Stillwater Post-Acute
510 E. Washington Avenue · El Cajon, CA · 92020 · 6194401211
256 certified beds For profit - Limited Liability company Chain: Links Healthcare Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- No federal fines or payment denials in CMS’s 3-year window.
The composite number cleared 73 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
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
No red flags in the current CMS record. Genuinely good news — pair it with an in-person tour before deciding.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.91 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.57 | 0.55–0.75 |
| Weekend hours / resident-day | 3.76 | ≈ weekday level |
| Nursing turnover / year | 46% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (62 in the current record)
-
Potential for harm · D March 19, 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 April 11, 2026 · Resident Assessment and Care Planning
-
Potential for harm · D April 18, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 11, 2025 · Resident Rights
-
Potential for harm · D April 18, 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 May 11, 2025 · Resident Rights
-
Potential for harm · D April 18, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected May 11, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D April 18, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected May 11, 2025 · Resident Assessment and Care Planning
-
Potential for harm · E April 18, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected May 11, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D April 18, 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 May 11, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D April 18, 2025
Provide activities to meet all resident's needs.
Corrected May 11, 2025 · Quality of Life and Care
-
Potential for harm · D April 18, 2025
Provide appropriate foot care.
Corrected May 11, 2025 · Quality of Life and Care
-
Potential for harm · D April 18, 2025
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected May 11, 2025 · Quality of Life and Care
-
Potential for harm · D April 18, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 11, 2025 · Quality of Life and Care
-
Potential for harm · D April 18, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected May 11, 2025 · Quality of Life and Care
-
Potential for harm · D April 18, 2025
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected May 11, 2025 · Quality of Life and Care
-
Potential for harm · E April 18, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected May 11, 2025 · Nursing and Physician Services
-
Potential for harm · D April 18, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected May 11, 2025 · Pharmacy Service
-
Potential for harm · D April 18, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected May 11, 2025 · Pharmacy Service
-
Potential for harm · D April 18, 2025
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.
Corrected May 11, 2025 · Pharmacy Service
-
Potential for harm · E April 18, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected May 11, 2025 · Nutrition and Dietary
-
Potential for harm · E April 18, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 11, 2025 · Nutrition and Dietary
-
Potential for harm · D April 18, 2025
Implement a program that monitors antibiotic use.
Corrected May 11, 2025 · Infection Control
-
Potential for harm · D April 18, 2025
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected May 11, 2025 · Environmental
-
Potential for harm · D April 3, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 23, 2025 · Quality of Life and Care
-
Potential for harm · D January 29, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 20, 2025 · Quality of Life and Care
-
Potential for harm · D January 2, 2025 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected January 3, 2025 · Environmental
-
Potential for harm · D December 27, 2024 · found via complaint
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected January 24, 2025 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 555076 · certified since August 4, 1977. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.