Inspection citations
13’22
25’24
23’25
3’26
64 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Aug 7, 2026 | D · potential | Respond appropriately to all alleged violations. | Complaint |
| Aug 7, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Mar 19, 2026 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Apr 18, 2025 | D · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Apr 18, 2025 | D · potential | 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. | Routine |
| Apr 18, 2025 | D · potential | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Routine |
| Apr 18, 2025 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Routine |
| Apr 18, 2025 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Apr 18, 2025 | D · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Apr 18, 2025 | D · potential | Provide activities to meet all resident's needs. | Routine |
| Apr 18, 2025 | D · potential | Provide appropriate foot care. | Routine |
| Apr 18, 2025 | D · potential | 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. | Routine |
| Apr 18, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Apr 18, 2025 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Apr 18, 2025 | D · potential | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Routine |
| Apr 18, 2025 | E · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Routine |
| Apr 18, 2025 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Routine |
| Apr 18, 2025 | D · potential | Ensure each resident’s drug regimen must be free from unnecessary drugs. | Routine |
| Apr 18, 2025 | D · potential | 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. | Routine |
| Apr 18, 2025 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Apr 18, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 18, 2025 | D · potential | Implement a program that monitors antibiotic use. | Routine |
| Apr 18, 2025 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Routine |
| Apr 3, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jan 29, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 2, 2025 | D · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Complaint |
| Dec 27, 2024 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Complaint |
| Oct 28, 2024 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Complaint |
| Jul 3, 2024 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Apr 26, 2024 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Apr 26, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Routine |
| Apr 26, 2024 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Apr 26, 2024 | E · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Routine |
| Apr 26, 2024 | D · potential | Assist a resident in gaining access to vision and hearing services. | Routine |
| Apr 26, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Apr 26, 2024 | E · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Apr 26, 2024 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Apr 26, 2024 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Apr 26, 2024 | E · potential | Provide care or services that was trauma informed and/or culturally competent. | Routine |
| Apr 26, 2024 | F · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Apr 26, 2024 | E · potential | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Routine |
| Apr 26, 2024 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Apr 26, 2024 | D · potential | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Routine |
| Apr 26, 2024 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Apr 26, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Apr 26, 2024 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Apr 23, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Mar 20, 2024 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Mar 20, 2024 | D · potential | Provide and implement an infection prevention and control program. | Complaint |
| Jan 18, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 11, 2024 | D · potential | Provide care and assistance to perform activities of daily living for any resident who is unable. | Complaint |
| Jun 29, 2022 | D · potential | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Routine |
| Jun 29, 2022 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Routine |
| Jun 29, 2022 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jun 29, 2022 | D · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Jun 29, 2022 | D · potential | Provide safe, appropriate pain management for a resident who requires such services. | Routine |
| Jun 29, 2022 | D · potential | Provide safe, appropriate dialysis care/services for a resident who requires such services. | Routine |
| Jun 29, 2022 | D · potential | Post nurse staffing information every day. | Routine |
| Jun 29, 2022 | D · potential | 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. | Routine |
| Jun 29, 2022 | D · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Jun 29, 2022 | D · potential | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Routine |
| Jun 29, 2022 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jun 29, 2022 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jun 29, 2022 | D · potential | Implement a program that monitors antibiotic use. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Stillwater Post-Acute
510 E. Washington Avenue, El Cajon, CA 92020 · (619) 440-1211
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 555076
- Certified beds
- 256
- Legal owner
- San Diego Bay Holdings LLC
- Part of
- Links Healthcare Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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