EL CAJON, CA - Federal inspectors documented widespread safety violations at Country Hills Post Acute during a March 2025 inspection, including shocking bathroom conditions that created fall hazards for residents.
Contaminated Bathroom Creates Safety Hazards
The most egregious violation involved a resident's bathroom where inspectors found extensive fecal contamination over multiple days. On March 12, 2025, at 9:13 AM, surveyors discovered white shower blankets spread on the floor from the toilet to the bathroom opening, with quarter to dime-sized liquid spots on walls and scattered droplet-sized drip-like stains and quarter-sized brown spots on walls near the toilet.
The contamination persisted throughout the inspection period. By 3:00 PM that same day, inspectors found skid-like dark brown stains outside the bathroom door with a white drawsheet spread on the floor containing brownish yellow streak-like stains. The bathroom maintained a strong feces-like odor throughout the documented period.
A Certified Nursing Assistant told inspectors that drawsheets were placed on the floor because "Resident 14 gets poop on the floor" and stated it was "convenient for staff" to have the sheets for cleanup. However, the same staff member acknowledged the sheets "could also be a fall hazard because it can slip and cause someone to lose balance when going to the bathroom."
Licensed Nurse Confirms Safety Concerns
A Licensed Nurse interviewed during the inspection confirmed the dangerous conditions. The nurse stated the bathroom "smelled like poop" and that the stained surfaces "looked like poop." Most critically, the nurse acknowledged that the "white draw sheet on the floor would also be a fall hazard and cause someone to slip and trip."
This resident had a documented history of balance issues and falls. Clinical records showed the resident experienced three or more falls in the last 90 days, earning a fall risk score of 16, considered high risk. Care plans documented unwitnessed falls on February 17, February 18, and February 20, with one notation indicating the resident had "two unwitnessed falls within one hour apart."
Critical Dialysis Care Failures
The facility failed to properly manage care for residents requiring life-sustaining dialysis treatments. Resident 51, who has End Stage Renal Disease requiring dialysis three times weekly, did not receive proper post-dialysis care according to physician orders.
Medical orders specified that pressure dressings should be "removed 4-6 hours post dialysis treatment if no bleeding noted." However, inspectors found that more than 21 hours after dialysis, the resident's dressing remained in place. A Licensed Nurse confirmed the dressing should have been removed per medical orders to prevent the dialysis access site from clotting.
Even more concerning, Resident 128's medical record contained special instructions stating "Staff must accompany to Dialysis." Despite this clear directive, inspectors observed the resident returning from dialysis unaccompanied by facility staff on two separate occasions. When questioned, the Director of Nursing acknowledged: "Yes, I know it's there, it's been there for a while. We just are not doing it."
Dangerous Medication Storage Practices
Resident 204, who requires breathing treatments for respiratory conditions, was found storing unlabeled, undated medication vials in his bedside drawer. The Ipratropium-Albuterol solution vials were removed from their protective foil packaging, violating manufacturer storage guidelines that require vials to remain in protective pouches and be used within one week of removal.
A Respiratory Therapist expressed repeated concerns to nursing staff about medications being left at bedside, noting there was no physician order for self-administration. The therapist emphasized that supervised administration was necessary to ensure "Resident 204 was receiving the correct dosage and frequency per the physician order."
Significant Weight Loss Goes Unmonitored
Resident 260 experienced dramatic weight loss that went inadequately monitored despite dietary recommendations. The resident lost 22.9 pounds (17.8%) from an admission weight of 128.7 pounds in October 2024 to 105.8 pounds by December 2024.
Despite the Registered Dietitian's documentation of this significant weight loss on January 3, 2025, and subsequent orders for weekly weights due to significant weight loss, no weekly weights were recorded for January and February 2025. The dietitian confirmed that weekly weights were taken for four weeks for newly admitted residents and if there was a change in condition.
Medical standards indicate that unintentional weight loss exceeding 5% in one month or 10% in six months requires immediate intervention and close monitoring to prevent further functional decline and loss of lean body mass.
Kitchen Sanitation Violations
Multiple food safety violations were documented in the facility's kitchen operations. Inspectors found drying racks with gritty residue that could be removed with finger swipes, and a drying cart near the sink contained debris on shelving where clean pots and pans were placed to dry.
Water sprinkler heads above the cooking area were covered in dust that could fall onto food during preparation. A dishwasher was observed working with an approximately one-inch beard without wearing the required beard net, and a dishwasher aide failed to wash hands after handling trash before returning to food preparation areas.
Resident Rights Violations
Four residents reported they were not properly informed about arbitration agreements they signed upon admission. These legally binding agreements waive residents' rights to jury trials in favor of private arbitration for dispute resolution.
Resident 180 reported being presented with the arbitration agreement during transport to the hospital and told that refusal would result in denial of re-admission to the facility. The resident described feeling pressured to sign without proper explanation or opportunity to review the document.
Facility Response Required
The Director of Nursing acknowledged multiple failures during the inspection, including that nursing staff should not be putting drawsheets and/or shower blankets on the floor for convenience when caring for residents with incontinence issues due to fall hazard potential.
Country Hills Post Acute must submit a plan of correction addressing each identified violation to ensure resident safety and regulatory compliance. The facility's Quality Assessment and Assurance Committee was also cited for failing to identify these concerning trends in resident care.
These violations represent systematic breakdowns in basic care standards that put vulnerable residents at risk for falls, infections, medication errors, and compromised safety during essential medical treatments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Hills Post Acute from 2025-03-14 including all violations, facility responses, and corrective action plans.
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