Country Hills Post Acute: Call Button Safety Failures - CA
Resident 55 was admitted in December with functional quadriplegia and metabolic encephalopathy. Despite having intact cognition and requiring substantial assistance with all daily activities, he couldn't operate the standard call button that required gripping and pressing with his thumb.
"I am unable to use the press the call button," he told inspectors on March 11. "To get staff I yell."
Both of his hands were visibly contracted, preventing normal movement. Yet for months, no one had provided him with an appropriate alternative.
Licensed Nurse 51 acknowledged the problem the next day. "Since R55's hands were contracted, he could not use the call button that was provided and would need a call button that he could tap," she said. She understood the stakes: "R55 needed to be able to communicate his needs with the staff."
The facility's own policy required alternative communication methods for residents with disabilities that prevent normal call button use. Assistant Director of Nursing 4 and Director of Nursing both confirmed during interviews that Resident 55 should have received a tap-activated button that accommodated his limitations.
Meanwhile, Resident 268 faced her own communication crisis. The 83-year-old woman, admitted in September with atrial fibrillation, chronic lymphocytic leukemia, and brain hemorrhage complications, had a completely non-functional call button.
Inspectors discovered on March 11 that her call button was missing its red centerpiece entirely. The device simply didn't work.
Facility Manager reviewed maintenance logs and found no record of repair requests for the broken button. "If a call button is broken, staff should call maintenance and write the request in maintenance log," he explained. "The broken call button should immediately be replaced with a functional one."
The breakdown in basic procedures was evident throughout the nursing staff. Licensed Nurse 54 admitted he had reported the broken call button to maintenance but never documented it in the required logbook. "The expectation was that if there is broken call button, he should have called and documented broken equipment in the log book," he acknowledged.
Certified Nursing Assistant 53 knew the protocol but it wasn't being followed. She said non-functional call buttons "should be reported to charge nurse, who would call maintenance and log the needed repair in maintenance logbook."
Both residents required substantial assistance with self-care activities. Resident 268 had intact cognition despite her medical conditions. The facility's 2001 call system policy was unambiguous: "Each resident is provided with a means to call staff directly for assistance from his/her bed" and "The resident call system remains functional at all times."
The communication failures extended beyond individual rooms. In a separate violation, inspectors found a cockroach infestation in a three-person room that had gone unreported and unaddressed.
Resident 258, who had been admitted in January for infections and surgical complications, witnessed the extent of the problem. "There were cockroaches all over the room," she told inspectors. The housekeeper had seen cockroaches behind the dresser that morning, and her roommates stored food in and around their furniture.
Dead cockroaches were visible in the daily menu frame and in the light fixture behind her bed when inspectors arrived March 11.
The facility's pest control contractor had identified activity in room 328 during a February 28 visit, recommending that tables be cleared and items removed for better access during treatment. But no maintenance log entry existed for the cockroach problem.
Facility Manager explained the required process: staff should call maintenance and log pest reports, then he would contact the contracted pest control service for focused extermination. Monthly routine checks were supposed to catch problems before they became infestations.
"The importance of keeping residents' rooms pest free was for maintaining the health of the residents in the room," he said.
Licensed Nurse 56 and Assistant Director of Nursing 3 both emphasized infection control as the primary concern with pest infestations. The Administrator added that pest-free rooms were essential for "resident's health and safety, and to maintain a homelike quality."
The facility's 2001 pest control policy required "an effective pest control program" to ensure "the building is kept free of insects and rodents."
Director of Nursing confirmed during her March 14 interview that the expectation was clear: "Residents' rooms should be pest free" and "All residents should have a functional call button."
For Resident 55, the failure meant continued dependence on shouting to get staff attention despite his complex medical needs and stage 3 and 4 pressure ulcers requiring specialized care. His care plan specifically noted he was "at risk for ADL/Mobility decline and requires assistance" and should "encourage to use call light for assistance."
The contradiction was stark. A resident identified as needing to use his call light for assistance couldn't actually use the call light provided to him.
Resident 268 faced similar isolation, unable to summon help when needed despite requiring substantial assistance with all self-care activities. Her adequate vision meant she could see her broken call button but remained powerless to fix it or get staff attention when alone.
The inspection revealed a systematic breakdown in basic safety protocols that left vulnerable residents without reliable means to communicate their needs to caregivers in a facility where such communication could mean the difference between timely care and dangerous delays.
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 15, 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 in December with functional quadriplegia 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.
Frequently Asked Questions
- What happened at COUNTRY HILLS POST ACUTE?
- Resident 55 was admitted in December with functional quadriplegia and metabolic encephalopathy.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in EL CAJON, CA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from COUNTRY HILLS POST ACUTE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 555431.
- Has this facility had violations before?
- To check COUNTRY HILLS POST ACUTE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.