San Diego Post-Acute Center

Nursing Home · El Cajon, CA

CMS overall rating 1/5 Abuse citation For profit - Limited Liability company

CMS certification number555659
This facility was cited for abuse, neglect or exploitation in a recent inspection (CMS abuse icon).

Contact & location

1201 South Orange Ave.
El Cajon, CA 92020
San Diego County
Phone
(619) 441-1988
ZIP code
92020 – all care providers

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Facility details

Certified beds
240
Residents per day
228.3 (95% occupied)
Ownership
For profit - Limited Liability company
Legal name
Pepperbush Holdings LLC
Chain
Pacs Group (274 facilities, avg 2.9★)
Medicare certified since
March 19, 1996
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 1/5
State avg 3.2
Health inspections★★★★★ 1/5
State avg 2.8
Staffing★★★★★ 4/5
State avg 3.3
Quality measures★★★★★ 4/5
State avg 4.1
Long-stay quality★★★★★ 5/5
Short-stay quality★★★★★ 3/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
4.16 (state 4.52 · U.S. 3.86)
Registered nurses (RN)
0.58 (state 0.67 · U.S. 0.69)
Licensed practical nurses
1.08 (state 1.20 · U.S. 0.86)
Nurse aides
2.50 (state 2.65 · U.S. 2.32)
Weekend total
3.92 (state 4.09 · U.S. 3.42)
Nursing staff turnover
36.5 (state 36.7 · U.S. 45.8)%
RN turnover
40.0 (state 38.1 · U.S. 42.9)%
Administrators who left
1 in the last year

Inspections

Last standard inspection
February 27, 2025
Health deficiencies (last cycle)
37.0 (state 15.7 · U.S. 9.3)
From complaints
21
Citations on record (3 years)
73 health · 7 fire safety · includes immediate jeopardy
DateCitationSeverityStatus
2026-06-16 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2026-07-07
2026-06-16 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-07-07
2026-06-16 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-07-07
2026-06-16 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-07-07
2026-06-04 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.
F0726 · Nursing and Physician Services Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 2026-07-03
2026-06-04 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-07-03
2026-06-04 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-07-03
2026-06-04 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.
F0838 · Administration Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-07-03
2026-05-20 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.
F0726 · Nursing and Physician Services Deficiencies · complaint inspection		 J
Immediate jeopardy to resident health or safety		 Corrected 2026-06-19
2026-04-16 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-05-16
2026-03-10 Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-04-02
2026-03-04 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-03-20
2026-01-23 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2026-02-22
2026-01-23 Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
F0559 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-22
2026-01-23 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-22
2026-01-23 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.
F0742 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-22
2026-01-23 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
F0744 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-22
2026-01-23 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-22
2025-12-02 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-12
2025-12-02 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F0657 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-12-12
2025-09-18 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.
F0761 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-09-30
2025-07-14 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Deficient, Provider has no plan of correction
2025-07-14 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F0686 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Deficient, Provider has no plan of correction
2025-06-03 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-06-27
2025-05-15 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2025-06-09
2025-05-15 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
F0925 · Environmental Deficiencies · complaint inspection		 F
No actual harm, potential for more than minimal harm		 Corrected 2025-06-09
2025-03-19 Respond appropriately to all alleged violations.
F0610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-04-16
2025-02-27 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.
F0761 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F0804 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Have a plan that describes the process for conducting QAPI and QAA activities.
F0865 · Administration Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 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.
F0622 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F0690 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Provide safe and appropriate respiratory care for a resident when needed.
F0695 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Ensure each resident’s drug regimen must be free from unnecessary drugs.
F0757 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 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.
F0758 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-02-27 Keep all essential equipment working safely.
F0908 · Environmental Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-27
2025-01-24 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-02-14
2024-09-05 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.
F0726 · Nursing and Physician Services Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-10-04
2024-07-17 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2024-07-31
2024-07-17 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F0655 · Resident Assessment and Care Planning Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-07-31
2024-05-28 Keep residents' personal and medical records private and confidential.
F0583 · Resident Rights Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-06-26
2024-05-01 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.
F0761 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-05-31
2024-02-20 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-03-12

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

3 penalties in the last three years, including $46,495 in fines.

DateTypeAmount
2026-01-23Payment Denial5 days payment denial
2026-01-23Fine$35,282
2024-07-17Fine$11,213

Ownership & management

NameRoleSince
Michlin, Bernard (individual)Contracted Managing Employee · NOT APPLICABLE
Apt, Frederick (individual)Corporate Officer · NOT APPLICABLE
Hancock, Mark (individual)Corporate Officer · NOT APPLICABLE
Jergensen, Joshua (individual)Corporate Officer · NOT APPLICABLE
Mitchell, John (individual)Corporate Officer · NOT APPLICABLE
Jenkins, William (individual)W-2 Managing Employee · NOT APPLICABLE

Frequently asked questions

What is the rating of San Diego Post-Acute Center?

San Diego Post-Acute Center has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.2-star average in California.

How many beds does San Diego Post-Acute Center have?

It has 240 certified beds and cares for about 228 residents per day.

Has San Diego Post-Acute Center been fined?

Yes. CMS lists 3 penalties totaling $46,495 in the last three years.

Who owns San Diego Post-Acute Center?

It is part of Pacs Group and is classified as for profit - limited liability company. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of San Diego Post-Acute Center?

(619) 441-1988. The facility is located at 1201 South Orange Ave., El Cajon, CA 92020.

Other nursing homes in El Cajon

Compare all nursing homes in El Cajon, CA →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.