Health inspection·July 29, 2025

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide routine bathing hygiene to one of four residents (Resident 2), dependent on staff for Activities of Daily Living, (ADL-bathing, dressing, toileting, and re-positioning), when reviewed for Quality of Care.This failure had the potential for skin issues to develop and for Resident 2 to experience low self-esteem. Findings:An unannounced visit was made to the facility on 7/29/25, regarding a complaint. Resident 2 was admitted to the facility on [DATE], with the diagnosis which included morbid (severe) obesity due to excess calories, per the facility's admission Record.Resident 2's clinical record review was conducted on 7/29/25.According to the Admission, Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 4/25/25, a cognitive score of 12 was listed, indicating moderately impaired cognition. The Functional Abilities assessment indicated Resident 2 required maximum staff assistant with turning and transferring. According to the physician's order, dated 7/18/25, .offer pain pill one hour before shower to aid with showers: infection control.According to the facility's Weights and Vitals, Resident 2's admission weight was 367.9 pounds.According to the facility's Shower book , dated June 2025, Resident 2 had received baths four times out of eight opportunities, Resident 2 received two showers on 6/2/25 and 6/30/25, and two bed baths on 6/1/25 and 6/23/25, with no documented refusals. According to licensed nurse 1 (LN 1) shower book documentation was discontinued at the end of June 2025, and in-services were provided for staff to document resident bathing in the computer, under the Task headline.The computer Task screen was reviewed for Resident 2, for July 1, 2025 through July 29, 2025. Three showers were provided (7/7/25, 7/10/25, 7/21/25), out of eight opportunities, and two refusals (7/17/25, 7/24/25) were documented. According to the facility's care plan, titled At Risk for Skin Breakdown, dated 4/18/25, interventions included, administered medication as orders and observe skin integrity for signs of skin breakdown or excoriation.An observation and interview was conducted with Resident 2 on 7/29/25 at 12:47 A.M. While standing outside Resident 2's room, observing the name plate on the wall, a strong odor was detected that did not resemble urine or feces. When entering the room, the odor grew stronger and was more pungent. Resident 2 was sitting up in bed, eating lunch. Resident 2 had long, greasy looking hair. Resident 2 stated she liked both showers and baths and her last shower was about a week ago. Resident 2 stated yes, she was being medicated before the shower and the pain medication helped her a lot. Resident 2 gave permission for this writer to return after she finished lunch, and to have staff assist me with a skin inspection.A follow up observation and interview was conducted with Resident 2 on 7/29/25 at 1:13 P.M. Staff present to assist with the skin inspection were licensed nurse 1 (LN 1), LN 5, certified nursing assistant 1 (CNA 1), and CNA 3. After the skin inspection, all staff left the room so a private interview could be conducted. Resident 2 stated she only refused to bathe one time, and that was when she first arrived at the facility. Resident 2 stated she was afraid of the Hoyer lift (a machine that staff used to safely lift or transfer Residents Affected - Few Page 1 of 8 555431 555431 07/29/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patients by the use of a sling). Since then, Resident 2 stated she would agree to a shower only if CNA 1 was working, because she trusted CNA 1 on the Hoyer lift. Resident 2 stated if she refused a shower, it was because of who was working the Hoyer lift and for no other reason. Resident 2 stated if she refused a shower, she would still like to have a bed bath. Resident 2 stated she had received some really good bed baths in the past and she really did not have a preference for showers over a bed bath. Resident 2 stated bathing twice a week was good for her. An interview was conducted with the Director of Staff Development (DSD) on 7/29/25 at 2 P.M. with the Director of Nursing (DON) present. The DSD stated since they stopped using the Shower book for documentation, In-services were provided to CNAs and LNs numerous times throughout the month of July, so everyone knew the changes and expectations. The DSD stated if showers were refused, then bed baths should be offered. If still refused, staff were expected to notify the LNs, and document why the refusals were made. The DSD stated bathing was important for prevention of skin breakdown and a resident's self-image.An interview and record review was conducted with the DON on 7/29/25 at 2 P.M. The DON reviewed Resident 2's June shower sheets and the bathing Task for July. The DON stated she expected all residents to have showers or bed baths at least twice a week and for the bathing to be documented. The DON stated if bathing was repeatedly refused, she expected staff to create a care plan for refusals, so appropriate interventions could be implemented.According to the facility's policy, titled Activities of Daily Living (ADL), Supporting, dated 2001, .5. Appropriate care and services are provided for residents who are unable to carry out ADLs independently, with the consent of the resident, and in accordance with the plan of care, including support n assistance with: s. Hygiene (bathing, dressing, grooming, and oral care); . 555431 Page 2 of 8 555431 07/29/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to administer pain medication for two of four residents (Resident 1 and Resident 2) per the Nursing Standards of Practice, reviewed for Quality of Care when: 1. Pain medication was administered to Resident 1 without assessing the level of pain before or after administration of a narcotic (a controlled that is regulated by the government due to its potential for abuse and addiction) and, 2. The correct pain medication was not administered to Resident 2 according to the pain scale (1-10: 1 being the least amount of pain and 10 being the worst pain). These failures had the potential for Resident 1 to experience addiction and for Resident 2 to not receive adequate pain relief.Findings:1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility, per the facility's admission Record.A review of Resident 1's clinical record was conducted on 7/29/25.According to Resident 1's annual Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 6/12/25, a cognitive score of 15 was listed, indicating cognition was intact. The Pain Assessment indicated no pain in the past five days. According to Resident 1's physician's orders, dated 4/21/25, give Hydrocodone-Acetaminophen, (a regulated pain medication to help with moderate to severe pain), 5-325 milligrams oral tablet. Give one tablet every eight hours as needed for moderate to severe pain. A review of Resident 1's Medication Administration Record (MAR), dated July 1 through July 29, 2025, was conducted. The pain medication Hydrocodone-Acetaminophen was administered 16 times. Four of the 16 times when the pain medication was administered the level of pain was marked 0 by Licensed Nurse 4 (LN 4) as a pain level (Pain scale: 1 indicates minimal amount of pain, 10 worst pain) before administration. The pain assessment after medication administration (one hour later) was marked U for unknown, per the facilities coding. According to the facility's care plan, titled Pain, dated 6/24/19, interventions included position for comfort, medications as ordered, and if pain not relieved, contact the physician.An interview and record review was conducted with LN 4, of Resident 1's July MAR on 7/29/25 at 12:10 P.M. LN 4 stated post (after) pain medication should always be assessed to ensure the pain medication was working. LN 4 stated if the medication was not therapeutic, then he would contact the physician. LN 4 reviewed Resident 1's July MAR and was asked the reason pain medication was administered when the resident had no documented pain. LN 4 stated he administered the hydrocodone, because the resident asked for it. LN 4 stated he did not inquire if there was pain, and he did not follow up afterwards to ensure the pain medication was working. LN 4 stated Resident 1 asked for the pain medication, so I gave it to her. LN 4 stated he understood hydrocodone was controlled medication and addictive. LN 4 stated he should have assessed Resident 1's pain before administering the pain medication, and he did not.An interview was conducted with LN 5 on 7/29/5 at 1:37 P.M. LN 5 stated pain levels should also be assessed and documented before administering pain medication. LN 5 stated the standard of practice was to assess the pain one hour afterwards, to ensure the resident had pain relief with the medication. If not, the physician should be contacted, to change or increase the medication. LN 5 stated she would never administer an as needed pain medication if there was no pain, because pain medication could be addictive and make someone dependent.An interview was conducted with the Director of Nursing (DON) on 7/29/25 at 1:53 P.M. The DON stated she expected all residents to be assessed for pain levels before and after administration. The DON stated as needed pain medication should not be administered if a pain level was not documented. According to the facility's policy, titled Administering Pain Medications, dated 2001, .1. The pain management program is based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice. Steps in the Procedure: .3. Conduct a pain assessment.9. Residents Affected - Few 555431 Page 3 of 8 555431 07/29/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Re-evaluate the resident's level of pain 30-60 minutes after administering.2. Resident 2 was admitted to the facility on [DATE], with the diagnosis which included morbid (severe) obesity due to excess calories, per the facility's admission Record.Resident 2's clinical record review was conducted on 7/29/25. According to Resident 2's Admission, Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 4/25/25, a cognitive score of 12 was listed, indicating moderately impaired. The Functional Abilities assessment indicated Resident 2 required maximum staff assistant with turning and transferring. According to Resident 2's physician's order, dated 4/18/25, Give Acetaminophen tablet (Tylenol) 325 milligrams (mg), two tablets by mouth every four hours as need for mild pain (1-3). An additional physician's order was added for pain on 4/30/25. Tramadol HCL (a strong pain medication for moderate to severe pain), 50mg, give one tablet by mouth every six hours as needed for moderate to severe pain.A review of Resident 2's MAR, dated July 1 through July 29, 2025, was reviewed. Acetaminophen was administered 32 times for pain as needed, of the 32 administrations, 23 administrations were for a pain scale level of 4-8, not 1-3 as ordered by the physician. An interview and record was conducted with the Director of Nursing (DON) on 7/29/25 at 1:53 P.M. The DON stated as needed pain medication should be administered according to the physician's order in accordance with the pain scale listed. If Resident 2 was receiving Tylenol for moderate pain, there was the possibility she was not getting sufficient pain relief. The DON stated she expected nurses to follow the physician's order based on the pain scale listed. According to the facility's policy, titled, Administering Pain Medication, dated 2001, .Pain management is defined as the process of alleviating the residents pain based on his or her clinical condition and established treatment goals.Steps in the Procedure: .3. Conduct a pain assessment.6. Administer pain medications as ordered. 555431 Page 4 of 8 555431 07/29/2025 Country Hills Post Acute 1580 Broadway 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 secure prescription medication when:1. A treatment cart (a cart with prescribed lotions and creams, used to treat wounds and skin conditions) was left unlocked for one of six treatment carts (Station 2 North); and,2. Medication was left on top of a medication cart, unsupervised for one of 11 medication carts (Station 3 North); and,3. Medication was left unsupervised at the bedside for one of four residents (Resident 1) when reviewed for safe medication storage.These failures had the potential for unauthorized people (resident, staff, and visitors) to have access to medications not prescribed to them.Findings: 1. An observation was conducted on 7/29/25 at 10:22 A.M. near the nursing station on 2 north. A treatment cart was unlocked, and no staff were nearby. The treatment cart contained medicated creams and lotions in the first and second drawers. Sitting across from the treatment cart were four residents. One male resident wearing a red outfit, walked past the treatment cart twice. Also observed walking past the unlocked treatment cart were staff and two maintenance staff.An observation and interview was conducted with Licensed Nurse 1 (LN 1) on 7/29/25 at 10:26 A.M. LN 1 was observed looking at the treatment cart which was unlocked. LN 1 stated the cart should always be locked when unattended, because anyone could have access to medications, which could be harmful.2. An observation was conducted on 7/29/25 at 10:39 A.M. of a medication cart in the east hallway of Station 3 north. A medication bottle was located sitting on top of the locked medication cart and no staff were seen in the hallway by the medication cart. The medication bottle was labeled D3 (a dietary supplement) 50 micrograms (mcg). The medication bottle was sealed with a white tab and the label indicated the bottle contained 100 tablets.An observation and interview was conducted with LN 2 on 7/29/25 10:41 A.M. LN 2 looked at the unattended medication bottled on top of the medication cart. LN 2 stated unattended medications could be harmful to unauthorized residents, staff, or visitors if taken and ingested. LN 2 stated she believed the medication nurse for this cart (LN 3) was on a break and LN 2 agreed to take the bottle of medication to the nurse's station for supervision purposes.An interview was conducted with LN 3 on 7/29/25 at 10:44 A.M. LN 3 stated she left the bottle of medication on top of her medication cart, but thought it was okay since the bottle was sealed. LN 3 stated, Yes, I guess anyone could have taken it. I probably should not have left it out. 3. An interview was conducted with Resident 1 on 7/29/25 at 12:21 P.M., in her room. Resident 1 stated she had not received her lidocaine patch (a pain relief medicated patch placed on the skin), that morning.An interview was conducted with LN 4, the medication nurse assigned to Resident 1 on 7/29/25 at 12:32 A.M. LN 4 stated he left the patch in her room. LN 4 stated Resident 1 was approved for self-medication of a cream, but he did not know if she had been approved to apply a pain medicated patch. LN 4 proceeded to Resident 1's room to show where he left the lidocaine patch. LN 4 retrieved a sealed lidocaine patch from the Resident 1's bedside table. LN 4 stated Resident 1 had her own pair of scissors to open up the medicated package, and she liked to put the patch on herself, because she had to lift her dress up to put the patch on her lower back.An interview was conducted with LN 5 on 7/29/25 at 1:27 P.M. LN 5 stated if a resident was not assessed and approved to apply a particular medication, then it should never be left with the resident unsupervised by a nurse.Resident 1's clinical record was reviewed. According to the Self-Medication Assessment, dated 4/28/25, Resident 1 was assessed and approved for the self-medication of Terbinafine cream (a cream used to treat itching caused by fungus) by the interdisciplinary team (IDT-when department heads meet to discuss resident issues). No other medications were approved for self-medication.An interview was conducted with 555431 Page 5 of 8 555431 07/29/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Director of Nursing (DON) on 7/29/25 at 2 P.M. The DON stated she expected all treatment carts, medication carts, and medications to be secured within a cart when not in use by staff. The DON stated medication should never be left at the bedside, unattended, unless the resident was approved for the medication listed on the Self-Medication Assessment. According to the facility's policy, titled Administering Medications, dated 2001, .19.the medication cart is kept closed and locked when out of sight of the medication nurse.27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.' 555431 Page 6 of 8 555431 07/29/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident records were accurate and concise for one of four residents (Resident 1) when: 1. A quarterly pain assessment was not conducted for Resident 1, to determine if pain levels had increased or decreased over the past three months; and;2. Routine pain mediation was not charted for Resident 1 after administrated and was charted hours later.These failures provided inaccurate documentation in Resident 1's clinical records and could cause staff confusion.Finding: 1. Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility, per the facility's admission Record.A review of Resident 1's clinical record was conducted on 7/29/25. According to Resident 1's annual Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 6/12/25, a cognitive score of 15 was listed, indicating cognition was intact. The Pain Assessment indicated no pain in the past five days. According to the facility's last quarter Pain Assessment, dated 3/17/25, Resident 1 had no pain reported. There was no documented evidence a quarterly Pain Assessment was conducted in June 2025, to determine if Resident 1 had a increase or change in pain.According to the facility's care plan, titled Pain, dated 6/24/19, interventions included, position for comfort, medications as ordered, and if pain not relieved, contact physician.An interview and record review was conducted with the Minimum Data Set Nurse 1 (MDSN 1) on 7/29/25 at 1:37 P.M. MDSN 1 stated Pain Assessments needed to be conducted with the resident and completed every three months, to determine if their pain had worsened or improved. MDSN 1 stated when completing Residents' MDS assessments, the MDSNs look at the facility's Pain Assessment, so they could complete the MDS. MDSN 1 reviewed Resident 1's quarterly Pain Assessments and stated her last Pain Assessment was completed in March 2025, and a pain assessment should have been done in June, but it was not. MDSN 1 reviewed Resident 1's Annual MDS, dated [DATE], and stated the MDS pain section was completed in July, by an MDSN 2. MDSN 1 stated she assumed MDSN 2 interviewed Resident 1, but if she had, then the facility's Pain Assessment should have been completed and added to Resident 1's record.An interview and record review was conducted with the Director of Nursing (DON) on 7/29/25 at 1:53 P.M. The DON reviewed Resident 1's Pain Assessments, and stated the last one was in March 2025, and another one should have been completed in June 2025. The DON stated quarterly Pain Assessments were important to evaluate residents' pain. The DON stated she expected pain evaluations to be completed every three months, as required.According to the facility's policy, titled Administering Pain Medication, dated 2001, .4. Comprehensive pain assessments are conducted upon admission, quarterly, whenever there is a significant change in condition.2. Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait and mobility, per the facility's admission Record. A review of Resident 1's clinical record was conducted on 7/29/25.According to Resident 1's Annual Minimum Data Set, (MDS-a federally mandated resident assessment tool), dated 6/12/25, a cognitive score of 15 was listed, indicating cognition was intact. The Pain Assessment indicated no pain in the past five days. According to the physician's order, dated 12/20/24, Lidocaine 5% topical, apply to lower back one time and day and remove at bedtime. According to Resident 1's Medication Administration Record (MAR), dated June 2025, The lidocaine was administered late 15 times out of 30 opportunities, (with a documented range of 2 to 6 hours late). According to the facility's policy titled, Administration of Medication, dated 2001, .23. As required.the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered; .According to the facility's care plan, titled Pain, dated 6/24/19, interventions included, position for comfort, medications as 555431 Page 7 of 8 555431 07/29/2025 Country Hills Post Acute 1580 Broadway El Cajon, CA 92021

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ordered, and if pain not relieved, contact physician.An interview and record review was conducted with Licensed Nurse 4 (LN 4) on 7/29/25 at 12:10 P.M. LN 4 stated Resident 1 received a lidocaine patch for back pain. LN 4 stated he administered the patch every morning as ordered. LN 4 reviewed Resident 1's July MAR, and stated the patch was administered as ordered around 9 A.M., but he charted the administration of the patch later, when he had time. LN 4 stated he was aware he should have documented the actual time when the patch was applied, not hours later, because it could be confusing for other staff. An interview was conducted with Resident 1 on 7/29/25 at 12:21 P.M. Resident 1 stated she always received her lidocaine patch in the morning, and it was never late because she would not be able to function for the day.An interview was conducted with LN 5 on 7/29/25 at 1:27 P.M. LN 5 stated lidocaine patches should be applied consistently to provide continuous pain relief. Once any medication was administered, it needed to be documented immediately after being given, so other staff were aware it was administered. LN 5 stated if not documented timely, another nurse might administer the same medication, unaware that it was already given.An interview was conducted with the Director of Nursing (DON) on 7/29/25 at 1:53 P.M. The DON stated she expected nurses to document medication was administered, immediately after being given. The DON stated it was not acceptable to document medication was administered later in the day, because it was confusing for the reader and inaccurate.According to the facility's policy, titled Administering Medication, dated 2001, .5. Medication administration times are determined by resident need and benefit, not staff convenience.22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 23. As required.the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; . 555431 Page 8 of 8