Magnolia Post Acute Care
635 S Magnolia Ave · El Cajon, CA · 92020 · 6194428826
99 certified beds For profit - Corporation Chain: The Ensign Group
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection results are getting worse cycle over cycle, not better.
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Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
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.
$117,475 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
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: 3 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.07 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.46 | 0.55–0.75 |
| Weekend hours / resident-day | 3.60 | ≈ weekday level |
| Nursing turnover / year | 40% | median 45% |
| Fines (3-yr window) | 1 · $117,475 |
Inspection citations (36 in the current record)
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Actual harm · H December 11, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 4, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 11, 2025 · found via complaint
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected January 4, 2026 · Resident Rights
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Potential for harm · D December 11, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected January 4, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 11, 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 January 4, 2026 · Resident Assessment and Care Planning
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Potential for harm · E August 29, 2025
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 September 17, 2025 · Resident Rights
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Potential for harm · D August 29, 2025
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected September 17, 2025 · Resident Rights
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Potential for harm · D August 29, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected September 17, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 29, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected September 17, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 29, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected September 17, 2025 · Quality of Life and Care
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Potential for harm · D August 29, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 17, 2025 · Quality of Life and Care
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Potential for harm · E August 29, 2025
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected September 17, 2025 · Nutrition and Dietary
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Potential for harm · E August 29, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 17, 2025 · Nutrition and Dietary
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Potential for harm · D August 29, 2025
Provide and implement an infection prevention and control program.
Corrected September 17, 2025 · Infection Control
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Potential for harm · D May 22, 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 June 4, 2025 · Resident Rights
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Potential for harm · D April 30, 2025 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected May 13, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 13, 2024
Assess the resident when there is a significant change in condition
Corrected July 27, 2024 · Resident Assessment and Care Planning
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Potential for harm · D June 13, 2024
Ensure each resident receives an accurate assessment.
Corrected July 27, 2024 · Resident Assessment and Care Planning
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Potential for harm · D June 13, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected July 27, 2024 · Resident Assessment and Care Planning
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Potential for harm · D June 13, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 27, 2024 · Resident Assessment and Care Planning
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Potential for harm · D May 24, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected June 3, 2024 · Pharmacy Service
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Potential for harm · D May 6, 2024 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected May 15, 2024 · Resident Rights
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Potential for harm · D February 16, 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 March 5, 2024 · Resident Assessment and Care Planning
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Potential for harm · D August 17, 2023 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 6, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 22, 2023 · found via complaint
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected June 30, 2023 · Resident Rights
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Potential for harm · D June 22, 2023 · found via complaint
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected June 30, 2023 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 11, 2025 | Fine | $117,475 |
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 055890 · certified since March 11, 1968. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.