Country Hills Post Acute: Dialysis Care Plan Failure - CA
Inspectors from the Centers for Medicare and Medicaid Services visited Country Hills Post Acute in March and documented what they found with Resident 128, a patient admitted with End Stage Renal Disease, a condition in which the kidneys have permanently failed and survival depends on regular dialysis treatment.
The facility's electronic medical record for Resident 128 carried a notation in the Special Instructions section: Staff must accompany to Dialysis. Inspectors saw him return from the dialysis center via medical transport on March 11 at 2:17 p.m. and again on March 13 at 2:43 p.m. No facility staff member was with him on either occasion.
When inspectors reviewed Resident 128's chart with the facility's Infection Preventionist on March 14, the gap was immediate. The special instruction was there in the record. The care plan section contained nothing about escorting him to dialysis. "Care plans are important because they drive resident care and keep the residents safe," the Infection Preventionist told inspectors.
Then came the Director of Nursing.
Shown the same record, shown the same special instruction requiring staff accompaniment, the Director of Nursing confirmed she recognized it. "Yes, I know it's there," she told inspectors. "It's been there for a while. We just are not doing it."
She continued. If Resident 128 had an outburst during treatment, she said, it could cause a stop in treatment and medical complications. The requirement to accompany him, she acknowledged, should also be in his care plan.
It was not.
The facility's own policy on End-Stage Renal Disease care, last revised in September 2010, states that a resident's comprehensive care plan will reflect the resident's needs related to ESRD and dialysis. The care plan for Resident 128 reflected none of it.
Dialysis for a patient with End Stage Renal Disease is not optional or supplemental care. The kidneys no longer function. Without regular treatment, waste and fluid accumulate in the blood. An interrupted or incomplete session carries real consequences. The Director of Nursing named one herself: an outburst disrupting treatment, leading to complications. She said it to inspectors while explaining why the care plan gap mattered. The care plan gap remained.
Inspectors rated the violation at the level of minimal harm or potential for actual harm, and noted it affected few residents. The finding covered one of seven residents whose records were sampled during the inspection.
What the inspection captured was not a charting error or a miscommunication between shifts. The Director of Nursing knew the instruction had been sitting in the record for some time. She knew it wasn't being followed. She knew the care plan didn't reflect it. She laid out, in her own words, what could go wrong if something happened during treatment and no staff member was present to intervene.
Resident 128 came back to the nurse's station alone on a Tuesday afternoon. He came back alone again on a Thursday afternoon. The medical transport dropped him off. Nobody from Country Hills Post Acute had been there.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 7, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
The facility's electronic medical record for Resident 128 carried a notation in the Special Instructions section: Staff must accompany to Dialysis.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.