The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited April 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
Nursing home report
STILLWATER POST-ACUTE
EL CAJON, CA · Medicare-certified · 256 beds
Needs attention
For-profitChain member
1 of 5 overall
Stillwater Post-Acute in El Cajon has a 1-star overall rating, with 2 stars for health inspections, 3 stars for staffing, and 1 star for quality measures. It has the lowest overall rating, no fines in the last 24 months, and reported nurse staffing of 3.91 hours per resident per day, just below the federal benchmark of 4.1.
Facility ratings
Health inspections
Staffing
3.906 hrs/resident/day
Quality measures
Last inspection: March 19, 2026Penalties, last 24 months: $0lowest overall rating
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.906.
Staffing detail
- Registered nurses
- 0.57
- Licensed practical nurses
- 1.09
- Nurse aides
- 2.25
- Weekend nursing
- 3.76
Hours per resident per day.
Total staff turnover: 46%
Registered nurse turnover: 54%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Residents with a fall causing major injury
1.8%Improving
Residents with pressure ulcers (bedsores)
3.7%Improving
Residents with a urinary tract infection
0.9%Improving
Residents who lost too much weight
3.2%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
5.9%Improving
Residents whose ability to walk got worse
9.2%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
24.9%Worsening
Short-stay residents newly given an antipsychotic
0%Steady
Residents with a long-term catheter
0.4%Worsening
Residents with new or worsening incontinence
4.4%Improving
Residents with depressive symptoms
5.4%Worsening
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
99.8%Steady
Short-stay residents given the seasonal flu vaccine
94.5%Steady
Short-stay residents given the pneumonia vaccine
99%Improving
What the inspectors found
The home failed to provide enough support staff to safely and effectively run food and nutrition services. Cited April 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 802 — 42 CFR §483.60 — S/S: F
The nursing home failed to develop and carry out a complete care plan that met each resident’s needs with clear steps and timelines. Cited April 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 656 — 42 CFR §483.21(b)(1) — S/S: E
The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited April 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 725 — 42 CFR §483.35 — S/S: E
The home failed to make food and drinks appealing and served them at a safe, appetizing temperature. Cited April 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 804 — 42 CFR §483.60 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 20 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of LINKS HEALTHCARE GROUP · 31 homes · 2.8 stars avg
- Occupancy
- 249.4 residents on an average day (97% of 256 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 48 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.