Country Hills Post Acute: Care Plan Failures - CA
The inspection, completed March 14, 2025, identified failures to include residents in care conferences, the scheduled meetings where staff review and update the individualized plans that govern how a resident is bathed, fed, medicated, and treated. When residents are left out, the plan gets written without their input. Their preferences don't get recorded. Their concerns don't get heard.
Resident 180 was not notified of a care conference scheduled for February 19, 2025. The facility's Social Services Director acknowledged the oversight directly, telling inspectors that Resident 180 should have been notified to allow participation and to update any preferences. There was no dispute about what happened. The meeting was held. The resident wasn't told.
Resident 239 was his own responsible party, meaning no family member or outside advocate was standing in for him. He did not attend a care conference scheduled for January 29, 2025. When inspectors reviewed his records, the Social Services Director said she could not find any documentation showing he had been notified of the meeting or that he had been offered the chance to decline. The absence of paperwork wasn't a technicality. It meant there was no evidence anyone had tried to reach him at all.
The Social Services Director, interviewed on March 13, told inspectors that all residents and their representatives should have the opportunity to participate in care conferences so they can be involved and help personalize their care plans by making updates to include preferences and concerns. The Director of Nursing, interviewed the following morning, said the same thing in different words. Care conferences, she said, were important because they give residents and families the opportunity to communicate and to have care plans updated.
Both administrators described, accurately, what is supposed to happen. Neither offered an explanation for why it hadn't.
The gap between what staff said and what the records showed was the finding. The facility's own policy, revised in March 2022, states that each resident has the right to participate in the development of their care plan and must be provided advance notice of care planning conferences. The policy existed. The notices, in at least two cases, did not go out.
Care conferences are one of the few formal mechanisms through which a nursing home resident can exercise control over their own life. For residents who cannot easily advocate for themselves in hallway conversations, who may not know who to ask or how to raise a concern, the care conference is the structured moment when the facility is required to stop and listen. Missing that moment, for a resident like Resident 239 who had no family representative to follow up on his behalf, means the plan of care moves forward shaped entirely by staff assumptions.
The violation was cited at a level of minimal harm or potential for actual harm, affecting some residents. In the hierarchy of nursing home deficiencies, that is not the most severe category. But the rating describes what inspectors could document, not necessarily what a resident experienced sitting in his room on January 29 while a meeting about his care was held without him.
Country Hills Post Acute is located at 1580 Broadway in El Cajon. The inspection was conducted by the California Department of Public Health on behalf of the Centers for Medicare and Medicaid Services.
Resident 239's care plan was updated at that January conference. He wasn't asked what he wanted in it.
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 11, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
When residents are left out, the plan gets written without their input.
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.