Cottonwood Canyon Healthcare Center
1391 Madison Avenue · El Cajon, CA · 92021 · 6194441107
96 certified beds For profit - Corporation Chain: Pacs Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.16 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.46 | 0.55–0.75 |
| Weekend hours / resident-day | 3.99 | ≈ weekday level |
| Nursing turnover / year | 44% | median 45% |
| Fines (3-yr window) | 2 · $25,423 |
Inspection citations (62 in the current record)
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Potential for harm · D April 15, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 7, 2026 · Quality of Life and Care
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Actual harm · G February 12, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 13, 2026 · Quality of Life and Care
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Potential for harm · D February 12, 2026 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected March 13, 2026 · Resident Assessment and Care Planning
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Potential for harm · D February 12, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 13, 2026 · Resident Assessment and Care Planning
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Potential for harm · D February 12, 2026 · found via complaint
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected March 13, 2026 · Quality of Life and Care
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Potential for harm · D February 12, 2026 · found via complaint
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.
Corrected March 13, 2026 · Nursing and Physician Services
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Potential for harm · D February 12, 2026 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected March 13, 2026 · Resident Assessment and Care Planning
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Potential for harm · D August 11, 2025 · found via complaint
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected September 10, 2025 · Resident Rights
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Potential for harm · D August 11, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 10, 2025 · Quality of Life and Care
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Potential for harm · D April 24, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · E April 24, 2025 · found via complaint
Plan the resident's discharge to meet the resident's goals and needs.
Corrected May 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 23, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 23, 2024 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected January 10, 2025 · Pharmacy Service
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Potential for harm · D December 23, 2024 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected January 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 12, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected January 10, 2025 · Resident Rights
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Potential for harm · E December 12, 2024
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.
Corrected January 10, 2025 · Resident Rights
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Potential for harm · D December 12, 2024
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected January 10, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 12, 2024
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.
Corrected January 10, 2025 · Resident Rights
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Potential for harm · D December 12, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 12, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 10, 2025 · Quality of Life and Care
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Potential for harm · D December 12, 2024
Assist a resident in gaining access to vision and hearing services.
Corrected January 10, 2025 · Quality of Life and Care
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Potential for harm · D December 12, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected January 10, 2025 · Quality of Life and Care
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Potential for harm · D December 12, 2024
Provide care or services that was trauma informed and/or culturally competent.
Corrected January 10, 2025 · Quality of Life and Care
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Potential for harm · D December 12, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected January 10, 2025 · Pharmacy Service
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Potential for harm · D December 12, 2024
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.
Corrected January 10, 2025 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 12, 2026 | Fine | $14,015 |
| August 1, 2023 | Fine | $11,408 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055064 · certified since January 1, 1967. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.