Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Magnolia Post Acute Care during CMS and state inspections, most recent first.
Three residents, all cognitively intact, reported that a CNA inappropriately touched them during personal care, including fondling and digital penetration. The CNA was hired despite negative references indicating poor past performance, and the facility lacked effective oversight of the hiring process and abuse prevention training. The affected residents experienced significant psychosocial harm as a result.
A resident who was cognitively intact filed a grievance requesting not to be assigned to a specific CNA after experiencing inappropriate behavior. Despite this, the CNA was assigned to the resident again, contrary to facility policy and the resident's expressed wishes. Facility leadership acknowledged this was an oversight and that the grievance process was not properly followed.
Three cognitively intact residents reported that a CNA inappropriately touched them during personal care, describing specific incidents of non-consensual sexual contact. The facility's investigations did not include clarifying questions to fully understand the allegations, and the investigative summaries inaccurately reflected only positive pre-employment references for the CNA, despite negative references in the personnel file. The DON and ADM acknowledged these investigative shortcomings, resulting in the facility failing to identify and substantiate sexual abuse.
A resident who was cognitively intact filed a grievance requesting not to be assigned to a specific CNA due to inappropriate behavior. The facility did not promptly update the care plan to reflect this request, resulting in the CNA continuing to provide care to the resident on multiple occasions. The care plan was only revised months later and did not specifically address the resident's request.
A resident with cognitive and mobility deficits was discharged without proper coordination of 24-hour care as recommended by OT, and without documented caregiver training or physician notification. The discharge proceeded despite unsuccessful attempts to confirm or train a caregiver, and the facility did not document alternative arrangements or address barriers to a safe transition.
A resident with severe cognitive and hearing impairments reported a missing gray bag containing hearing aids and other personal items. Staff did not follow facility policy to investigate or document the loss, and the Social Services Director did not follow up with the resident's personal caregiver due to lack of information. No investigation was recorded in the missing items binder, resulting in failure to protect the resident's property.
A resident with a terminal prognosis due to cerebral infarction was admitted to hospice services, but the facility failed to submit the significant change MDS on time. The MDS Nurse and DON confirmed the assessment was incomplete, as it lacked the necessary signatures and was not submitted by the expected deadline.
A resident's MDS inaccurately indicated no tobacco use, despite evidence of smoking. The MDS Nurse admitted the error, and the DON acknowledged responsibility for MDS accuracy. The Administrator expected timely and accurate MDS completion.
A resident with schizoaffective disorder and bipolar disorder was admitted to a facility, but their PASRR Level I assessment was inaccurately coded as having no serious mental illness. This error was not identified or corrected due to inadequate review processes. The DON acknowledged the mistake, and the Administrator expected staff to ensure document accuracy.
A facility failed to document a care plan for a resident receiving Lasix for edema. The resident, with a history of stroke, COPD, chronic kidney disease, atrial fibrillation, and hypertension, was admitted with moderate cognitive impairment. Despite an active order for Lasix, the care plan lacked documentation, as confirmed by the MDS Nurse and DON.
A facility failed to follow its policy for receiving narcotics, resulting in a resident's pain medication being unaccounted for. The medication was later found at another facility and returned to the pharmacy. Interviews revealed that the nurse who signed for the delivery did not verify the contents, contrary to facility policy.
The facility failed to notify a resident's physician regarding an altered mental status, leading to a delay in care. The resident, with chronic kidney disease stage three, exhibited increased drowsiness and lethargy, becoming nonverbal and hard to arouse. Despite the facility's policy requiring immediate notification, the physician was not informed, and the resident was eventually taken to the hospital via 911.
Failure to Protect Residents from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect three residents from sexual abuse by a certified nursing assistant (CNA). Each of the three residents, all of whom were cognitively intact and able to communicate, reported separate incidents in which CNA 4 inappropriately touched them during personal care. One resident described the CNA fondling her clitoris and inserting his fingers into her vagina during a brief change, which she reported to both her husband and the facility. Another resident stated that the CNA massaged her vagina, both externally and internally, under the pretense of helping her sleep, and she later expressed regret for not reporting the sexual nature of the abuse sooner. The third resident reported that the CNA inserted his finger into her vagina after a brief change and noted that the inappropriate touching only occurred when the CNA was alone with her. The facility's hiring process for CNA 4 was deficient, as his personnel file contained two negative reference checks from previous employers, both indicating poor performance and stating they would not rehire him. Despite this, the facility's investigative summaries inaccurately reflected only positive references. The director of nursing (DON) and administrator (ADM) stated they had not seen the negative references prior to hiring and would have hesitated to hire CNA 4 had they been aware of them. The facility did not have a policy regarding reference checks, and the responsibility for checking references was left to human resources, resulting in a lack of oversight. Additionally, the facility did not provide abuse-related in-service training to CNA 4 after the first report of sexual abuse, as he was suspended and subsequently resigned. The facility's policy stated that all employees would be properly screened prior to employment and that staff would be trained to identify and report abuse, but these procedures were not effectively implemented. The residents involved experienced psychosocial harm, including feelings of humiliation, anger, anxiety, and worry, as a direct result of the abuse and the facility's failure to prevent it.
Failure to Honor Resident Grievance Regarding CNA Assignment
Penalty
Summary
The facility failed to honor a resident's grievance requesting not to be assigned to a specific CNA after the resident reported discomfort and inappropriate behavior by that CNA. The resident, who was cognitively intact and had the capacity to make decisions, filed a grievance stating that the CNA was too friendly and requested not to have the CNA provide care. Despite this, the CNA was assigned to the resident on at least one subsequent occasion, which was acknowledged by the Director of Nursing as an oversight. The facility's own policy required immediate action to resolve grievances and prevent further potential violations of resident rights during investigations, but this was not followed. The resident reported that the CNA had previously engaged in inappropriate touching during care, which made her feel uncomfortable and angry. She expressed concern for herself and other vulnerable residents who might not be able to voice similar grievances. Facility records confirmed that the CNA provided care to the resident after the grievance was filed, and interviews with facility leadership confirmed that this assignment should not have occurred according to the resident's request and facility policy.
Failure to Thoroughly Investigate and Substantiate Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and identify sexual abuse after receiving and investigating three separate allegations against a certified nursing assistant (CNA). Three residents, all of whom were cognitively intact and had the capacity to make decisions, reported that the CNA inappropriately touched them during personal care. Each resident described specific incidents where the CNA engaged in non-consensual sexual contact, including rubbing and inserting fingers into their vaginal area. The residents reported feeling uncomfortable, humiliated, and taken advantage of, and two expressed concern that there may be other victims. Despite these detailed allegations, the facility's investigations into each incident were incomplete. The investigative summaries for each resident did not include clarifying questions to fully understand the nature of the alleged abuse. The DON acknowledged during interviews that she did not clarify what the residents meant by terms such as "uncomfortable experience" or "inappropriate touch" during her interviews. As a result, the facility concluded that the allegations were unsubstantiated without thoroughly exploring the residents' statements or the context of the alleged incidents. Additionally, the facility's review of the CNA's pre-employment references was flawed. The investigative summaries indicated only positive references, but the CNA's personnel file contained two negative references, both stating the CNA was unreliable and would not be rehired. The DON and ADM admitted they had not seen these negative references during the hiring process or the subsequent investigations. The facility's failure to properly review and verify the CNA's references, combined with the lack of thorough investigation into the residents' allegations, resulted in a failure to identify and substantiate sexual abuse within the facility.
Failure to Timely Update Care Plan After Resident Grievance Against CNA
Penalty
Summary
The facility failed to develop and implement a person-centered care plan in a timely manner after a resident filed a grievance requesting that a specific CNA not be assigned to her. The resident, who was cognitively intact and had the capacity to make decisions, filed a grievance stating that the CNA was too friendly and requested not to have this CNA provide her care. Despite this request, the facility did not update the resident's care plan to reflect her wishes, and the CNA continued to be assigned to her on at least two occasions after the grievance was filed. The care plan was not revised to specifically address the resident's request until several months later, and even then, it only generally noted that the resident had preferences for some CNAs over others without specifying the reason or naming the CNA in question. Interviews with facility staff, including the Medical Record Director and the DON, confirmed that the care plan was not promptly updated in response to the resident's grievance. The facility's own policy required care plans to be revised to accommodate resident needs, but this was not followed in this case.
Failure to Ensure Safe and Coordinated Discharge Planning
Penalty
Summary
The facility failed to provide proper discharge planning for a resident with a history of visuospatial deficit and spatial neglect following a stroke, who had moderate cognitive deficits. The resident received physical, occupational, and speech therapy, with occupational therapy recommending 24-hour care and the use of a walker with a tray. Despite these recommendations, there was no documentation that the resident's physician was notified about the need for 24-hour care, nor was there evidence that the resident's potential caregiver received any training or confirmed their ability to provide the necessary care. Attempts to contact the resident's girlfriend, who was identified as a possible caregiver, were unsuccessful, and there was no documentation of alternative arrangements or notification to the physician regarding these barriers to a safe discharge. The discharge proceeded without ensuring that the recommended 24-hour care was in place, and the resident was sent home with home health services but without a confirmed or trained caregiver. The facility's own staff, including the Director of Rehab, Case Manager, and Director of Nursing, acknowledged the lack of documentation and coordination regarding caregiver training and notification of the physician about the occupational therapy recommendations. The facility's policy required that residents only be discharged when it was safe and appropriate, but this was not followed in this case.
Failure to Investigate and Document Missing Resident Property
Penalty
Summary
The facility failed to follow its policies and procedures for investigating missing items, specifically in the case of a resident with severe cognitive deficits and hearing loss. The resident was admitted with a history of cognitive communication deficit and right ear hearing loss, and her minimum data set assessment indicated severe cognitive impairment. After returning from a hospital stay, her inventory list included a gray bag, keys, charger for hearing aids, identification card, and two hearing aids. The gray bag, containing her hearing aids and other personal items, was reported missing, and the resident was unable to use her hearing aids since the bag went missing. Staff interviews revealed that the Social Services Director (SSD) was informed of the missing bag when nursing staff could not locate the resident's hearing aids. The SSD learned from the resident that a personal caregiver, not employed by the facility, may have had the bag, but the SSD did not follow up with the caregiver due to lack of contact information and only knowing the caregiver's first name. The SSD did not document or investigate the missing items in accordance with facility policy, which requires loss or theft of resident property worth $25 or more to be documented, reported, and investigated, with completed reports filed in the Social Service Department Office. Further interviews with facility staff, including the Quality Assurance (QA) Nurse and Director of Nursing (DON), confirmed that the expected procedure was not followed. The SSD did not attempt to verify with the personal caregiver whether the bag was given to her or was still missing, despite the resident's cognitive impairments. There was no recorded investigation in the facility's missing items binder regarding the missing gray bag or hearing aids, and the lack of follow-up and documentation failed to protect the resident's personal property as required by facility policy.
Failure to Timely Submit Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to ensure a significant change Minimum Data Set (MDS) was submitted timely for a resident who was admitted to hospice services. The resident, who had a medical history including cerebral infarction, chronic obstructive pulmonary disease, hemiplegia, hemiparesis, and sepsis, was admitted to the facility in January 2024. The resident's care plan indicated a terminal prognosis due to cerebral infarction, and an order for hospice services was placed in May 2024. However, the significant change MDS, which was required to be completed following the resident's admission to hospice, was not completed on time. The MDS Nurse and the Director of Nursing (DON) both confirmed that the significant change MDS for the resident should have been completed by the end of May 2024. The MDS was considered complete only when signed by the DON, but the section for the RN Assessment Coordinator's signature was left blank, indicating the assessment was incomplete. Interviews with the MDS Nurse, DON, and Administrator revealed an expectation for timely completion and submission of the MDS, which was not met in this instance.
Inaccurate MDS Assessment for Resident's Tobacco Use
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) for a resident, leading to a deficiency in the assessment process. The resident in question was admitted with a medical history that included cellulitis, local infection of the skin and subcutaneous tissue, and homelessness. The admission MDS inaccurately indicated that the resident did not use tobacco, despite progress notes and observations showing the resident was actively smoking. A nicotine transdermal patch was not applied due to the resident's smoking, which was documented in the progress notes. Interviews with facility staff revealed that the MDS Nurse was responsible for the section of the MDS regarding tobacco use and admitted to the inaccuracy. The Director of Nursing (DON) acknowledged her responsibility for the overall accuracy of the MDS and stated that residents who smoked should be accurately reflected in the MDS. The Administrator also emphasized the expectation for the MDS to be completed accurately and in a timely manner. The deficiency was identified as a failure to accurately assess and document the resident's tobacco use in the MDS.
Inaccurate PASRR Assessment for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure accurate coding of a Preadmission Screening and Resident Review (PASRR) Level I assessment for a resident with a history of schizoaffective disorder and bipolar disorder. The resident was admitted to the facility with these diagnoses, as documented in their hospital history and physical note. However, the PASRR Level I screening incorrectly marked the resident as having no serious mental illness, resulting in a negative PASRR Level I and no requirement for a Level II assessment. This discrepancy was not identified or corrected by the facility at the time of admission. Interviews with facility staff revealed a lack of a robust process for reviewing PASRR assessments for accuracy. The Social Services staff, who was responsible for requesting PASRRs during the admission process, did not start in her position until after the resident's admission. The Director of Nursing acknowledged the PASRR was incorrect and stated that the facility did not have a good process in place at the time. The Administrator admitted to having limited understanding of the PASRR process but expected staff to ensure the accuracy of the documents received.
Failure to Document Diuretic Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was completed for a resident receiving diuretics, specifically Lasix (furosemide), which was prescribed for edema. The resident, who was admitted on January 22, 2024, had a medical history that included cerebral infarction, chronic obstructive pulmonary disease, chronic kidney disease, atrial fibrillation, and hypertension. The resident's admission Minimum Data Set (MDS) indicated moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9. Despite the resident receiving a diuretic, the comprehensive care plan lacked documentation for its use. Interviews with facility staff revealed that the MDS Nurse acknowledged the responsibility to create a care plan when the diuretic order was entered. The Director of Nursing (DON) confirmed that care plans should align with resident charts and noted the absence of a care plan for the diuretic. This oversight was identified during a review of the resident's Order Summary Report, which showed an active order for Lasix dated May 16, 2024, but no corresponding care plan documentation.
Failure to Follow Policy for Receipt of Narcotics
Penalty
Summary
The facility failed to follow its own policy regarding the receipt of narcotics for one of the sampled residents. Specifically, a licensed nurse did not check or inventory medications, including narcotics, delivered by the pharmacy. This resulted in the whereabouts of the resident's narcotic medication being unknown. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis, requested the narcotic pain medication Norco, but was informed by a licensed nurse that the medication was not available and had to be reordered. The medication was eventually administered from the facility's emergency kit. Interviews with various licensed nurses and the Director of Nursing revealed that the facility's policy required licensed staff to check and sign for the receipt of medications, including narcotics, upon delivery. However, the nurse who signed for the delivery did not verify the contents of the pharmacy bag. The narcotic medication was later found at another facility and returned to the pharmacy. An audit initiated by the facility failed to locate the missing medication, highlighting a lapse in the facility's medication management procedures.
Failure to Notify Physician of Resident's Altered Mental Status
Penalty
Summary
The facility failed to notify a resident's physician regarding an altered mental status for one resident reviewed for a change in condition. The resident, who had chronic kidney disease stage three, exhibited increased drowsiness and lethargy, becoming nonverbal and hard to arouse. Despite these significant changes, the physician was not notified immediately, which had the potential to delay care and treatment. The resident was eventually taken to the hospital via 911 later that evening. Interviews with licensed nurses and the Director of Nurses (DON) confirmed that the facility's policy required immediate notification of the physician for any change in a resident's condition. The facility's policy and procedure also mandated that any sudden or serious change in a resident's condition be communicated to the physician by the licensed nurse. However, in this case, the policy was not followed, leading to a delay in addressing the resident's altered mental status.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Cajon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stillwater Post-acute | 0 mi | ★★★★★ | 2 | 0 |
| Somerset Post Acute Care | 0.4 mi | ★★★★★ | 2 | 0 |
| Victoria Post Acute Care | 0.6 mi | ★★★★★ | 12 | 0 |
| Villa Las Palmas Healthcare Center | 0.6 mi | ★★★★★ | 2 | 0 |
| San Diego Post-acute Center | 0.6 mi | ★★★★★ | 13 | 1 |
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