Country Hills Post Acute: Dignity Violations Found - CA
That is what inspectors found at Country Hills Post Acute on March 13, 2025.
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See the Derila PillowThe resident, identified in inspection records as Resident 51, was admitted to the facility with end-stage renal disease, meaning irreversible kidney failure. She was rarely able to understand others or make herself understood, and had severe cognitive deficits. She was fully dependent on staff for her care, contributing nothing to the effort of completing daily activities. When it came time to eat, she could not feed herself.
At 9:47 in the morning, an inspector observed CNA 14 standing upright while feeding Resident 51, who was lying in bed. CNA 14 was not seated. CNA 14 was not at eye level. A licensed nurse present in the room, identified as LN 12, told the inspector that CNA 14 should have pulled up a chair, sat beside the resident, and fed her from that position, to promote safety, respect, dignity, and what the nurse called a non-intimidating feeding experience.
The next morning, the Director of Staff Development told inspectors the same thing. Standing over a resident while feeding them, she said, can make the resident feel rushed. It can feel intimidating. "I would feel a little intimidated," she told inspectors, "like, oh no, did I do something wrong."
The Director of Nursing went further. His expectation, he said, applied to every resident in the building, regardless of whether they were cognitively intact or confused. Every resident being fed deserved to have a staff member seated at eye level with them. No exceptions based on cognitive status. The goal was to prevent intimidation.
The facility's own written policy, revised in March 2023, said residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, and listed as an example: not standing over residents while assisting them with meals.
The policy existed. The expectation was clear. The leadership knew it, articulated it without prompting, and could explain precisely why it mattered. The CNA stood anyway.
What makes this finding land differently than a paperwork violation is the specific nature of Resident 51's vulnerability. She could not communicate distress in any reliable way. She could not ask the person feeding her to sit down. She could not say she felt rushed or afraid. She had severe cognitive deficits and was rarely able to make herself understood at all. Whatever she experienced during that feeding, she experienced without the ability to report it to anyone.
The Director of Staff Development's framing is worth sitting with. She imagined herself in that position, food being offered by someone looming above her, and her instinct was: did I do something wrong? That's the internal experience she was describing for a person who cannot ask the question out loud, cannot seek reassurance, and cannot tell a family member what happened at breakfast.
Inspectors classified the harm level as minimal, with potential for actual harm, and noted that some residents were affected.
Country Hills Post Acute is located at 1580 Broadway in El Cajon. The inspection was completed March 14, 2025.
Resident 51 remained in that facility, still dependent, still rarely able to make herself understood, still relying on the staff around her to decide, on their own, whether to pull up a chair.
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 13, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
That is what inspectors found at Country Hills Post Acute on March 13, 2025.
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.