Health inspection·June 10, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ountry Hills 558-E Accommodation of Needs Residents Affected - Some Based on observation, interview, and record review, the facility failed to provide residents with an alert call system for 20 of 44 Residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 17, 19, 20, 21, 22, and 23) in order for staff to respond to their needs, after their electronic call system stopped working on Station 3 North, when reviewed for Accommodation of Needs. In addition, three of the 21 residents (23, 24, and 25) with manual call bells had their call bells out of reach. This failure had the potential for 26 Residents to not have their needs met in a timely manner. Findings: On 6/10/25, an unannounced visit was conducted in response to a complaint of call lights not working on Station 3 North. An interview was conducted with the Director of Nursing (DON) on 6/10/25 at 11:58 A.M. The DON stated the call light system on Station 3 North stopped working on Wednesday 6/4/25. The DON was unaware if the call light outage was reported to the California Department of Public Health, (CDPH), saying I would need to check with the Administrator. An interview was conducted with the Administrator (ADM). The ADM stated he was unaware of any issues with the call light system. The ADM stated he just returned to the facility on 6/10/2525, since he had been on vacation. The ADM stated he was unaware if the call light failure was reported to CDPH, in his absence. The ADM request time to contact the facility's Director of Maintenance (DM) who was currently home sick. An interview was conducted via telephone on with the DM on 6/10/25 at 12:30 P.M. The DM stated the electronic call light system stopped working last Wednesday on 6/4/25. The DM immediately call the repair company and while waiting, he sent a maintenance aide out to purchase more manual call bells. The DM stated the repair company was at the facility on 6/4/25, 6/5/25, 6/8/25, and 6/9/25, in attempts to fix the call light system. The DM stated the plan now was to replace the entire call light system, since the system was old and parts were limited. Then DM stated the facility was waiting for the quote invoice, so repairs could be made as soon as possible. The DM stated every resident on Station 3 North was provided their own manual bell to use, in the mean time. Page 1 of 7 555431 555431 06/10/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0558 Level of Harm - Minimal harm or potential for actual harm The ADM provided an internal document of how many manual bells were at the facility on 6/4/25 and how many were purchased, with proof of receipt. According to the documents, 22 manual bells were purchased from Staples, (an office supply store) at 11:23 A.M., and 20 manual bells were obtained from social services department, while 25 manual bells were retrieved from the maintenance department, for a total of 67 bells. Residents Affected - Some Starting on 6/10/25 at 12:13 P.M., room rounds were conducted by the State surveyor. a. Resident 1 was admitted to the facility on [DATE], with diagnoses which included cerebral vascular accident (Stroke), per the facility's admission Record. According to the Minimum Data Set, (MDS-a clinical assessment tool, dated 5/8/25, Resident 1 had a cognitive score of 14, indicating cognition was intact. According to the Functional Abilities assessment, Resident 1 used a wheelchair for mobility and required staff assistance for transfers from bed to chair. An observation was conducted on 6/10/25 at 12:13 P.M. The call light system was not functioning and no manual call bell was observed on or around Resident 1's bed. b. Resident 2 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease (a progressive disorder that affects the nervous system), per the facility's admission Record. According to the MDS, dated [DATE], Resident 2 had a cognitive score of 6, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 2 used a wheelchair for mobility and required staff assistance for transfers from bed to chair. Resident 2 was coded as having a fall in the facility within the last six months. An observation was conducted on 6/10/25 at 12:13 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 2's bed. Resident 2 had fall mats on both sides of the bed. C. Resident 22 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), per the facility's admission Record. According to the MDS, dated [DATE], Resident 22 had a cognitive score of 5, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 22 was able to ambulate on his own with no assistive devices, and required minimal staff assistance. Resident 22 was coded as having a fall in the facility within the last six months. An observation was conducted on 6/10/5 at 12:13 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 3's bed. d. Resident 3 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke), per the facility's admission Record. According to the MDS, dated [DATE], Resident 3 had a cognitive score of 12, indicating cognition was intact. According to the Functional Abilities assessment, Resident 3 was able to ambulate on his own with no assistive devices. Resident 3 was coded of having a fall in the facility within the last six months. 555431 Page 2 of 7 555431 06/10/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0558 Level of Harm - Minimal harm or potential for actual harm An observation was conducted on 6/10/25 at 12:20 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 3's bed. e. Resident 4 was admitted to the facility on [DATE], with diagnoses which included Guillan-Barre Syndrome (a rare autoimmune disorder), per the facility's admission Record. Residents Affected - Some According to the MDS, dated [DATE], Resident 4 had a cognitive score of 12, indicating cognition was intact. According to the Functional Abilities assessment, Resident 3 was able to ambulate on his own with no assistive devices. An observation was conducted on 6/10/25 at 12:20 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 4's bed. f. Resident 15 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD-poor gas exchange in the lungs), per the facility's admission Record. According to the MDS, dated [DATE], Resident 15 had a cognitive score of 12, indicating cognition was intact. According to the Functional Abilities assessment, Resident 15 was able to ambulate on his own with no assistive devices. Resident 15 was coded of having a fall in the facility within the last six months. An observation was conducted on 6/10/25 at 12:20 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 15's bed. g. Resident 19 was admitted to the facility on [DATE], with diagnoses which included sepsis (a life threatening infection), per the facility's admission Record. According to the MDS, dated [DATE], Resident 19 had a cognitive score of 3, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 19 required maximum assistance from Resident 19 was coded of having a fall in the facility within the last six months. An observation was conducted on 6/10/25 at 12:22 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 19's bed. h. Resident 21 was admitted to the facility on [DATE], with diagnoses which included COPD, per the facility's admission Record. According to the MDS, dated [DATE], Resident 21 had a cognitive score of 5, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 21 required maximum assistance from staff. An observation was conducted on 6/10/25 at 12:23 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 21's bed. i. Resident 5 was admitted to the facility on [DATE], with diagnoses which included surgical after care, per the facility's admission Record. According to the MDS, dated [DATE], Resident 5 had a cognitive score of 1, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 5 required moderate 555431 Page 3 of 7 555431 06/10/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0558 assistance from staff. Resident 5 was coded for having a fall in the facility within the last six months. Level of Harm - Minimal harm or potential for actual harm An observation was conducted on 6/10/25 at 12:23 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 5's bed. Residents Affected - Some j. Resident 13 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a brain dysfunction), per the facility's admission Record. According to the MDS, dated [DATE], Resident 13 had a cognitive score of 3, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 13 required a wheelchair for mobility and was dependent on staff for all daily activities. moderate assistance from staff. Resident 13 was coded for having a fall at the facility within the last six months. An observation was conducted on 6/10/25 at 12:23 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 13's bed. k. Resident 14 was admitted to the facility on [DATE], with diagnoses which included Parkinson's disease, per the facility's admission Record. According to the MDS, dated [DATE], Resident 14 had a cognitive score of 7, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 14 required maximum staff assistance for all daily activities. An observation was conducted on 6/10/25 at 12:23 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 14's bed. l. Resident 6 was admitted to the facility on [DATE], with diagnoses which included COPD, per the facility's admission Record. According to the MDS, dated [DATE], Resident 6 had a cognitive score of 11 indicating cognition was moderately impaired. According to the Functional Abilities assessment, Resident 6 required a wheelchair for mobility and was dependent on staff for all daily activities. An observation was conducted on 6/10/25 at 12:24 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 6's bed. m. Resident 7 was admitted to the facility on [DATE], with diagnoses which included dementia, per the facility's admission Record. According to the MDS, dated [DATE], Resident 7 had a cognitive score of 3, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 7 required a wheelchair for mobility and was moderately dependent on staff for all daily activities. Resident 7 was coded for having a fall in the facility within the last six months. An observation was conducted on 6/10/25 at 12:24 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 7's bed. n. Resident 8 was admitted to the facility on [DATE], with diagnoses which included dementia, per 555431 Page 4 of 7 555431 06/10/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0558 the facility's admission Record. Level of Harm - Minimal harm or potential for actual harm According to the MDS, dated [DATE], Resident 8 had a cognitive score of 10, indicating cognition was moderately impaired. According to the Functional Abilities assessment, Resident 8 required set-up assistance by staff for daily functions. Residents Affected - Some An observation was conducted on 6/10/25 at 12:24 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 8's bed. o. Resident 23 was admitted to the facility on [DATE], with diagnoses which included COPD, per the facility's admission Record. According to the MDS, dated [DATE], Resident 23 had a cognitive score of 13, indicating cognition was intact. According to the Functional Abilities assessment, Resident 23 required a wheelchair for mobility and set-up assistance by staff for daily functions. An observation and interview was conducted with Resident 23 on 6/10/25 at 12:26 P.M. The call light system was not functioning. The manual call bell was on a bedside table down past the foot of the bed and out of the resident's reach. Resident 23 stated its was hard for the staff to hear her call bell when rung, because it was so busy and loud in the hallway. Resident 23 stated if staff did not come in a reasonable amount of time, she yells and they eventually come to see what she needs. p. Resident 9 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction, per the facility's admission Record. According to the MDS, dated [DATE], Resident 9 had a cognitive score of 00, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 9 required maximum assistance by staff for daily functions. An observation was conducted on 6/10/25 at 12:39 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 9's bed. q. Resident 10 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (a mental illness), per the facility's admission Record. According to the MDS, dated [DATE], Resident 10 had a cognitive score of 3, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 10 was independent for all daily activities. An observation was conducted on 6/10/25 at 12:39 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 10's bed. r. Resident 24 was admitted to the facility on [DATE], with diagnoses which included dementia, per the facility's admission Record. According to the MDS, dated [DATE], Resident 24 had a cognitive score of 3, indicating cognition was severely impaired. According to the Functional Abilities assessment, Resident 24 was completely dependent on staff for daily functions. 555431 Page 5 of 7 555431 06/10/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0558 Level of Harm - Minimal harm or potential for actual harm An observation was conducted on 6/10/25 at 12:39 P.M. The call light system was not functioning, and the manual call bell was observed on a bedside dresser behind the Resident 24's head and out of reach. s. Resident 11 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental disorder), per the facility's admission Record. Residents Affected - Some According to the MDS, dated [DATE], Resident 11 had a cognitive score of 9, indicating cognition was moderately impaired. According to the Functional Abilities assessment, Resident 11 was independent for performing daily activities. An observation was conducted on 6/10/25 at 12:41 P.M. The call light system was not functioning, and no manual call bell was observed on or around Resident 11's bed. t. Resident 25 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), per the facility's admission Record. According to the MDS, dated [DATE], Resident 25 had a cognitive score of 12, indicating cognition was intact. According to the Functional Abilities assessment, Resident 25 required a wheelchair for mobility and was dependent on staff for all activities. An observation and interview was conducted on 6/10/25 at 12:41 P.M. The call light system was not functioning, and the manual call bell was observed on Resident 25's bedside table The bedside table was pulled away from the bed and out of the resident's reach. Resident 25 stated the staff do come in when she rings the manual bell. Resident 25 stated when staff move her bedside table, her call bell was out of reach and she yells to get there attention. An interview and record review was conducted with the Director of Staff Development (DSD), on 6/10/25 at 1:23 P.M. The DSD stated when the call light system stopped working they immediately provided each resident with a manual call bell. The DSD stated they tested the call bells in the rooms farthest from the nursing station to ensure staff could hear them. The DSD stated they have no idea what happened to the call bells, since they are no longer in some resident rooms. The DSD stated he also in-serviced staff on all shifts who were assigned to that 3 North, to ensure every 30 minutes residents were being checked within their rooms. The DSD stated he did not discuss staff documenting the 30 minutes resident checks An interview and record review was conducted with the DON on 6/10/25 at 2 P.M. The facility's transfer list was reviewed from 6/4/25 through 6/10/25, to see if any residents sustained any injuries or were sent to the hospital from Station 3 North. No residents from 3 North were injured or transferred out to the hospital. The DON stated all residents should have a means to contact staff if help was needed. The DON stated she has no idea where the missing call bells went to, but residents without a call bell were at risk of injury or of not getting their needs met. According to the facility's policy, titled Call System, Residents, dated 2001, .1. Each resident is provided with a means to call staff directly for assistance .3. The resident call system remains functional at all times . According to the facility's policy, titled Accommodation of Needs, dated March 2021, Our facility's environment .assisting the resident in maintaining and/or achieving self-independent functioning, 555431 Page 6 of 7 555431 06/10/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0558 dignity, and well-being. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 555431 Page 7 of 7