Country Hills Post Acute: MDS Coding Failures - CA
The error wasn't caught internally. It took a federal inspection, completed March 14, 2025, to surface it.
The resident, identified in inspection records as Resident 137, was receiving dialysis. That much was documented in his progress notes, which also noted a history of refusing dialysis on some occasions. But when staff completed the Minimum Data Set assessments — the standardized clinical evaluations that nursing homes submit to the Centers for Medicare and Medicaid Services to establish each resident's care status — they coded the dialysis field as "No."
The first miscoded assessment was dated August 15, 2024. Two subsequent quarterly assessments, dated November 13, 2024, and February 11, 2025, repeated the error. For roughly six months, the federal government's records for this resident said he wasn't on dialysis.
The MDS Coordinator, interviewed by inspectors on March 13, 2025, confirmed the mistakes directly. The coordinator acknowledged that the August 2024 annual assessment was coded incorrectly and that both quarterly assessments that followed carried the same inaccuracy. The coordinator also said it was important to get the coding right because the assessments were submitted to CMS and were meant to reflect the resident's actual status.
That acknowledgment didn't explain how the error persisted across three separate assessment cycles.
The Director of Nursing, interviewed the following afternoon, said the MDS assessment should be accurate because it was the summary of patient care and was sent to CMS. Neither the coordinator nor the director offered an explanation for why the dialysis coding had gone uncorrected between August 2024 and the inspection date in March 2025.
The MDS is not a minor administrative form. It drives care planning, staffing calculations, and Medicare reimbursement. It is the document that tells regulators, insurers, and the facility itself what a resident needs and what they are receiving. When a patient is on dialysis — a treatment that requires scheduled sessions, vascular access management, fluid and dietary restrictions, and coordination with outside providers — that information has to be accurate. Miscoding it as absent doesn't just create a paperwork discrepancy. It describes a different patient.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, and noted that some residents were affected. The citation covered the accuracy of resident assessments, a basic requirement that the facility's own policy addressed. That policy stated that anyone who completed any portion of an MDS assessment must sign it, attesting to its accuracy.
Someone signed these assessments. Three times.
Country Hills Post Acute is a post-acute and long-term care facility located at 1580 Broadway in El Cajon. The inspection was conducted by the California Department of Public Health on behalf of CMS.
The facility was given the opportunity to submit a plan of correction. What the plan said, and whether the underlying assessment process has changed, was not detailed in the inspection record.
Resident 137's dialysis status has presumably been corrected in the federal system. What his care coordination looked like during the months when the official record said he wasn't on dialysis at all is not something the inspection report addresses.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 8, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
The error wasn't caught internally.
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.