Country Hills Post Acute: Catheter Left on Floor - CA
Inspectors visited Country Hills Post Acute on May 15, 2026, and found Resident 18 resting in bed watching television. She was alert, cooperative, and told the inspector she had no problems with her catheter and that staff cleaned it every shift. What she may not have known was that her catheter bag, which drains urine from her bladder, was on the ground.
It stayed there for at least two hours while inspectors watched and asked questions.
At 2:40 p.m., the inspector spoke with LN 6, the licensed nurse assigned to Resident 18 as her medication nurse. The bag was still on the floor. LN 6 explained that the catheter bag should be secured below the resident's bladder, attached to the bed frame, and kept off the ground, specifically to prevent bacteria from the floor from traveling up the tubing and infecting the catheter.
Five minutes later, CNA 5, the certified nursing assistant assigned to Resident 18, was interviewed in the same room with the bag still in the same position. CNA 5 said the same thing: the bag should be below the bladder, secured to the bed frame, off the floor, to prevent the bag from being stepped on and to prevent bacteria from causing an infection.
Both staff members described the correct procedure precisely. Neither had corrected it.
At 4:30 p.m., the inspector showed a photograph of the bag to the facility's Infection Preventionist. The Infection Preventionist explained that a catheter bag on the floor creates a direct pathway for bacteria to cause a urinary tract infection, and that UTIs in catheter patients can progress to sepsis.
Sepsis is a life-threatening response to infection that can cause organ failure and death.
The facility's own catheter care policy, dated 2001, states that catheter tubing and drainage bags must be kept off the floor. The physician's order for Resident 18, written on February 19, 2026, directed staff to monitor proper placement and check for kinking or compression that could obstruct urine flow every single shift.
On May 28, nearly two weeks after the initial observation, the Director of Nursing was interviewed. The Director of Nursing stated that catheter bags should be secured to the bedside below the bladder and not on the floor, to prevent unwanted infections and accidental pulling on the catheter.
The pattern across every interview is the same: the nurse knew, the aide knew, the infection preventionist knew, the Director of Nursing knew. The order was in the chart. The policy had been written for 25 years. And on the afternoon of May 15, Resident 18's catheter bag was on the ground.
Inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. The complaint inspection was completed May 28, 2026.
What the record doesn't show is how long the bag had been there before the inspector arrived, or how many shifts had passed with staff completing catheter care, documenting it, and leaving the bag on the floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Hills Post Acute from 2026-05-28 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 8, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on May 28, 2026.
Inspectors visited Country Hills Post Acute on May 15, 2026, and found Resident 18 resting in bed watching television.
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.