stated LN 1 gave one of the cups of medicine to Resident 1, then handed Resident 2 the second cup of medications. Resident 2 stated he did not recognize the medications and asked LN 1 if the pills belonged to him. Resident 2 stated LN 1 mistakenly handed him Resident 1's medications and vice versa. Resident 2 stated, [LN 1] took the meds away from me and went to [Resident 1]. [LN 1] realized what happened, went to grab the meds from [Resident 1] but [Resident 1] already took [the medications]., I'm the one who caught it [the medication error]. Resident 2 stated LN 1 mistakenly handed him Resident 1's medications and vice versa. During a record review on 7/9/25, the IDT (Interdisciplinary Team- a group of people with different areas of expertise) Note dated 3/28/25 indicated, Incident Details: approximately 6-6:30 pm on 03/27/2025 LN administered wrong medication [sic] to another resident. Sotalol and Eliquis was administered.MD gave parameters to send to ER [sic] if SBP [Systolic Blood Pressure-the top number of a blood pressure reading] less than 90 DBP [Diastolic Blood Pressure - the bottom number of a blood pressure reading] less than 60 and HR [Heart Rate] less than 50. At approximately 4:07 am 03/28/2025 resident blood pressure dropped below parameters and was sent 911 to [Hospital].Root Cause: LN failed to use identifiers and to follow the 7 rights of medication administration.During a record review on 7/9/25, Resident Residents Affected - Few Page 1 of 3 555878 555878 08/14/2025 Granite Hills Healthcare & Wellness Centre, LLC 1340 E Madison Ave El Cajon, CA 92021

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2's Physician's Orders indicated resident was to receive Solatol Hcl Oral Tablet 160 MG twice a day and Eliquis Oral Tablet 5 MG twice a day. On 7/9/25 at 11:45 A.M., an interview was conducted with the Director of Staff Development (DSD). The DSD stated the medication error occurred because LN 1 did not use resident identifiers, such as the arm band, birth date, or picture in the Electronic Health Record prior to administering the medications. The DSD stated LN 1 no longer worked at the facility and was unavailable for an interview.On 7/9/25 at 1:20 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated it was her expectation that licensed nurses verify a resident's identify prior to administering medications. The IDON stated it was important to follow the seven rights of medication administration to ensure residents receive the correct medication. The IDON stated it was important to avoid medication errors to protect residents from any adverse reactions to medications that are not intended for them.During a record review on 7/14/25, the facility's policy titled Medication-Errors revised 7/2018 indicated, Medication Error means the administration of medication.To the wrong resident.or.Which is not currently prescribed. During a record review on 7/14/25, the facility's policy titled Medication-Administration revised 1/1/12 indicated, Purpose.To ensure the accurate administration of medications for residents in the facility.No medication will be used for any patient other than the patient for whom it was prescribed.The Licensed Nurse will verify the resident's identity before administering the medication.Nursing Staff will keep in mind the seven rights of medication when administering medication.The seven rights of medication are: i. The right medication. Ii. The right amount. Iii. The right resident. Iv. The right time. V. The right route. Vi. Resident has right to know what the medication does. Vii. Resident has the right to refuse the medication. 555878 Page 2 of 3 555878 08/14/2025 Granite Hills Healthcare & Wellness Centre, LLC 1340 E Madison Ave El Cajon, CA 92021

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure one of four medication carts and narcotic storage boxes was locked, secured, and inaccessible to unauthorized staff, residents and visitors.This failure had the potential for visitors, residents, and unauthorized staff to access medications and narcotics stored in the medication carts.Findings:On 7/2/25 at 10:21 A.M., an observation was conducted in the west station hallway. A medication cart was in front of a resident room. The cart was unattended and was unlocked with the key observed inserted into one of the cart's drawers. On 7/2/25 at 10:28 A.M., a concurrent observation and interview was conducted with Licensed Nurse (LN) 2. LN 2 was observed walking out of a resident's room and opened the top drawer of the medication cart. LN 2 removed the keys from the cart drawer and placed the keys in her pocket. LN 2 stated she left the medication cart unlocked and the keys were in the narcotic storage box. LN 2 stated, I thought I was only going to be in the room for a few seconds. LN 2 stated she should not have left the keys in the narcotic storage drawer, which contained several packages of narcotics. LN 2 stated .we won't know who will go in there especially when there's narcotics in the drawer.On 7/2/25 at 4:25 P.M., an interview was conducted with the Interim Director of Nursing (IDON). The IDON stated the medication carts and narcotic boxes should always be locked when unattended. The IDON stated, .I tell my nurses, you never know who is around, who could grab a key, grab stuff out of the drawer. People have dementia, they can grab something, narcotics out of the drawer. A review of the facility's policy titled Medication Storage in the Facility revised 01/25 indicated, Medications and biologicals are stored safely, securely, and properly.The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. 555878 Page 3 of 3