Country Hills Post Acute: Weight Monitoring Failure - CA
Resident 260 weighed 117.9 pounds on October 2, 2024. By December 26, she was down to 95 pounds. That kind of loss, nearly one in five pounds of a person's total body weight in under three months, is the kind of number that triggers closer monitoring. The facility's own registered dietician documented the 17.8 percent loss on January 3, 2025. A covering dietician put it in writing again on February 3: "Lost 22# in one month. Follow weights weekly for now due to significant weight loss."
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When inspectors reviewed Resident 260's weight record on March 13, 2025, there were no weekly weights recorded for January or February. The resident had gone from late December through at least mid-March without the closer monitoring her own care team had put in writing.
The registered dietician, interviewed that morning alongside his own progress notes, said he was the one who decided when to start and stop weekly weights, and that they were standard for newly admitted residents and for anyone with a change in condition. He acknowledged the February 3 note calling for weekly monitoring. Then he said he was not sure why the weekly weights had not been taken.
A licensed nurse explained how the system was supposed to work: one certified nursing assistant was assigned to take all residents' weights and was expected to notify a nurse for any significant change. Whether that CNA was ever told about the weekly weight order for Resident 260, the inspection report does not say.
The Director of Nursing, interviewed on the afternoon of March 14, confirmed that weekly weights were important when a dietician recommended them for weight loss monitoring. She did not offer an explanation for why they had not happened.
By January 23, Resident 260 weighed 96.2 pounds. By February 20, she was back up to 100 pounds. Those two data points exist in the record. What does not exist is the string of weekly measurements that would have shown, week by week, whether she was continuing to lose ground, stabilizing, or starting to recover. The dietician himself told inspectors that weekly weights were important for closer monitoring. The gap in the record is the gap in the care.
The facility's written nutrition protocol, dated September 2012, instructs nursing staff to monitor and document weight in a format that permits comparisons over time. The protocol does not address what happens when a dietician issues a specific recommendation. There was nothing in the policy to catch what fell through.
Inspectors cited the deficiency at the lower end of the harm scale, classifying it as minimal harm or potential for actual harm, affecting a small number of residents. That classification reflects the regulatory framework, not necessarily what it means to lose nearly a quarter of your body weight and then go unmonitored for two months in a skilled nursing facility. Resident 260 recovered some of what she lost. The weekly record that might have shown how close the margin was never existed.
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 12, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
Resident 260 weighed 117.9 pounds on October 2, 2024.
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.