EL CAJON, CA - A federal inspection at Country Hills Post Acute revealed multiple violations including unsanitary bathroom conditions, inaccurate resident assessments, and failures to provide comprehensive care planning that put vulnerable residents at risk.
Unsanitary Bathroom Conditions Created Health Hazards
The most serious violation documented involved Resident 297, a hospice patient with prostate cancer whose bathroom remained in deplorable condition for multiple days. Federal inspectors found brown fecal stains scattered across the floor, walls, and toilet fixtures, creating an environment that violated basic health and safety standards.
During the March 11-13 inspection period, surveyors documented persistent contamination despite multiple visits. The bathroom contained two shower blankets laid on the floor with brown streaked stains, various-sized fecal spots on walls near the toilet, and brown and yellow drip-like stains on toilet surfaces. The room maintained a strong feces-like odor throughout the inspection period.
Staff members acknowledged the unsanitary conditions during interviews. Certified Nursing Assistant 11 explained that "draw sheets were placed on the floor because Resident 297's roommate gets poop on the floor" and that it was convenient for cleaning purposes. However, the CNA also recognized that the sheets created fall hazards that "could cause someone to lose balance when going to the bathroom."
Licensed Nurse 12 confirmed the bathroom "smelled like poop" and that the stained surfaces "looked like poop." The nurse also acknowledged the safety hazard, stating the draw sheets on the floor "would also be a fall hazard and cause someone to slip and trip."
The facility's Director of Nursing ultimately admitted that staff "should not have placed drawsheets and/or shower blankets on the floor" and acknowledged the bathroom "did not promote a home-like sanitary, orderly, and hazard-free environment." This was particularly concerning given that Resident 297 was receiving hospice care and required a comfortable, dignified environment.
Critical Assessment Errors Compromised Patient Care
The facility failed to accurately complete federally mandated assessments for five residents, creating risks for inappropriate medical decisions and compromised care quality. These Minimum Data Set (MDS) assessments serve as the foundation for care planning and federal quality monitoring.
Resident 36 had documented diagnoses of paranoid schizophrenia and bipolar disorder, yet the MDS assessment incorrectly indicated no serious mental illness. This error could have led to inadequate mental health interventions and monitoring.
Resident 166 was actively smoking under facility supervision and had cigarettes stored by staff, but was coded as a non-tobacco user in the assessment. The MDS Coordinator acknowledged that "the use of tobacco by Resident 166 was not captured and it should have been," preventing federal oversight of tobacco-related health risks.
Resident 178 received anti-anxiety medication (Lorazepam) every six hours as needed, with a care plan specifically addressing anxiety management. Despite this active treatment, the MDS failed to document anxiety as an active diagnosis, leaving federal regulators unaware of this significant health condition.
Resident 303 was admitted with an indwelling urinary catheter documented in the physician's history and physical examination. However, the admission assessment failed to record this critical medical device, which requires specific monitoring protocols and infection prevention measures.
Resident 137 presented the most complex assessment error involving dialysis treatment documentation. While the resident had an arteriovenous fistula requiring monitoring and had refused dialysis treatments, two quarterly assessments incorrectly indicated active dialysis treatment. This discrepancy could have led to inappropriate care planning and resource allocation.
Medical Significance of These Violations
Unsanitary conditions in healthcare facilities create multiple health risks, particularly for immunocompromised patients like those receiving hospice care. Fecal contamination can harbor dangerous bacteria including Clostridium difficile, E. coli, and other pathogens that cause severe infections. For cancer patients with weakened immune systems, exposure to these contaminants can result in life-threatening complications.
The presence of contaminated materials on bathroom floors creates immediate fall hazards, especially dangerous for elderly residents who may have mobility limitations or medication-related balance issues. Falls are a leading cause of serious injury in nursing homes and can be fatal for frail residents.
Accurate MDS assessments are essential for appropriate care delivery and federal quality monitoring. When mental health conditions go undocumented, residents may not receive necessary psychiatric services, medication monitoring, or behavioral interventions. Incorrect tobacco use documentation prevents implementation of smoking cessation programs and tobacco-related health monitoring.
Missing urinary catheter documentation creates serious infection control risks, as these devices require specific cleaning protocols, regular monitoring, and sterile maintenance procedures. Catheter-associated urinary tract infections are among the most common healthcare-associated infections and can progress to life-threatening sepsis.
Care Planning Deficiencies Created Safety Risks
Beyond assessment errors, the facility failed to develop comprehensive care plans that addressed all resident needs. Resident 128, who required kidney dialysis three times weekly, had special instructions indicating "Staff must accompany to Dialysis" in his medical record, but no corresponding care plan existed to ensure this safety measure was implemented.
Federal inspectors observed Resident 128 returning from dialysis appointments without facility staff accompaniment on multiple occasions. The Director of Nursing acknowledged the oversight, stating "We just are not doing it" and recognizing that "if he had an outburst, it could cause a stop in treatment and medical complications."
This failure to create actionable care plans based on documented medical needs represents a fundamental breakdown in the care planning process. For residents requiring dialysis, interruptions in treatment can quickly become life-threatening, leading to fluid overload, electrolyte imbalances, and cardiac complications.
Regulatory Context and Standards
Federal regulations require nursing homes to maintain sanitary conditions that promote a homelike environment while ensuring resident safety and dignity. The facility's own policy mandated "clean, sanitary and orderly environment" characteristics, which were clearly not met in this case.
MDS assessments must be completed accurately and submitted within 14 days of completion to federal databases that monitor nursing home quality and determine reimbursement rates. The facility also failed to submit one resident's assessment timely, with the MDS Coordinator acknowledging that "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."
Additional Issues Identified
The inspection revealed other concerning practices including failure to properly notify residents and families about care conferences and resident council meetings. Three residents were not properly invited to participate in their own care planning processes, violating person-centered care requirements that give residents voice in their treatment decisions.
These violations collectively demonstrate systemic problems with basic healthcare standards, assessment accuracy, and care planning processes that are fundamental to nursing home operations and resident safety.
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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