What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EL CAJON, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COUNTRY HILLS POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

Health Inspection: Country Hills Post Acute

FF0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise

stated CNA 14 should have gotten a chair while feeding Resident 5 to be at eye level with Resident 5.

eye-level to prevent intimidation while being fed.

A review of the facility's policy and procedure titled ASSISTANCE with MEALS revised March 2023, indicated, .Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals; .

A record review of Resident 51's admission Record indicated Resident 51 was admitted to the

facility on [DATE] with diagnoses which included a history of End Stage Renal Disease (ESRD: irreversible kidney failure).

A record review of Resident 51's Minimum Data Set (MDS: nursing facility assessment tool) dated 2/24/24 indicated that Resident 51 was rarely or unable to understand others or make self-understood and had severe cognitive (the mental processes that take place in the brain, including thinking, attention, language, learning, memory, and perception) deficits to make decisions. Resident 51's MDS also indicated Resident 51 was dependent (helper does ALL the effort, resident does none of the effort to complete the activity).

On 3/13/25 at 9:47 A.M., an observation and interview was conducted with LN 12, in Resident 51's room. CNA 14 was observed feeding another resident (Resident 51) who was in bed. CNA 14 stood and was not at eye-level with Resident 51. LN 12 stated CNA 14 should have sat on a chair at eye-level with Resident 51 to promote safety with eating, respect, dignity, and a non-intimidating feeding experience.

On 3/14/25 at 8:32 A.M., an interview was conducted with the Director of Staff Development (DSD).

The DSD stated CNA 14 should be seated next to Resident 51 and not standing at an eye level to promote dignity and respect.

The DSD stated standing over any resident while feeding them can make them feel rushed with their meals and can be an intimidating experience for the residents (all facility residents being fed).

The DSD further stated, I would feel a little intimidated like oh no did I do something wrong.

On 3/14/25 at 9:03 A.M., an interview was conducted with the Director of Nursing (DON).

The DON stated CNA 14 should have gotten a chair while feeding Resident 51 to be at eye level with Resident 51.

The DON stated his expectations where regardless of a any resident's cognitive status (confused or not) the nursing staff should be promoting dignity and respect for all facility residents while feeding at an eye-level to prevent intimidation while being fed.

A review of the facility's policy and procedure titled ASSISTANCE with MEALS revised March 2023, indicated, .Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals; .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0558

Reasonably accommodate the needs and preferences of each resident.

Review of the facility policy titled ACCOMMODATION OF NEEDS, dated 2001, indicated .2.

The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis .4. In order to accommodate individual needs and preferences staff .are directed towards assisting the residents in maintaining independence, dignity, and well being to the extent possible and in accordance with the residents wishes .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0584

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not

draw sheet spread on the floor surrounding toilet.

The toilet seat and edges had the same stain

on the walls by the toilet.

The white faucet with leather-like cover had dried dark brown various sized

feces-like odor.

An observation of Resident 297's bathroom with an interview from Certified Nursing Assistant (CNA) 11 was conducted on 3/13/25 at 8:22 A.M. CNA 11 stated the draw sheets were placed on the floor because Resident 297's roommate gets poop on the floor. CNA 11 stated it was convenient for staff to have the drawsheets on the floor to clean up after Resident 297's roommate used the bathroom. CNA 11 stated the brown stains scattered across the walls, floors, and faucet covers looked like poop and the room smelled like poop. CNA 11 stated the draw sheet could also be a fall hazard because it could cause someone to lose balance when going to the bathroom.

On 3/13/25 at 8:28 A.M., an observation and interview was conducted with Licensed Nurse (LN) 12, in Resident 297's bathroom. LN 12 stated that the bathroom smelled like poop. LN 12 stated that the white faucet cover stains, and bathroom floors with stained brown spots looked like poop and that the walls scattered by the toilet looked like poop. LN 12 stated that white draw sheet on the floor would also be a fall hazard and cause someone to slip and trip. LN 12 stated that Resident 297's bathroom did not promote a home-like sanitary environment for Resident 297.

On 3/14/25 at 9:32 A.M., an interview with the Director of Nursing (DON) was conducted.

The DON stated that the nursing staff should not have placed drawsheets and/or shower blankets on the floor of Resident 297's bathroom for staff convenience when caring for Resident 297's roommates incontinence issues.

The drawsheets and or shower blankets created a potential fall hazards.

The DON stated Resident 297's bathroom did not promote a home-like sanitary, orderly, and hazard-free environment.

The DON stated this was not a comfortable environment for Resident 297 who was on hospice.

A review of the facility's policy and procedure titled HOMELIKE ENVIRONMENT dated February 2021, indicated, .The facility staff and management maximizes, to the extend possible, the characteristics of the facility that reflect a personalized, homelike setting.

These characteristics include: a. clean, sanitary and orderly environment .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0625

Notify the resident or the resident?s representative in writing how long the nursing home will hold the

resident?s bed in cases of transfer to a hospital or therapeutic leave.

interview and record review, the facility failed to provide a written notice of the bed-hold policy to

As a result, Resident 187 may not have been fully aware of the facility's bed-hold policy.

Findings

Per the facility's admission Record, Resident 187 was admitted to the facility on [DATE] with diagnoses of paraplegia (Inability to move part of the body).

On 3/13/25 at 10:10 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated, when she transferred a resident to an acute care hospital a written notice of bed-hold was not provided to the resident.

On 3/13/25 at 10:18 A.M., an interview was conducted with LN 2. LN 2 stated, when she transferred Resident 187 to an acute care hospital, she did not provide a written notice of bed-hold to Resident 187. LN 2 further stated, she forgot to document offering a bed-hold to Resident 187.

On 3/13/25 at 10:32 A.M., an interview was conducted with Assistant Director of Nursing (ADON) 2.

ADON 2 stated, LNs did not provide a written notice of bed-hold to residents who were transferred to an acute care hospital.

On 3/13/25 at 11:07 A.M., an interview was conducted with the Director of Nursing (DON).

The DON stated, when a resident was being transferred to the hospital, LNs should have provided a written notice of bed-hold to the resident.

Per the facility's policy, titled Bed-Holds and Returns, dated 2001, .All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization .at the time of transfer .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0640

Encode each resident?s assessment data and transmit these data to the State within 7 days of

assessment.

interview, and record review, the facility failed to submit the Minimum Data Set (MDS: a federally

signed by the LN for one of 36 residents (Resident 196) sampled.

This failure resulted in the late submission of the MDS to the federal database.

Findings

A review of Resident 196's admission Record indicated Resident 196 was re-admitted to the facility on [DATE] with diagnoses which included a history of Heart Failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).

A record review of Resident 196's quarterly MDS dated [DATE] indicated, the MDS completion date was completed and signed on 1/27/25.

On 3/13/25 at 12:26 P.M., a record review was conducted on the MDS Final Validation Report.

The MDS Final Validation Report dated 2/16/25 indicated the quarterly MDS (dated 1/13/25) was submitted late.

The MDS Final Validation Report indicated, .the submission date is more than 14 days after Z0500 (A0050 equals 1) assessment .

On 3/13/25 at 2:47 P.M., a record review was conducted with the MDS Coordinator (MDSC).

The MDSC stated the MDS quarterly dated 1/13/25 was submitted (2/16/25) late because she completed and signed Z0500 (Signature of RN [Registered Nurse] Assessment Coordinator Verifying Assessment Completion) on 1/27/25.

The MDSC stated she should have submitted the MDS within 14 days (2/10/25) after signing the Z0500.

The MDSC stated it was important to submit a timely MDS assessments to let the federal database know the status of the facility residents.

The MDS Coordinator continued to state, a late submission of the quarterly MDS delays the information needed by the federal database to know the status of the facility's quality measures related to resident care.

The MDSC stated it was important to make sure all MDS completed were submitted timely to ensure care is not delayed and to be in compliance with the data being given to the federal database.

On 3/14/25 at 9:47 A.M., an interview was conducted with the Director of Nursing (DON).

The DON stated his expectations was for the MDS to be completed timely and accurately according to the MDS Resident Assessment Instrument (RAI: MDS manual).

A record review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2024, (Page 5-2 and Page 5-3) 5.2 Timeliness Criteria: Transmitting Data .Assessment Transmission: .MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days)

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0641

Ensure each resident receives an accurate assessment.

During an interview with the Director of Nursing (DON) on 3/14/25 at 1:17 P.M., the DON stated the MDS assessment should be accurate because it was the summary of patient care, and it was sent to CMS.

A record review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 was conducted.

Chapter 1.2, page seven of the User's Manual indicated, .the Resident Assessment Instrument (RAI) consisted of the MDS .

The User's Manual chapter 1.2, page eight indicated, .The RAI process has multiple regulatory requirement .Federal regulations .require that (1) the assessment accurately reflects the resident's status .

Furthermore chapter 5.5, page 668 of the User's Manual indicated, .the MDS must be accurate as of the ARD [Assessment Reference Date].

Minor changes in the resident's status should be noted in the resident's record .in accordance with standards of practice and documentation .

During a record review of the facility's policy and procedure (P&P) titled, Resident Assessments, dated March 2022, the P&P indicated, .All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and

Based on observations on 3/11/25 at 2:17 P.M. and 3/13/25 at 2:43 P.M. at the 2 South Nurse's Station, Resident 128 was returned to the facility via medical transport. Resident 128 was not accompanied by a facility staff member on either occasion.

During a concurrent interview and record review on 3/14/25 at 10:45 A.M. with Infection Preventionist (IP)1, Resident 128's electronic medical record was accessed and reviewed.

The record indicated in the Special Instructions section that Staff must accompany to Dialysis. IP1 stated that means a staff member must go to dialysis with Resident 128. IP1 further stated, The staff member must stay there [at the dialysis center] with Resident 128.

During the same concurrent interview and record review with IP 1, the care plan section of Resident 128's chart was reviewed. IP1 stated Resident 128 does not have a care plan for staff to escort him to dialysis. IP1 further stated, care plans are important because they drive resident care and keep the residents safe.

During a concurrent interview and record review on 3/14/25 at 10:50 A.M. with the Director of Nursing (DON), Resident 128's electronic medical record was accessed and reviewed.

The record indicated in the Special Instructions section that Staff must accompany to Dialysis.

The DON stated Yes, I know its there, it's been there for a while. We just are not doing it.

The interview and Resident 128's record review with the DON continued.

The care plan section of Resident 128's chart was reviewed.

The DON stated It (It-staff to accompany Resident 128 to dialysis) should be in the care plan too, if he had an outburst, it could cause a stop in treatment and medical complications.

A record review of the facility policy titled End-Stage Renal Disease, Care of Resident revised September 2010, indicated .5.

The Resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared,

declined to join the care conference that had been scheduled on 2/19/25.

The SSD stated Resident

On 3/13/25 Resident 239's record of care conference was reviewed.

The SSD stated Resident 239

stated she was unable to find documentation if Resident 239 was notified or declined to join the care conference that was scheduled on 1/29/25.

The SSD stated Resident 239 should have been notified of the care conference to promote resident participation and inclusion of resident preferences.

On 3/13/25 at 12:13 P.M., an interview was conducted with the SSD.

The SSD stated that all residents and/or their RP should have the opportunity to participate and join their care conference in order for them (residents) to be involved and help personalize their care plan by making updates to include preferences and concerns.

On 3/14/25 at 9:50 A.M., an interview was conducted with the Director of Nursing (DON).

The DON stated that it was important for all residents and/or RP's to be included to discuss their plan of care and encourage residents to participate with care conferences.

The DON stated care conference were important because this was an opportunity for residents (all facility residents) and their families/RPs to communicate and care plans to be updated.

Resident plans of care should be personalized according to their preferences and concerns.

A review of the facility's policy and procedure titled CARE PLANS, COMPREHENSIVE PERSON-CENTERED revised March 2022, indicated, .4.

Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development of his or her plan of care, including the right to .h. see the care plan and sign it after significant changes are made. 5.

The resident is informed of his or her right to participate in his or her treatment, and provided advance notice of care planning conferences .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .General

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Cerebral Infarction (a condition where blood flow to the brain is interrupted, causing brain tissue to

A record review of R219's Minimum Data Set (MDS-a standardized, federally mandated assessment

(BIMS- a standardized assessment tool used to screen for cognitive impairment in long-term care facilities) was not able to be completed as resident is rarely/never understood indicating resident was not able to complete task.

A record review of R219's MDS Section M-Skin Conditions dated 12/4/24 indicated that R219 was assessed at being at risk for developing pressure ulcers/injuries.

On 3/11/25 at 9:23 A.M., an observation was conducted of Resident 219's LALM during initial pooling.

R219's LALM was set to the highest setting 400lbs, max.

On 3/12/25 at 9:45 A.M., a concurrent interview with Licensed Nurse 51(LN51) and observation of R219's LALM was conducted. R219's LALM was set to the highest setting 400lbs, max. LN51 stated that LALM should be set according to resident's weight. LN51 stated R55 did not weigh 400 lbs. LN51 stated the importance of setting the LALM to resident's weight was that R55 could sink into mattress and hit bedframe if set too low, and if set too high the LALM might not promote skin integrity.

On 3/12/25 at 9:55 A.M., a concurrent interview with Assistant Director of Nursing 4 (ADON4) and observation of R219's LALM was conducted. R219 's LALM was set to the highest setting 400lbs, max. ADON4 stated that LALM should be set to R219's weight. ADON4 stated the importance of setting the LALM to R219's weight was to prevent skin breakdown and resident's maintain skin integrity.

On 3/14/25 at 10 A.M., an interview with the Director of Nursing (DON) was conducted.

The DON stated that for LALM settings, the expectation if the resident had intact cognition, then set to resident's comfort, and if resident was not cognitively intact set to the resident's weight.

The DON stated that the importance of setting LALM correctly was to maintain skin integrity.

A record review of facility policy titled SUPPORT SURFACE GUIDELINES, dated 2001 indicated, .1.

Redistributing support surfaces are to promote comfort for all bed-or chairbound residents, prevent skin breakdown, and promote circulation, and provided pressure relief or reduction .

A record review of LALM A-20 OPERATION MANUAL, MODEL MDT24A20, undated, indicated .1.

Pressure Adjustment Knob .Higher pressures will support heavier patients.

The pressure should be adjusted according to individual comfort preferences .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to

Resident Assessment indicated .The resident assessment coordinator is responsible for ensuring that

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 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0692

Provide enough food/fluids to maintain a resident's health.

During an interview on 3/13/25 at 8:24 A.M. with Licensed Nurse (LN) 31, LN 31 stated one CNA was assigned to take all residents' weights and the CNA will notify a LN for any weight gain or weight loss.

An interview and concurrent record review was conducted on 3/13/25 at 11:08 A.M. with the Registered Dietician (RD).

The RD reviewed his progress notes (PN) and stated he documented the 17.8% weight loss on 1/3/25.

The RD stated the following PN dated 2/3/25 was completed by the RD who was covering for him.

The PN dated 2/3/25 indicated, .Lost 22# [pounds] in one month .Follow weights weekly for now due to significant weight loss .

The RD reviewed Resident 260's weight record and stated there were no weekly weights recorded for the month of January and February

The RD stated weekly weights were taken for four weeks for newly admitted residents and if

there was a change in condition.

The RD stated he determined when to discontinue a resident's weekly weights.

The RD stated he was not sure why the weekly weights were not taken for Resident 260.

The RD further stated it was important to do weekly weights for closer monitoring of the resident's weight.

During an interview on 3/14/25 at 1:17 P.M. with the Director of Nursing (DON), the DON stated it was important to weigh residents weekly per the RD's recommendation to monitor the resident's weight loss.

A review of the facility's policy and procedure (P&P) titled, Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, dated September 2012 was conducted.

The P&P indicated, .The nursing staff will monitor and document weight and dietary intake of residents in a format which permits comparisons over time .The staff and physician will define the individual's current nutritional status (weight, food/ fluid intake and pertinent laboratory values) .

The P&P did not provide guidance regarding RD assessment and recommendations.

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0698

Provide safe, appropriate dialysis care/services for a resident who requires such services.

2010, indicated .5.

The Resident's comprehensive care plan will reflect the resident's needs related to

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0761

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted

manufacture guidelines for storage because the drug loses potency.

stores all medications .in locked compartments .1.

Medications .are stored in the packaging,

for maintaining medication storage .in a safe .manner .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and

According to the facility's policy, titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 2001, .Hairnets: 15.

Hair nets of caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens .

An observation and interview was conducted with the DM and the dishwasher aide (DWA) on

3/12/25 at 8:58 A.M., as the DWA removed trash from the kitchen.

The DWA removed his gloves and wheeled the trashcan outside to the trash dumpsters.

The DWA washed out the trashcan and returned to the kitchen.

The DWA returned inside the kitchen to the dishwashing area and started to handle dishes without performing handwashing.

The DWA stated he forgot to wash his hands when he returned to the kitchen, which could cause cross contamination.

The DM stated he expected all staff to wash their hands when returning to the kitchen.

An interview and record review was conducted with the DM on 03/12/25 at 9 A.M. of kitchen staff training, which included hair/beard nets and handwashing.

The DSWH and the DWA completed training in August 2024.

According to the facility's policy, titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, dated 2001, .Hand Washing/Hand Hygiene: .c.

Whenever entering or re-entering the kitchen; .

An interview and record review was conducted with the Registered Dietician (RD) on 3/12/25 at 10:34 A.M.

The RD stated he expected all shelves and surfaces to be clean and sterile, to prevent cross contamination.

The RD stated dust on fire sprinklers above the stove could fall down and contaminate any food being prepared.

The RD stated all staff needed to wear hair and beard covers to prevent hair from falling onto surfaces or into food.

The RD stated anyone who entered or re-entered the kitchen, must wash their hands to prevent cross contamination.

The RD stated he did a kitchen audit on 3/10/25, and provided a copy.

The RD made handwritten notes on the bottom of the 2-page audit sheet.

The handwritten notes pertained to undated/labeled food and the thawing of meat.

The remaining list had line-by- line areas for inspection, which were blank.

The RD stated he did not look at everything in the kitchen when he performed the audit and he should have.

An interview was conducted with the Director of Nursing (DON) on 3/12/25 at 10:39 A.M.

The DON stated he expected the kitchen to be cleaned daily and maintained in a clean, sanitary condition at all times.

The DON stated he expected the kitchen to have a deep cleaning list, so staff knew what was expected to be cleaned.

The DON stated all staff should wear hair and beard nets to prevent hair from falling into food.

The DON stated he expected everyone to wash their hands whenever entering the kitchen to prevent cross contamination.

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0813

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

According to the facility's policy, titled Food Brought by Family/Visitors, dated 2001, .5.

Food brought by family/visitors that is left with the resident to consume later .b.

Perishable food are stored in re-sealable containers with tight fitting lids .Containers are labeled with the resident's name, the item and the used by date. 6.

The nursing staff will dispose perishable food on or before the use by date.

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0847

Inform resident or representatives choice to enter into binding arbitration agreement and right to

Data Set (MDS: federally mandated assessment tool) dated 1/21/25 on cognitive (mental process like

(BIMS: to assess a resident's cognitive function) score of 15 out of 15 that indicated no cognitive problems. Resident 180 an arbitration agreement was signed electronically on 10/8/21.

The AC stated there was no documented evidence showing that a copy of the agreement was given to Resident 180 or discussed with Resident 180. Resident 180's MDS dated [DATE] indicated a BIMS score of 12 out of 15, that indicated Resident 180 had moderate difficulty with memory and thinking. Resident 239 an arbitration agreement was signed electronically on 10/31/23.

The AC stated there was no documented evidence showing that a copy of the agreement was given to Resident 239 or discussed with Resident 239. Resident 239's MDS dated [DATE] indicated a BIMS score of 11 out of 15, that indicated Resident 239 had moderate difficulty with memory and thinking. Resident 229's arbitration agreement was given back to Resident 229 per AC.

The AC stated there was no documented evidence showing that a copy of the agreement was given to Resident 229 or discussed with Resident 229. Resident 229's MDS dated [DATE] indicated a BIMS score of 12 out of 15, that indicated Resident 229 had moderate difficulty with memory and thinking.

On 3/13/25 at 11:41 A.M., an interview was conducted with the AC.

The AC stated that it was important to have documented evidence in the residents (Residents 239, 229, 180, and 150) medical record that the residents (Residents 239, 229, 180, and 150) acknowledged and understood the arbitration agreement because they needed to be aware that by signing it, they were waiving their right to a trial and agreeing to resolve disputes outside court.

The AC stated the residents (Residents 239, 229, 180, and 150) should have received a copy of the arbitration agreement to confirm and review the document at any time and have the information available to them in order to cancel the agreement within 30 days.

On 3/14/25 at 9:54 A.M., an interview with the Director of Nursing (DON) was conducted.

The DON stated that he believed it was important for the admissions team to fully explain the details of any contracts/agreements to the residents (all facility residents) and to provide copies of what they signed.

The DON also stated that admissions should have documented in the resident's (Residents 239, 229, 180, and 150) medical record, that the arbitration agreement was explained to the resident and was given a copy to review and understand their rights.

A review of the facility's policy and procedure titled BINDING ARBITRATION AGREEMENTS dated November 2023, indicated, .a. A signature alone is not sufficient acknowledgement of understanding. b.

The resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0867

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop

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 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0880

Provide and implement an infection prevention and control program.

During a review of the facility's current P&P titled, Infection Prevention and Control Program, dated

and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .The program is reviewed annually and updated as necessary .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Review of facility policy titled CALL SYSTEM, RESIDENTS, dated 2001, indicated that .1.

Each resident is provided with a means to call staff directly for assistance from his/her bed .3.

The resident call system remains functional at all times .4. If the resident has a disability that prevents him/her from making use of call system, an alternative means of communication that is usable for the resident is provided and documented in care plan .

555431 03/14/2025

Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

FF0925

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Review of facility policy titled PEST CONTROL, dated 2001, indicated Our facility shall maintain an effective pest control program .1.

This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .

FF558

Minimal harm or contracted he could not press the provided call button, and he would need a call button he could tap. ADON4 Few affected

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

FF584

Minimal harm or toilet. [NAME] spotted scattered droplet sized drip like stains and quarter sized brown spots on the walls by Few affected

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

FF657

TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46235 Few standards of practice when: affected

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

FF689

Minimal harm or on the floor that had a brownish yellow streak like stain on the edge of the sheet. There were brown quarter Few There were brown scattered various sized large paper clip and coin sized brown thick spots found on the affected

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

FF867

Minimal harm or she was unable to find documentation if Resident 180 was notified or declined to join the care conference Some affected

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

FF919

Minimal harm or contracted he could not press the provided call button, and he would need a call button he could tap. ADON4 Few affected

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

Country Hills Post Acute

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