Country Hills Post Acute
COUNTRY HILLS POST ACUTE in EL CAJON, CA — inspection on March 14, 2025.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Admission Record indicated Resident 55 (R55)was admitted on [DATE] with diagnoses which included Cognitive ( process of thinking) Communication Deficit (difficulties in communication stemming from impairments in cognitive functions like attention, memory, or problem-solving, rather than a primary language or speech problem), Functional Quadriplegia (the complete inability to move due to severe disability or frailty, but without physical injury or damage to the brain or spinal cord), and Metabolic Encephalopathy (a condition where the brain does not function properly).
Review of Minimum Data Set (MDS-a standardized, federally mandated assessment tool used in nursing homes) Section C dated 12/31/24 indicated a Brief Interview For Mental Status (BIMS- a standardized assessment tool used to screen for cognitive impairment in long-term care facilities) score of 13 which indicated intact cognition.
Review of MDS Section M-Skin Conditions dated December 31, 2024, indicated R55 with one stage 3 pressure ulcer ( bed sore) and one stage 4 pressure ulcer on admission. MDS Section M also indicated R55 required B.
Pressure reducing device for bed .E.
Pressure Injury Care .
Review of MDS Section GG dated December 31, 2024 indicated R55 was either dependent or required Substantial/maximal assistance for all his Self-Care needs.
Review of Care Plan Report dated 3/12/25 indicated 1. ADL (Activities of Daily Living)/Mobility .at risk for ADL/Mobility decline and requires assistance .Encourage to use call light for assistance .
On 3/11/25 at 10:13 A.M., a concurrent observation and interview was conducted with R55. R55's call button was observed to be one that needed to be gripped with his hand and pressed with thumb. R55 stated I am unable to use the press the call button. To get staff I yell.
Both of R55's hands were observed to be contracted (muscle shortening preventing normal movement).
On 3/12/25 at 9:45 A.M., an observation of R55's call button and interview with Licensed Nurse 51 (LN51) was conducted. LN51 stated that since R55's hands were contracted, he could not use the call button that was provided and would need a call button that he could tap. LN51 stated the importance of having an appropriate call button was that R55 needed to be able to communicate his needs with the staff.
555431
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555431 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Country Hills Post Acute 1580 Broadway El Cajon, CA 92021
According to the facility's policy and procedure for Resident Assessments, revised March 2022.
The Resident Assessment indicated .The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements .Quarterly Assessment .
On 3/13/25 at 2:54 P.M., an interview and record review was conducted with the Minimum Data Set Coordinator (MDSC).
The MDSC stated Resident 15's last smoking assessment was completed on 5/13/24.
The MDSC stated that smoking assessments should be done on a quarterly basis because this information was needed to capture if Resident 15 smoked during the MDS look-back period and that it was necessary to re-evaluate if there were any changes to Resident 15's smoking safety (e.g. changes to finger dexterity of holding a cigarette) that needed to be updated in Resident 15's care plan for smoking and/or if he stopped smoking to make necessary recommendations and update interventions.
The MDSC stated smoking assessments were important because of safety to prevent smoke-related injuries and burns from happening.
On 3/14/25 at 9:40 A.M., an interview was conducted with the Director of Nursing (DON).
The DON stated a quarterly smoking assessment was needed for any residents who smoked to evaluate if residents were continuing to smoke and to update their care plans.
The DON further stated Resident 15 should have a quarterly smoking assessment completed for safety and to prevent smoke-related injuries and burns.
A review of the facility's policy and procedure SMOKING POLICY revised 8/28/18, did not indicate a frequency for a smoking assessment to be completed.
555431
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555431 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Country Hills Post Acute 1580 Broadway El Cajon, CA 92021
During the recertification, deficient trends were identified in delay of call lights, smokers, Registered Dietician (RD) recommendations, kitchen hygiene, RD kitchen audits, resident care conferences, and low air loss mattress settings.
The ADM stated they were not aware of the issues identified during the survey and the issues were not included in their current QAPI Program.
The ADM stated it was important to add these concerns to promote the highest standard of care for their residents.
According to the Centers for Medicare and Medicaid Services (CMS) QAPI AT A GLANCE 9/10/24 accessed at https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/qapiataglance.pdf.
555431
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555431 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Country Hills Post Acute 1580 Broadway El Cajon, CA 92021
According to the facility's Admission Record, Resident 166 was admitted to the facility on [DATE], with diagnoses which included cirrhosis of the liver, (a type of liver damage where healthy cells are replaced by scar tissue).
Resident 166's clinical record was reviewed on 3/11/25.
According to the facility's Smoking Observation/Assessment form, dated 12/13/24, Resident 166 was a tobacco user and required supervision while smoking.
Resident 166's clinical record was reviewed on 3/11/25.
According to Resident 166's care plan, titled Potential for Injury related to smoking, revised 2/12/25, listed interventions such as, cigarettes and lighter will be stored by the smoking monitor.
Resident 166's clinical record was reviewed on 3/11/25.
According to the Admission MDS (Minimum Data Set: a federally required assessment tool), dated 12/19/24, Section J, titled Health Condition, Resident 166 was coded as not a tobacco user.
An observation of Resident 166 was conducted on 3/13/15 at 4:03 P.M., while smoking on the outside smoking patio. Resident 166 was sitting alone, smoking and not interacting with others.
555431
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555431 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Country Hills Post Acute 1580 Broadway El Cajon, CA 92021
Observation on 3/12/25 at 8:46 A.M. Resident 207 in bed using oxygen via tubing in the nose in upright position being assisted by nursing staff with feeding. Resident 207's LALM was set on 320 lbs.
On 3/12/25 a clinical chart review was conducted on Resident 207's weight. Resident 207's weight on 3/6/25 indicated Resident 207 weighed 129.9 lbs.
555431
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555431 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Country Hills Post Acute 1580 Broadway El Cajon, CA 92021
Review of Minimum Data Set (MDS-a standardized, federally mandated assessment tool used in nursing homes) Section C dated 12/31/24 indicated a Brief Interview For Mental Status (BIMS- a standardized assessment tool used to screen for cognitive impairment in long-term care facilities) score of 13 which indicated intact cognition.
Review of MDS Section M-Skin Conditions dated December 31, 2024, indicated R55 with one stage 3 pressure ulcer (bed sore) and one stage 4 pressure ulcer on admission. MDS Section M also indicated R55 required B.
Pressure reducing device for bed .E.
Pressure Injury Care .
Review of MDS Section GG dated December 31, 2024 indicated R55 was either dependent or required Substantial/maximal assistance for all his Self-Care needs.
Review of Care Plan Report dated 3/12/25 indicated .1. ADL[activity of daily living]/Mobility .at risk for ADL/Mobility decline and requires assistance .Encourage to use call light for assistance .
On 03/11/25 at 10:13 A.M., a concurrent observation and interview was conducted with R55. R55's call button was observed to be one that needed to be gripped with his hand and pressed with his thumb. R55 stated I am unable to use and press the call button. To get staff I yell.
Both of R55's hands were observed to be contracted (a shortening of muscles that prevents movement).
On 3/12/25 at 9:45 A.M., an observation of R55's call button and interview with Licensed Nurse 51 (LN51) was conducted. LN51 stated that since R55's hands were contracted, he could not use the call button that was provided and he would need a call button that he could tap. LN51 stated the importance of having an appropriate call button was that R55 needed to be able to communicate his needs with the staff.
555431
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555431 B.
Wing 03/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Country Hills Post Acute 1580 Broadway El Cajon, CA 92021