EL CAJON, CA - State health inspectors documented multiple instances of medication mismanagement and inadequate resident supervision at Stillwater Post-Acute during an April 2025 inspection, including an incident where a resident experienced choking while eating breakfast without required staff supervision.
Choking Incident Reveals Supervision Failures
Inspectors documented a critical incident on April 18, 2025, involving a resident with Parkinson's Disease and swallowing difficulties. The resident, identified in records as having dysphagia and a history of stroke-related paralysis, was discovered choking on breakfast without any staff present in the room.
According to the inspection report, the resident was found with his head elevated in bed, face flushed red, attempting to cough while his breakfast tray sat before him containing scrambled eggs, cubed potatoes, fruit, cream of wheat, and thin liquids. When asked if he was choking, the resident nodded while struggling to breathe. No nursing staff were in the room at the time.
The facility's Assistant Director of Nursing responded to the emergency and acknowledged that a Certified Nursing Assistant had been specifically assigned to supervise the resident during breakfast. "The CNA should have been there," the assistant director stated according to the report. The nursing administrator indicated the resident required specialized dining supervision due to aspiration risk and noted plans to discuss enhanced protocols with the attending physician.
Medical professionals recognize dysphagia as a serious condition requiring careful monitoring during meals. When individuals with swallowing difficulties eat without proper supervision, food or liquid can enter the airway rather than the esophagus, potentially causing aspiration pneumonia, respiratory distress, or complete airway obstruction. For residents with Parkinson's Disease, swallowing difficulties commonly worsen over time due to the progressive nature of the neurological condition affecting muscle control.
The incident occurred despite clear documentation that the resident required mealtime supervision. A whiteboard at the nurses' station indicated the resident needed supervision during meals as of April 17, 2025. The Assistant Director of Nursing confirmed she had personally instructed the assigned CNA before breakfast, handing the resident's breakfast tray directly to the staff member with explicit directions to provide supervision because the resident "coughs with food."
The CNA assigned to provide supervision, identified as registry staff (temporary agency personnel), stated she was unaware of the supervision requirement and did not remember receiving instructions from the nursing administrator. "I wasn't focused," the CNA acknowledged, adding that it was "very important to listen to the direction of the nurses because a resident's condition could change at any time."
The facility's Director of Nursing confirmed that licensed nurses could initiate meal supervision for residents at aspiration risk without physician orders when clinical judgment indicated the need. The director stated all CNAs should follow nursing instructions to prevent such incidents.
Tube Feeding Protocols Not Followed
Inspectors identified two separate instances where residents receiving nutrition through feeding tubes did not receive their prescribed feedings according to physician orders, placing individuals at risk for malnutrition and related complications.
One resident with a history of protein-calorie malnutrition had a physician's order for tube feeding at a specific rate and schedule: the feeding was to run at 55 milliliters per hour for 20 hours, turned on at 2:00 PM and stopped at 10:00 AM. During inspection observations on April 15, 2025, at both 12:07 PM and 4:14 PM, the resident's feeding bag from the previous day remained hanging with 100 milliliters of formula still in the container. The feeding had not been restarted at the scheduled 2:00 PM time.
Licensed nurses interviewed confirmed the feeding should have been discarded at 10:00 AM and a fresh feeding initiated at 2:00 PM according to the physician's order. One nurse noted the delay was particularly concerning given the resident's malnutrition history, stating that tube feeding "was his food" and delays could lead to insufficient nutrition and weight loss.
For individuals who cannot consume food orally, tube feedings provide complete nutritional requirements in a carefully calculated formula. When feedings are delayed or not administered according to prescribed schedules, residents receive fewer calories and nutrients than medically necessary. This is especially critical for individuals with existing malnutrition, as further nutritional deficits can lead to muscle wasting, weakened immune function, delayed wound healing, and increased mortality risk.
In a second case, inspectors observed a resident's tube feeding running at 50 milliliters per hour when physician orders specified 65 milliliters per hour. The licensed nurse responsible for the feeding acknowledged the error, confirming she had refilled the feeding that morning and was responsible for ensuring it ran at the ordered rate.
The facility's registered dietician confirmed that running tube feedings at rates lower than prescribed could contribute to weight loss. The Director of Nursing stated nurses should verify orders to ensure correct feeding rates, noting that lower-than-ordered rates could result in weight loss.
Controlled Medication Tracking Failures
The inspection revealed the facility could not account for controlled medications prescribed to one resident. Documentation showed two doses of hydrocodone-APAP 5/325mg (a pain medication with high abuse potential) had been removed from locked storage on February 8 and February 28, 2025, but the resident's medication administration record had blank entries for both dates, making it impossible to determine whether the medication had been administered to the resident.
Controlled substances require strict tracking protocols due to their potential for abuse and diversion. Federal and state regulations mandate detailed documentation each time these medications are accessed and administered. When documentation gaps occur, facilities cannot readily identify whether medications reached intended recipients or were lost, wasted, or diverted for unauthorized use.
Licensed nursing staff confirmed the requirement to sign controlled medications out on tracking records and document administration on medication records. The Director of Nursing acknowledged the documentation failures and revealed that required weekly random audits of controlled medications were not being conducted as facility policy required.
Intravenous Line Management Deficiencies
Inspectors documented an intravenous line that had been in place for seven days without proper labeling or documented orders for monitoring and changing. The IV access in the resident's right hand was unlabeled when observed on April 15, 2025. The resident reported the IV had been in place for one week, and the licensed nurse acknowledged it needed to be changed.
Professional standards for peripheral IV management recommend changing sites every 72-96 hours to reduce infection risk and prevent complications such as phlebitis (vein inflammation). Unlabeled IV sites create additional risks because staff cannot readily identify insertion dates or determine when changes are due. Extended IV dwell times increase risks of catheter-related bloodstream infections, infiltration, and thrombophlebitis.
The facility's policy on peripheral IV catheter flushing and locking did not include guidance on labeling IVs or changing them at specific frequencies, representing a significant gap in clinical protocols.
Medication Administration Errors
The inspection identified multiple medication administration errors that violated professional standards:
A resident prescribed pantoprazole (acid reflux medication) to be taken once daily before breakfast at 6:30 AM was found with the medication in a cup at his bedside at 9:45 AM. The resident quickly self-administered the tablet when questioned. The licensed nurse assigned to the resident confirmed he had not given the medication and stated it should have been administered by night shift staff. The resident had no order to self-administer medications.
Pantoprazole belongs to a class of medications called proton pump inhibitors that work most effectively when taken before meals on an empty stomach. Taking the medication after eating reduces its effectiveness in controlling stomach acid production. Licensed nurses are expected to remain with residents until medications are swallowed and to verify oral administration.
In another case, a nurse was observed administering Advair Diskus (an inhaled steroid medication) but did not follow manufacturer instructions requiring the resident to rinse his mouth with water and spit it out after inhalation. This step is specifically designed to prevent oral thrush, a fungal infection that commonly occurs when inhaled steroids remain in the mouth and throat. The nurse acknowledged not following the manufacturer's instructions after reviewing the medication packaging.
Staffing Shortages Impact Care Quality
Multiple residents reported extended wait times for assistance and delayed care related to staffing shortages, particularly during weekends. The facility's Payroll Based Journal data for the first quarter of fiscal year 2025 (October-December 2024) indicated "excessively low weekend staffing."
Residents interviewed described waiting hours for assistance with toileting, positioning, and pain management. One resident stated, "Don't answer call lights for hours." Another reported not being changed overnight and falling twice due to lack of bedside assistance, including one fall that occurred during incomplete care when four staff members were needed to assist from the floor.
The facility's Staffing Coordinator acknowledged weekend shortages during holidays and in January and February, attributing gaps to staff illness and call-offs. Registry staff (temporary agency personnel) were used to fill gaps, though residents reported registry staff sometimes arrived late or took longer to respond to call lights.
Certified nursing assistants confirmed that staffing shortages increased workload and affected resident care quality. One CNA stated that during shortages, "residents would complain about getting changed and yell out." Nursing staff reported working double shifts to cover gaps when colleagues called out.
Adequate staffing is fundamental to meeting residents' basic care needs and maintaining safety. When staff-to-resident ratios fall below appropriate levels, essential care such as toileting assistance, repositioning to prevent pressure injuries, medication administration, and fall prevention measures may be delayed or incomplete. Extended wait times for assistance can result in preventable complications including pressure ulcers, falls, urinary tract infections, and psychological distress.
Additional Issues Identified
Inspectors documented several other violations during the April 2025 survey. A resident receiving IV antibiotics had no documentation of orders to monitor or change the IV access prior to the inspection date, despite the IV being in place for seven days. The facility's policy lacked guidance on IV labeling and change frequency.
Monthly medication reconciliation reviews for residents receiving antibiotics were not completed as required, placing residents at risk for unnecessary medication use and potential side effects from prolonged antibiotic therapy.
The facility's policy on accidents and incidents did not provide specific guidance for preventing aspiration and choking incidents through meal supervision protocols, despite serving multiple residents with documented swallowing difficulties.
The Director of Nursing acknowledged multiple systemic failures identified during the inspection and confirmed expectations that staff should follow physician orders, professional standards, and facility policies to ensure resident safety and quality care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avocado Post Acute from 2025-04-18 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.