Cottonwood Canyon Healthcare: Shower Denied 11 Days - CA
The inspection, completed August 11, 2025, followed a complaint filed July 7 by someone who reported the resident, identified in records only as Resident 4, had not been bathed in over ten days. Inspectors reviewed activity of daily living records covering June 23 through July 7, 2025. The records confirmed it: no shower assistance from June 23 through July 4. Eleven days.
Resident 4 had been admitted to the facility with a fracture of the left ilium, the large bone that forms the upper pelvis. The resident preferred morning showers. The facility had scheduled them for the PM shift.
That mismatch, between what the resident wanted and when staff planned to provide it, sat unresolved for a week and a half. No one rescheduled. No one found a workaround.
When inspectors interviewed the Assistant Director of Nursing on July 8, she did not dispute the timeline. She confirmed Resident 4 was scheduled for showers every Wednesday and Saturday and said the resident had refused three times. Then she said something that cut against any reading of this as routine refusal: not showering for 11 days was a long time, she told inspectors, and should have involved the family and the physician.
It hadn't.
The ADON said there was no documented evidence that the doctor or any family member had been made aware of the situation. She said staff should have offered alternatives. They hadn't done that either. The licensed nurses assigned to Resident 4 were not available for interview.
Three refusals across an 11-day stretch, with no escalation, no outreach, and no documented attempt to find a time that worked for the resident, is what inspectors found. The facility's own shower policy, dated February 2018, describes the purpose of bathing as promoting cleanliness, providing comfort, and allowing staff to observe the condition of a resident's skin. For Resident 4, none of that happened for nearly two weeks.
The inspection cited the failure as causing minimal harm or the potential for actual harm, and noted few residents were affected. But the categories used in federal inspection reports are clinical designations, not a full accounting of what it means to go 11 days without bathing while recovering from a pelvic fracture and relying entirely on staff for help with basic hygiene.
Resident 4 was not available for an interview on July 8. The report does not say why.
What the record does say is that someone outside the facility noticed before anyone inside it acted. A complainant called on July 7. Inspectors arrived. The ADON acknowledged the failure in the interview room. The nurses assigned to the resident were gone.
The facility's shower policy has been on the books since 2018. It describes exactly what bathing is supposed to accomplish. For 11 days in the summer of 2025, for one resident with a broken pelvis who preferred her showers in the morning, it accomplished nothing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cottonwood Canyon Healthcare Center from 2025-08-11 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
COTTONWOOD CANYON HEALTHCARE CENTER in EL CAJON, CA was cited for violations during a health inspection on August 11, 2025.
Inspectors reviewed activity of daily living records covering June 23 through July 7, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.