Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
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| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jun 16, 2026 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jun 16, 2026 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Complaint |
| Jun 16, 2026 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jun 16, 2026 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Jun 4, 2026 | J · harm | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| Jun 4, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Jun 4, 2026 | D · potential | Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Complaint |
| Jun 4, 2026 | E · potential | Provide and implement an infection prevention and control program. | Complaint |
| May 20, 2026 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Routine |
| May 20, 2026 | D · potential | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Routine |
| May 20, 2026 | D · potential | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Routine |
| May 20, 2026 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| May 20, 2026 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| May 20, 2026 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| May 20, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| May 20, 2026 | J · harm | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| May 20, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| May 20, 2026 | D · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| May 20, 2026 | K · harm | Ensure that residents are free from significant medication errors. | Routine |
| May 20, 2026 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| May 20, 2026 | D · potential | Provide or obtain dental services for each resident. | Routine |
| May 20, 2026 | D · potential | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Routine |
| May 20, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| May 20, 2026 | F · potential | Hire a qualified full-time social worker in a facility with more than 120 beds. | Routine |
| May 20, 2026 | D · potential | Have a plan that describes the process for conducting QAPI and QAA activities. | Routine |
| May 20, 2026 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Apr 16, 2026 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Complaint |
| Mar 10, 2026 | D · potential | Ensure that residents are free from significant medication errors. | Complaint |
| Mar 4, 2026 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Jan 23, 2026 | D · potential | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Complaint |
| Jan 23, 2026 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Jan 23, 2026 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Jan 23, 2026 | D · potential | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Complaint |
| Jan 23, 2026 | D · potential | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Complaint |
| Jan 23, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Dec 2, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 2, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Sep 18, 2025 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Complaint |
| Jul 14, 2025 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Jul 14, 2025 | D · potential | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Complaint |
| Jun 3, 2025 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| May 15, 2025 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| May 15, 2025 | F · potential | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Complaint |
| Mar 19, 2025 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Feb 27, 2025 | D · potential | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Routine |
| Feb 27, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Feb 27, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Feb 27, 2025 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Feb 27, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Feb 27, 2025 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Feb 27, 2025 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Feb 27, 2025 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Feb 27, 2025 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Routine |
| Feb 27, 2025 | D · potential | Ensure that residents are free from significant medication errors. | Routine |
| Feb 27, 2025 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Feb 27, 2025 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Feb 27, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Feb 27, 2025 | E · potential | Have a plan that describes the process for conducting QAPI and QAA activities. | Routine |
| Feb 27, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 27, 2025 | D · potential | Keep all essential equipment working safely. | Routine |
| Jan 24, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Sep 5, 2024 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Complaint |
| Jul 17, 2024 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Complaint |
| Jul 17, 2024 | G · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| May 28, 2024 | D · potential | Keep residents' personal and medical records private and confidential. | Complaint |
| May 1, 2024 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Complaint |
| Feb 20, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Feb 9, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Dec 28, 2023 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Dec 28, 2023 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Oct 30, 2023 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Oct 5, 2023 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Complaint |
| Oct 5, 2023 | D · potential | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Complaint |
| Oct 5, 2023 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Jun 16, 2022 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jun 16, 2022 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Jun 16, 2022 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Jun 16, 2022 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Jun 16, 2022 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Jun 16, 2022 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jun 16, 2022 | D · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Jun 16, 2022 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jun 16, 2022 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Jun 16, 2022 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Jun 16, 2022 | D · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Jun 16, 2022 | D · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 16, 2022 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jun 16, 2022 | D · potential | Perform COVID19 testing on residents and staff. | Routine |
| Jun 16, 2022 | D · potential | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
San Diego Post-Acute Center
1201 South Orange Ave., El Cajon, CA 92020 · (619) 441-1988
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555659
- Certified beds
- 240
- Legal owner
- Pepperbush Holdings LLC
- Part of
- Pacs Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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