Stillwater Post-Acute
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 132 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Above-median deficiencies (21 vs median 13.0)
Bottom 25% in CA · Below recommended RN staffing · Worst in LINKS HEALTHCARE GROUP chain · No penalties on record
What this means for your family
This facility is an excellent choice for patients focused on intensive physical rehabilitation, as the therapy team is consistently praised. However, families must be vigilant advocates for their loved ones, specifically regarding medication schedules and responsiveness to call lights, as multiple serious lapses have been reported.
Google Reviews
Google Reviews
132 reviews on Google“Families generally praise the facility for its exceptional physical therapy team and the compassionate, attentive nature of the nursing staff. However, some reviewers have raised serious alarms regarding medical neglect, medication errors, and poor responsiveness to call lights. While many find the environment clean and welcoming, others have reported issues with facility odors and outdated equipment.”
Quality Themes
Tap a score for detailsStrengths
- Excellent physical therapy and rehab team
- Compassionate and attentive nursing staff
- Clean and well-maintained environment
- Friendly and professional administrative staff
Concerns
- Medical neglect and delayed response to call lights (mentioned by 3 reviewers)
- Inaccurate medication administration or delays (mentioned by 2 reviewers)
- Issues with food quality and meal accuracy (mentioned by 2 reviewers)
- Facility cleanliness and unpleasant odors (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 262 analyzed
How They Respond to Reviews
The owner provides personalized responses that acknowledge specific details from the reviews, such as names of family members or specific staff members. For negative reviews, the owner maintains a professional tone, expressing concern and requesting direct contact to resolve issues.
Questions for Your Tour
- 1We've heard wonderful things about your physical therapy and rehab team; could you tell us more about how they work with residents to meet their mobility goals?
- 2What specific protocols do you have in place to ensure medications are administered accurately and on a strict schedule?
- 3How does the nursing team manage call lights during busy shifts to ensure residents receive timely assistance when they need it?
- 4Could you describe your process for maintaining consistent food quality and ensuring meal accuracy for every resident?
- 5What steps does the facility take to ensure a fresh and clean environment, particularly regarding daily room maintenance and odor control?
- 6What kind of daily activities or social programs are available to help residents stay engaged and connected with one another?
Personalized based on this facility's data
Key Review Excerpts
“The physical therapy department is excellent. They are all caring, understanding in all of the different ailments from all kinds of different patients.”
“They are going to put makeup on for her and do her hair and celebrate with sugarless ice Cream on her 90th birthday next week!”
“My uncle came here to recover from having g 2 toes removed for diabetic issues. his infection had cleared and he came here for the physical therapy. He was on pain medication and never given a laxitive even though it was on the instructions from his doctor.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 16 measures
12
measures
1
measures
3
measures
Residents whose bladder or bowel control got worse
Residents on anti-anxiety or sleep medication
Residents needing more daily help over time
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents vaccinated for pneumonia
Residents whose walking got worse
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility has a concerning pattern with 84 deficiencies across 15 surveys, including 13 complaint-triggered issues where families reported problems. The most recurring issues involve nutrition and food services, fire safety systems, and care planning. Problems persist across multiple years in areas like food safety, infection control, and safety hazards, though the facility reports correcting each violation. The frequency of family complaints and repeated deficiencies in basic care areas warrant careful consideration.
Mar 19, 2026Complaint1
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Feb 10, 2026Complaint1
Construction Deficiencies
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Apr 18, 2025Routine30
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Smoke Deficiencies
Provide properly protected cooking facilities.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
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.
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Apr 3, 2025Complaint2
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Jan 29, 2025Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Jan 2, 2025Complaint1
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Ownership & Operations
Who Operates This Facility
Stillwater Post-Acute
for profit
Chain Affiliation
Links Healthcare Group
31 facilities nationwide
Chain avg rating: 2.8/5 · Rank 30 of 31 (Worst)
Ownership & Management
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
132 reviews from families & visitors
Official Website
Visit magnoliapostacute.com
Medicare data downloads
Original nursing home datasets
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