Stillwater Post-Acute

Inspectors wroteBased on observation, interview, and record review, the facility did not develop a patient centered care plan for one resident reviewed for care planning (Resident 4). This deficient practice had the potential for Resident 4 to not meet her needs for safety and well-being.

Inspectors wroteBased on observation, interview, and record review, for four of 37 sampled residents (148, 163, 92, 141) the facility failed to: 1. Notify the doctor of high blood sugar readings, 2. Develop a careplan for a palm guard splint, 3. Develop a careplan for supervision during dining, and 4. Ensure a care plan was implemented for foot care. As a result, there was not a consistent approach by staff to address residents' care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the minimum required staffing to adequately care for all 248 residents to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident This deficient practice placed all residents at risk for unmet care needs, including delayed assistance, missed treatments and potential harm due to insufficient nursing staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served to all residents was in a palatable, flavorful manner that maintained the nutritional value of the menu items served when they: 1. Did not take resident's preferences and tastes into account for meals, 2. Did not follow recipe for pureed garden meat loaf, 3. Did not follow recipe for garden meat loaf. This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 248.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: 1. Frozen biscuits, hash brown potatoes, and chicken breast were in a sealed, labeled, and dated container in facility's walk in freezer. 2. One food services worker wore a beard restraint not completely over his full beard and mustache during tray line service. These failures had the potential for food borne illness related to poor quality food or contamination by facial hair.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the dignity of one resident out of thirty-seven sampled residents (Resident 227) when she was asked by staff to have a bowel movement in her brief. This failure had the potential to affect this Resident 227's dignity and mental health.

Inspectors wroteBased on observation and interview, the facility failed to provide a blanket after showering to one of 37 sampled residents (148). As a result, Resident 148 felt cold.

Inspectors wroteBased on interview and record review, the facility failed to complete a mental health screening accurately for one of 37 sampled residents (17). As a result, Resident 17 may not have received necessary mental health services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate an initial activities care plan within 48 hours for one of 11 reviewed new admitted residents (Resident 570). This deficient practice placed all newly admitted residents at risk for depression (a mood disorder that causes a persistent feeling of sadness) and missed opportunities to take part in enjoyable activities that supported their emotional and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to create a comprehensive care plan for one of 37 sampled residents (Resident 183). This failure caused Resident 183's medication to be unmonitored. Cross Reference F757 and F881.

Inspectors wroteBased to observation, interview and record review, the facility failed to provide individualized therapeutic and/or social activities according to their plan of care for one of seven reviewed residents (Resident 67) that promotes their highest physical, mental, and psychosocial well-being. This deficient practice placed Resident 67 at risk for decreased emotional well-being, social isolation, and reduced quality of life due to the lack of meaningful engagement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 37 sampled residents (Resident 141) received foot care and treatment as ordered by the physician. This failure resulted in missed appointments and treatment aimed to prevent complications from conditions such as diabetes, peripheral vascular disease, or immobility

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate the use of palm guard splints for one of four reviewed residents (Resident 163) according to professional standards of practice. These deficient practices placed Resident 163 at risk for improper care and worsening of hand contractures (a shortening of muscles).

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide adequate supervision to prevent choking during mealtimes for one sampled resident (Resident 92). As a result of this deficient practice, the resident experienced a choking episode while eating breakfast without supervision (cross reference F656 #3).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow nutrition orders for two of 37 sampled residents (Resident 82, Resident 208) with tube feedings (TF: nutritional intake via tube) when: 1. Resident 82's TF was not started timely. 2. Resident 208's TF was not ran at the ordered rate. These deficient practices placed all residents on TFs at risk for malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and change a peripheral intravenous access (IV, location to administer medication into the blood stream) for one of 37 sampled residents (179) based on professional standards of practice. As a result, Resident 179 was placed at an increased risk of infection and medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to professional standards of practice for three of seven residents (37, 81, 92) reviewed for pharmacy services when: 1. Resident 81's pantoprazole (a prescribed medication to treat acid reflux) was dispensed and left at the resident's bedside for the resident to self-administer. 2. The manufacturer's instructions for Advair Diskus (an inhaled steroid medication) were not followed when the medication was administered to Resident 92. 3. A controlled medication (drugs with high abuse potential) prescribed to Resident 37 could not be accounted for. As a result: -Resident 81 self-administered his pantoprazole at the wrong time and not according to the physician's order. -Resident 92 was at risk of developing thrush (a fungal infection). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a monthly medication reconciliation (reviewing and creating an accurate list of all medications a resident is taking if appropriate to continue, hold or stop) review (MRR) for one of 20 sampled residents (Resident 183) receiving antibiotics. This deficient practice placed residents at risk for unnecessary medication use, side effects, and harm due to lack of proper review. Cross-Reference F881 and F657.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 37 sampled residents (321) and one unsampled resident (59) had medications that were labeled and stored appropriately when: 1. Resident 321's intra venous antibiotic was labeled incorrectly. 2. Resident 59's prescribed medicated ointment was kept in a bowl at the resident's bedside. As a result, there was the potential for a medication errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their Antibiotic Stewardship policy and procedures to evaluate and monitor the ongoing use of a long-term antibiotic for one of 20 sampled residents receiving antibiotics. This deficient practice placed residents at risk for antibiotic overuse, potential side effects, and the development of antibiotic-resistant infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were functioning in three residents' rooms (401, 405, 406). As a result, the residents in rooms [ROOM NUMBER] had the potential to not have their needs met in a timely manner.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Licensed Nurses (LNs) assessed a resident prior to sending the resident to the general acute care hospital (GACH), for one of three sampled residents (Resident 1). This deficient practice had the potential in a delay in the resident receiving treatment to address the onset of infection and placed Resident 1's health at risk.

Inspectors wroteBased on interview, and record review, the facility failed to provide resident ' s (Resident 1) safety when Resident 1 eloped (leave without notice) from a facility ' s entrance/exit without their knowledge. As a result, Resident 1 had a successful elopement (leaving the facility unsafely and unescorted) on 1/28/25, and was not found as of today, 1/30/25. The facility did not know Resident 1 ' s exit point and his whereabouts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the floor in the hallway was safe for the residents, staff, and visitors. This failure had the potential for residents, staff and visitors passing the hallway to be at risk for stumbling and injuries.

Inspectors wroteBased on interview and record review, the facility failed to document on a dialysis (a communication form sent to dialysis with the resident and returned to the facility with documentation from the dialysis team) communication form, a witnessed fall prior to a dialysis treatments (an off site treatment, which removes toxins from the blood because the kidneys fail to function property) for one of three resident's reviewed for Quality of Care. This failure had the potential for the dialysis staff to be unaware and not monitoring or evaluating for potential injuries related to the previous fall.

Inspectors wroteBased on interview, and record review, the facility staff failed to identify, assess, and notify the attending physician for one of three sampled residents (Resident 1) when Resident 1 had no urine output (UO) for more than 24 hours and no stool output (bowel movement, BM) from her colostomy (stools moving through the intestine draining into a bag that is attached to the skin of the abdomen) bag. In addition, Resident 1 ' s output was not documented consistently in Resident 1 ' s clinical record. This failure had the potential for Resident 1 to have urinary tract infection (UTI) and went untreated.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a comprehensive resident-centered care plan to provide interventions of a physician ' s order to place side rails on Resident 1 ' s bed. As a result, the facility did not follow a physician ' s order to install side rails which placed Resident 1 at an increased risk to fall related to decreased mobility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the kitchen staff competently performed and carried out the functions of the food and nutrition services department when: 1. Two Diet Aides (DAs) did not correctly test the sanitizer in the low temperature dish machine, and 2. One Diet Aide (DA) could not properly calibrate a food thermometer. These failures had the potential for food contamination, resulting in food borne illnesses for all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation methods in the kitchen were followed according to standards of practice and facility policy when: 1. The ice machine had dark black and dark gray debris around the chute opening and inside the ice making evaporator, and was not cleaned according to manufacturer's guidelines. 2. The ice machine did not have an air gap. 3. Two bags of hoagie rolls were found to be outdated and expired. 4. A walk-in and reach-in refrigerator did not have internal working thermometers for temperature monitoring. 5. Four food scoopers were found with brown, crusted debris and 12 scoops were found with water in them and seven sharp butcher cutting knives were found with greasy grime and food particles crusted on them. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure call lights were positioned within reach for 11 of 58 residents (3, 23, 33, 85, 87, 140, 156, 189, 197, 221, 401) , during initial tour, reviewed for call lights; and 2. A bariatric bed (a specialized bed made to accommodate larger, heavier than usual residents) was not provided as ordered by the physician for one of one resident (401) reviewed for accommodation of needs. This failure had the potential to endanger the health, safety, and recovery of the residents.

Inspectors wrote1b. Resident 164 was admitted to the facility on [DATE] with diagnoses which included PTSD according to the facility's admission Record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL - basic and everyday skills that are essential to living independently) was provided to four of four residents (67, 86,185, 167) reviewed for ADL when: 1. Resident 67 and 86 were not provided incontinence (loss of bladder control) care in a timely manner. and, 2. Resident 86, 185 and 167 were not offered nail care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen and continuous positive airway pressure (CPAP-a machine that uses mild air pressure to keep breathing airways open while you sleep) as ordered by the physician for two of four residents (Resident 89 and 401), reviewed for oxygen therapy. As a result, residents were not given the care and service prescribed, which had the potential to hinder or worsen their recovery process.

Inspectors wrote2. Resident 164 was admitted to the facility on [DATE] with diagnoses that included PTSD according to the facility's admission Record. An observation of Resident 164 was conducted on 4/23/24 at 2:30 P.M. Resident 164 was reclining in bed, on her right side, with her hand over her face and the room dark. Resident 164 requested the surveyor to leave. A review of Resident 164's medical record was conducted on 4/24/24 at 3:57 P.M. A care plan for PTSD indicated, .resident is trigged by emotional distress . The care plan did not state what the triggers were or what to do about them. A concurrent interview and record review was conducted with the unit manager (UM) on 4/25/24 at 8:02 P.M. The UM stated, This resident is triggered by a history with family especially her father. I haven't gone into it too much because it was sexual. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the approved menus by the Registered Dietitian (RD) were followed as printed. This failure had the potential to alter the palatability and nutritional value of the food, which could decrease food intake and compromise the resident's nutritional status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the food was served at an acceptable temperature and palatability taste to the residents, according to the facility policy and the facility's resident council. This failure had the potential to affect meal and food intake which could impair the nutrition status of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to demonstrate infection control practices when: 1. A continuous positive airway pressure machine (CPAP- a machine worn on the face at night for the treatment of sleep apnea), mouthpiece was not stored properly for one of four residents (401) reviewed for infection control. 2. An oxygen humidifier (a clear plastic bottle which contains distilled water, that infuses oxygen with water droplets for moisture and comfort during use) was not dated when it was initiated for one of four residents (187), reviewed for oxygen therapy. 3. A urinary catheter bag (a clear flexible tube placed inside the body to drain urine into an external bag) was on the floor for one of two residents (216), reviewed for urinary catheter care. 4. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to report an injury of unknown origin to the California Department of Public Health for one of two allegation of abuse incidents. As a result, investigation into the injury was delayed and placed Resident 220 at risk for further injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up on one of five resident's broken eyeglasses who was reviewed for visual devices, Resident 124. The deficient practice resulted in the resident using broken eyeglasses and had the potential for decreased vision, and diminished self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were safe when: 1. Staff did not identify and address a potential hazard in one of two resident rooms (Resident 221), reviewed for accidents and, 2. Safe smoking assessments were not completed for one of two residents reviewed for smoking (Resident 35). As a result, there was the potential for Resident 221 and 35 to become injured from the room hazard and from not being assessed by a licensed nurse for smoking safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify, treat or manage a resident's (155) pain prior to wound care. This failure had the potential to cause unnecessary pain for Resident 155.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments were completed before a resident's dialysis (process of removing toxins from the kidneys and blood through a machine) treatment for one of three residents reviewed for dialysis. (Resident 219) This deficient practice had the potential to result in undetected complications such as infection and bleeding at the access site (part of the body where dialysis is received), and abnormal vital signs (temperature, breathing, heart rate) which can lead to a delay in necessary care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a Vegetarian Diet (no consumption of animal meat) meal preference was honored for an unsampled resident, Resident 48. This failure had the potential for decreased food intake which could increase the risk of unintended weight loss due to the facility not meeting the resident's nutritional needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clinical record was completed for one of one resident (Resident 219) reviewed for accurate medical record. This failure did not provide an accurate representation of the care provided to Resident 219 and had the potential to cause confusion amongst care providers.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices when the facility. a. did not elevate the medical supplies above the floor. b. the storage area had water leak damaging the medical supplies. c. an employee entered an isolation room without appropriate personal protective equipment (PPE) This failure had the potential to spread germs and placed residents at risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' skin and nails were assessed and treatment were provided to two of three sampled residents (Resident 1 and Resident 3), when; 1. staff failed to assess and provide care to Resident 1's left big toe ingrown, and, 2. staff failed to assess and provide care to Resident 3's lower lip sutures. These failures placed Resident 1 and Resident 3 for delayed healing and potential for infection.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure safe and sanitary measure was met when an ice scooper was left in the cart without a holder. This failure had the potential to result in harmful bacteria growth and cross contamination with the ice that could lead to pathogens to come in contact with the residents' food and drinks and may cause food borne illness to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to a resident while changing his clothing (Resident 1). This failure resulted in Resident 1 falling off of the bed and obtaining an injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care to one of three sampled residents (Resident 1), reviewed for Activities of Daily Living (ADL, activities related to personal care). As a result, Resident 1 ' s health and wellbeing were at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clean and sanitary kitchen. As a result, the residents were at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to fully implement infection control standards of practice for residents on transmission-based precautions (isolation precautions to reduce the spread of infection) for the use of Personal Protective Equipment (PPE- gowns) during 4 of 8 staff interviews. This failure could expose other residents to potential infection and multi-drug resistant organisms (MDROs).

Inspectors wroteBased on interview and record review, the facility failed to ensure the in house dialysis provider coordinated the plan of care and monthly Interdisciplinary Team (IDT) meetings with the facility and the dialysis provider, and the resident or the residents responsible party for 2 of 35 sample residents (174, 200). As a result. the residents plans of care was not completed timely and did not include the resident or their responsible party's input.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an order to crush medication, and failed to administer crushed medications based on standards of practice for one sampled resident (20).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 2 dependent residents (39) was repositioned every two hours. As a result, Resident 39 was at risk for worsening pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the prescribed amount of gastrostomy tube feeding nutrition (tube inserted in the stomach used to provide nutrition) for one of two sampled residents reviewed for tube feeding (20). Failure to provide the prescribed amount of tube feeding had the potential for residents to experience weight loss and receive inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently and accurately assess the effectiveness of pain management medication for 2 unsampled residents (40, 53) and 1 sampled resident (101). As a result, there was potential the residents pain was not adequately controlled.

Inspectors wroteBased on interview and record review, the facility failed to ensure consistent completion of hemodialysis (dialysis-a life support treatment that replaces many of the kidney's functions) communication for 1 of 2 sampled dialysis residents (87). This failure had the potential for miscommunication between the facility and dialysis center and could affect the continuity and quality of care for Resident 87.

Inspectors wroteBased on interview and record review, the facility failed to post the actual staffing hours when the facility only posted anticipated staffing for the day. As a result, the daily staffing information may not have been accurate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure target behaviors and adverse side effects were monitored for the use of psychotropic medications, for two of 35 sampled residents (102, 171). This failure had the potential to affect the ordering physician's ability to determine the effectiveness of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that food was palatable and had an appetizing temperature. These failures can result in residents not eating the food served which could result in weight loss and further compromise their medical status.

Inspectors wroteBased on observation and interview the facility failed to ensure evening snacks were available to all residents on each unit. As a result, some residents may not have been able to get an evening snack before bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently implement its antibiotic stewardship tool for 1 of 3 sampled residents (141) colonized with multi-drug resistant organisms (MDRO). This failure could potentially increase the risk to Resident 141 for adverse side effects or the development of further MDROs.