Country Hills Post Acute: Pressure Mattress Failures - CA
Federal inspectors found Country Hills Post Acute failed to properly adjust specialized mattresses designed to prevent pressure ulcers for five residents during a March inspection. The violations left residents at risk for skin breakdown, with some already suffering from severe bedsores.
Resident 240 told inspectors over three consecutive days that she needed extra pillows and blankets to relieve pressure on her lower back because "her bed felt too hard." The resident, who weighed 164.7 pounds, had her low air loss mattress set at 450 pounds on March 11 and 12, then 250 pounds on March 13.
"She still needed to adjust her lower back with pillows and extra blankets to be comfortable because her bed felt too hard," inspectors documented after observing the resident on March 13.
Licensed Nurse 12 told inspectors the mattress should be set according to the resident's comfort level since she was "verbal and cognitively intact." But the nurse couldn't find any records showing comfort settings had been tested or documented in the care plan.
The Director of Nursing acknowledged residents who can determine their comfort level should be involved in testing mattress settings. "For Resident 240 to be comfortable with the LALM settings Resident 240 should not need to put extra pillows and/or blankets on her back to make use of the benefits of the pressure reducing device," the director said.
The most extreme case involved Resident 55, who had stage 3 and stage 4 pressure ulcers on admission and weighed significantly less than 400 pounds. Inspectors found her mattress set at the maximum 400-pound setting on March 11 and 12.
Licensed Nurse 51 explained the problem: if set too low, the resident "could sink into mattress and hit bedframe," but if set too high, "the LALM would not promote skin integrity."
Licensed Nurse 52, who was treating the resident's sacral wounds, said the high setting "might not promote healing of wounds or maintain current skin integrity."
Assistant Director of Nursing 4 confirmed the mattress should be set to the resident's weight "to prevent skin breakdown and maintain skin integrity."
Resident 51, who suffered from end-stage renal disease and severe cognitive deficits, presented another case of improper settings. The resident weighed 91.4 pounds on March 13 but had her mattress set at approximately 120 pounds, according to Licensed Nurse 12.
"The setting should be less because Resident 51 did not weigh 120 lbs," the nurse told inspectors. "Resident 51's LALM should be set according to her weight to be effective in preventing pressure ulcers and skin injuries."
Resident 207, who weighed 129.9 pounds and had moderate cognitive deficits, had her mattress set at 320 pounds on March 11 and 12. By March 13, staff had adjusted it to 150 pounds, but Licensed Nurse 12 said it should be set according to weight since the resident "had cognitive deficits and was at risk for pressure ulcers."
Resident 219, who couldn't complete cognitive assessments due to communication difficulties, also had her mattress set at the maximum 400 pounds despite weighing far less.
The facility's own policy requires staff to "review and select medical devices with consideration the ability to minimize tissue damage." The mattress manufacturer's manual states "the pressure should be adjusted according to individual comfort preferences" and that "higher pressures will support heavier patients."
None of the residents had documented evaluations for personalized comfort settings in their care plans, inspectors found.
The Director of Nursing told inspectors the expectation was clear: for residents with intact cognition, set the mattress to their comfort level; for those with cognitive deficits, set it according to their weight. The importance of correct settings, she said, was "to maintain the resident's skin integrity."
The violations occurred despite the facility's policy stating that pressure-reducing surfaces should "promote comfort for all bed-or chairbound residents, prevent skin breakdown, and promote circulation, and provided pressure relief or reduction."
Inspectors also found safety hazards in bathrooms where nursing staff placed shower blankets and drawsheets on floors "for convenience," creating slipping hazards that could result in serious injury to residents.
The inspection was completed March 14, 2025.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
The violations left residents at risk for skin breakdown, with some already suffering from severe bedsores.
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.