Granite Hills Healthcare & Wellness Centre, Llc

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Granite Hills Healthcare & Wellness Centre, LLC

1340 E Madison Ave El Cajon, CA 92021

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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