Country Hills Post Acute: Bed-Hold Notice Failures - CA
Not in writing. Not at all.
The licensed nurse who handled the transfer told inspectors she forgot. She forgot to provide the written notice, and she forgot to document that she had even offered a bed-hold. A second licensed nurse confirmed the same thing happened. Then the Assistant Director of Nursing confirmed it was a pattern, not an isolated slip: nurses at the facility were not providing written bed-hold notices to residents being transferred to hospitals.
The inspection, conducted on March 14, 2025, flagged the failure after investigators reviewed the case of Resident 187, a patient with paraplegia who had been admitted to the facility and was later transferred to an acute care hospital. Paraplegia means the resident had lost the ability to move part of their body.
A bed-hold is exactly what it sounds like. When a long-term care resident leaves for a hospital stay, the facility can reserve their bed for a set period so they have a place to return to. Residents are supposed to be told about this in writing at the time of transfer, so they understand their options and can make arrangements. Without that notice, a resident may not know the bed is being held, may not know how long it will be held, or may not know what happens if the hospital stay runs longer than the hold period.
For a resident with paraplegia, the stakes of losing a placement are not abstract.
The licensed nurse who transferred Resident 187, identified in the report as LN 2, told inspectors directly: she did not provide a written notice of bed-hold to the resident, and she forgot to document offering one. LN 1, a second nurse interviewed that same morning, said the same thing about her own transfers: no written notice was given when she sent a resident to the hospital.
By mid-morning, inspectors had worked their way up the chain. The Assistant Director of Nursing, ADON 2, confirmed that licensed nurses were not providing the written notices. The Director of Nursing acknowledged that they should have been.
The facility's own policy, titled Bed-Holds and Returns and dated 2001, states that all residents or their representatives are provided written information about the bed-hold policy at the time of transfer. The policy has been in place for more than two decades. On the day Resident 187 was transferred, it was not followed.
Inspectors rated the violation as causing minimal harm or potential for actual harm, and noted it affected few residents among the 37 sampled during the inspection. One resident was identified as directly affected.
The finding is categorized as an F-tag deficiency under federal nursing home regulations, documented on a standard Statement of Deficiencies form submitted to the Centers for Medicare and Medicaid Services.
Country Hills Post Acute is located at 1580 Broadway in El Cajon. The facility's plan to correct the deficiency was not included in the inspection report reviewed for this article.
What the report leaves open is what Resident 187 understood about their situation when they left. Whether they knew the bed was being held. Whether anyone told them verbally, even if not in writing. Whether the hospital stay stretched past whatever hold period applied. The inspection document does not say. What it does say is that a resident who could not move part of their body was transferred to a hospital, and the nurse responsible for that transfer forgot to hand them a piece of paper that explained what would happen to the place they were living.
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.
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Last verified: November 7, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
The licensed nurse who handled the transfer told inspectors she forgot.
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.