Country Hills Post Acute: Call Button Failures - CA
The facility, located at 1580 Broadway in El Cajon, was inspected on March 14, 2025. Among the deficiencies documented was a broken call button in the room of a resident identified in inspection records as R268. The button was not working. The resident had no reliable way to summon staff.
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See the Derila PillowA call button is not a convenience. For residents who cannot get out of bed, cannot raise their voice loud enough to be heard, or cannot walk to a doorway, it is the one tool standing between them and silence. It is how a person asks for water, reports pain, or signals that something has gone wrong.
The inspection team observed R268's broken call button on March 11 at 3:55 in the afternoon, during a concurrent interview with the Assistant Director of Nursing. That administrator, identified in records as ADON4, confirmed what inspectors already knew. "The expectation was that all residents should have a functional call button," ADON4 said. The importance, she added, was "for resident safety and for communication of needs with staff."
She described the procedure: when a call button breaks, staff are supposed to notify maintenance and document it in the maintenance log. The log existed. The documentation process existed. The button was still broken.
A charge nurse identified as LN54 told inspectors the same thing. Staff who find broken equipment are supposed to call it in and write it down. LN54 said the expectation was that all call buttons should be functional. LN54 said the reason was so residents could communicate their needs.
Three days later, on the morning of the final inspection, the Director of Nursing was interviewed. The DON said call buttons should be functional and should accommodate a resident's ability to use them. If a resident's disability prevents them from using the standard call system, an alternative means of communication should be provided and written into the care plan. The DON said the point was to make sure residents' needs were met.
The facility's own call system policy, in place since 2001, states that each resident is provided with a means to call staff directly for assistance from their bed, that the call system remains functional at all times, and that residents who cannot use it are given an alternative.
The policy was written. The expectation was clear. Every supervisor interviewed said the same thing. The button in R268's room did not work.
What the inspection record does not say is how long it had been broken. It does not say whether R268 had any way to call for help in the meantime. It does not say whether anyone checked on R268 more frequently because the call button was out, or whether the room was simply a room where the button did not work and staff moved on to other things.
CMS classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. That classification reflects regulatory language. It does not describe what it is like to need something and have no way to ask for it.
The maintenance log was there. The procedure was there. The policy had been on the books for more than two decades. What was missing, when inspectors walked into R268's room on a Tuesday afternoon, was a working call button.
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 13, 2026 · Our methodology
COUNTRY HILLS POST ACUTE in EL CAJON, CA was cited for violations during a health inspection on March 14, 2025.
The facility, located at 1580 Broadway in El Cajon, was inspected on March 14, 2025.
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.