Country Hills Post Acute: Call Button Failures - CA
Resident 55 was admitted to Country Hills Post Acute with functional quadriplegia, cognitive communication deficits, and metabolic encephalopathy. His assessment showed he required substantial assistance for all daily activities and had intact cognition despite his communication difficulties.
The resident developed severe pressure ulcers during his stay. His December assessment documented one stage 3 and one stage 4 pressure ulcer, requiring specialized pressure-reducing devices and wound care.
Both of his hands were contracted, preventing normal grip and finger movement. Yet staff provided him with a standard call button that required gripping with the hand and pressing with the thumb.
"I am unable to use and press the call button," the resident told inspectors during their March 11 visit. "To get staff I yell."
Licensed Nurse 51 acknowledged the problem the next day. She explained that because the resident's hands were contracted, "he could not use the call button that was provided and he would need a call button that he could tap."
The nurse understood the stakes. She told inspectors the importance of having an appropriate call button was "that R55 needed to be able to communicate his needs with the staff."
Assistant Director of Nursing 4 confirmed the same issue during a March 12 observation. She stated that because the resident's hands were contracted, "he could not press the provided call button, and he would need a call button he could tap."
She emphasized that residents "should be able to communicate his needs with the staff."
The Director of Nursing admitted the facility's failure during the final inspection interview. She stated "the expectation for R55's call button was that it should accommodate R55's ability and it should have been a tap call button."
The nursing director explained that providing the correct type of call button was essential "to enable R55 to make his needs known to staff."
The facility's own policy required accommodation of individual needs. The 2001 policy on accommodation of needs stated that "the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis."
The policy directed staff toward "assisting the residents in maintaining independence, dignity, and well being to the extent possible and in accordance with the residents wishes."
Despite having this policy for over two decades, staff failed to provide basic adaptive equipment for a resident who clearly needed it.
The resident's care plan from March 12 noted he was "at risk for ADL/Mobility decline and requires assistance" and instructed staff to "encourage to use call light for assistance."
But encouraging someone to use equipment they physically cannot operate represents a fundamental misunderstanding of disability accommodation.
The resident's medical complexity made communication access even more critical. His admission diagnoses included cognitive communication deficits stemming from impairments in thinking functions like attention, memory, and problem-solving.
Yet his Brief Interview for Mental Status score of 13 indicated intact cognition, meaning he understood his situation and needs but struggled to communicate them effectively.
For a resident with stage 4 pressure ulcers, the ability to call for repositioning, pain medication, or emergency assistance could prevent further tissue breakdown or life-threatening complications.
Stage 4 pressure ulcers extend through skin and tissue to underlying muscle, tendon, or bone. They represent the most severe category of bedsores and can lead to sepsis, bone infection, or death without proper care.
The facility also failed to maintain basic sanitation standards in another area. Inspectors found a shared bathroom used by hospice resident 297 was dirty with feces on surfaces and had a strong odor.
This created exposure risks for residents, staff, and visitors to harmful bacteria and potential health hazards. The unsanitary conditions violated residents' right to a clean, comfortable, and homelike environment.
The inspection documented systemic failures in two fundamental areas of nursing home care: providing adaptive equipment for disabled residents and maintaining basic cleanliness standards.
Three separate nursing supervisors acknowledged that the quadriplegic resident needed a tap call button instead of a grip-and-press model. Yet none had ensured he received appropriate equipment during his months-long stay.
The resident remained dependent on yelling to summon help, a method that might fail during medical emergencies or when his voice was weak. His contracted hands made him completely reliant on staff responsiveness to verbal calls.
For someone with severe pressure ulcers and total dependency for daily care, the inability to reliably summon assistance represented a significant safety risk that the facility's own nursing leadership recognized but failed to address.
The violations occurred at a facility responsible for caring for some of the most vulnerable patients in the healthcare system, including those receiving end-of-life hospice care who depend entirely on staff for comfort and dignity in their final days.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
Resident 55 was admitted to Country Hills Post Acute with functional quadriplegia, cognitive communication deficits, and metabolic encephalopathy.
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.