Country Hills Post Acute: Sanitation Failures - CA
Federal inspectors documented the conditions at Country Hills Post Acute during a March 2025 visit. The resident at the center of the findings, identified in inspection records as Resident 297, was receiving hospice care at the time.
What inspectors found in that bathroom on March 12 was a draw sheet spread across the floor surrounding the toilet. The toilet seat and its edges had brown and yellow drip-like stains. The walls near the toilet were scattered with droplet-sized brown spots and quarter-sized brown marks. The white faucet, wrapped in a leather-like cover, had dried dark brown streaks ranging from thumb-sized to baseball-sized running across it. The room had a strong feces-like odor.
When a Certified Nursing Assistant identified in the report as CNA 11 was asked about the draw sheet on the floor the following morning, the explanation was direct. Resident 297's roommate, the CNA said, sometimes defecated on the floor when using the bathroom. Staff had started laying the draw sheets down so they would have something ready to clean it up. It was easier that way.
CNA 11 also acknowledged what the stains were. The brown marks on the walls, the floor, the faucet cover — they looked like poop, the CNA said. The room smelled like poop. And then, in the same breath, CNA 11 noted that the draw sheet on the floor could cause someone to lose their balance going to the bathroom.
A licensed nurse, LN 12, walked through the same bathroom six minutes later and reached the same conclusions. The smell was feces. The stains on the faucet cover looked like feces. The spots scattered across the walls by the toilet looked like feces. The draw sheet was a slip and trip hazard. And the bathroom, LN 12 said, did not promote a home-like sanitary environment for Resident 297.
The Director of Nursing was interviewed the next day. She confirmed that nursing staff should not have placed draw sheets or shower blankets on the bathroom floor as a convenience measure for managing a roommate's incontinence. She confirmed the fall hazard. She confirmed the bathroom did not meet the standard of a clean, sanitary, orderly, and hazard-free environment.
And then she noted what the inspection report had already established: Resident 297 was on hospice.
The facility's own written policy, dated February 2021, describes a commitment to maintaining a personalized, homelike setting for residents, one defined in part by a clean, sanitary, and orderly environment. The inspection found that standard unmet in one of the most intimate spaces a resident occupies.
There is nothing in the inspection record indicating how long the conditions had persisted before inspectors arrived. There is nothing indicating whether Resident 297 had complained, or whether anyone had flagged the bathroom before the survey team walked in. What the record contains is a CNA who described the arrangement as convenient, a nurse who called the environment unsanitary, and a Director of Nursing who agreed with both of them.
Resident 297 was dying. The bathroom assigned to that resident smelled like feces, had feces on the walls, and had linen on the floor that two staff members independently identified as a fall risk. Staff knew. The question the inspection record leaves open is how long they had known, and how many times someone had walked past that bathroom door and decided it was someone else's problem to fix.
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.
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Last verified: November 4, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
Federal inspectors documented the conditions at Country Hills Post Acute during a March 2025 visit.
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.