Country Hills Post Acute: Call Button Failure - CA
The resident, identified in inspection records as Resident 55, required a tap call button, one designed to accommodate his specific physical abilities. He didn't have one. Without it, he had no reliable way to let staff know he needed anything.
The Director of Nursing, interviewed by inspectors at 10 a.m. on the day of the inspection, confirmed the failure directly. The expectation, she said, was that the call button should have been a tap call button suited to Resident 55's abilities. The purpose of getting it right, she explained, was straightforward: to enable him to make his needs known to staff.
That hadn't happened.
The facility's own policy, titled Accommodation of Needs and dated 2001, spelled out what was supposed to occur. Residents' individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, were to be evaluated upon admission and reviewed on an ongoing basis. Staff were directed to assist residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with residents' wishes.
The policy existed. The evaluation process existed on paper. Resident 55 still ended up without the right equipment.
Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting a small number of residents. That classification reflects the regulatory language, not the practical reality for a person lying in a nursing home bed, pressing a call button that doesn't work for him, waiting to see if anyone comes.
A call button is not a luxury accommodation. In a nursing home, it is the primary way a resident communicates urgency to staff. The wrong button, for a resident whose physical abilities require a specific design, is functionally no button at all. It means waiting. It means hoping someone walks by. It means having no reliable way to say that something hurts, or that something is wrong, or simply that a basic need has gone unmet.
Country Hills Post Acute has operated at 1580 Broadway in El Cajon since well before this inspection. The facility's own admissions process was supposed to catch exactly this kind of gap. The policy the Director of Nursing cited required needs to be evaluated at admission and reviewed on an ongoing basis. At some point between Resident 55's arrival and the morning inspectors walked through the door, that process broke down. Nobody caught it. Or nobody fixed it.
The Director of Nursing did not dispute any of it. The tap call button was the right call button. Resident 55 should have had it. He didn't.
What inspectors could not document, and what the inspection report does not say, is how long Resident 55 went without the correct device. The report captures a single morning, a single interview, and a single admission by the facility's top nursing official that something basic had been missed. It does not capture how many times Resident 55 reached for a call button that couldn't register his touch, or what he needed in those moments, or whether anyone came.
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 8, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
The resident, identified in inspection records as Resident 55, required a tap call button, one designed to accommodate his specific physical abilities.
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.