EL CAJON, CA - Federal inspectors documented multiple care plan violations at Stillwater Post-Acute nursing facility during an April 2025 survey, finding inadequate monitoring protocols for medical devices, failure to supervise high-risk residents during meals, and delayed specialized foot care for diabetic patients.
Critical Gaps in Medical Device Management
State inspectors identified concerning lapses in care for residents requiring specialized medical equipment. A stroke patient with left-side paralysis had been wearing a palm guard splint for approximately three months without proper care protocols or physician orders in place.
The resident, who experienced contractures following a cerebral infarction, told inspectors he wore the splint "the whole day yesterday and the other day" and could not remember when staff removed the device. When questioned, a nursing assistant assigned to his care admitted she "did not know the care for Resident 163's palm guard splint and was not sure when Resident 163's palm guard splint was supposed to be taken off."
Further investigation revealed that no formal care plan existed for the medical device. A licensed nurse stated she "was not aware Resident 163 had a palm guard splint to his left hand" and confirmed there was "no care plan in place for the palm guard splint to communicate with the nursing staff for when it should be on and off."
Medical professionals emphasize that improper splint management can lead to serious complications. Palm guard splints require scheduled removal for skin inspection, circulation checks, and range-of-motion exercises. Extended wear without monitoring can cause skin breakdown, pressure sores, and worsening contractures. For stroke patients with limited sensation and mobility, regular assessment becomes even more critical to prevent secondary injuries.
The facility's Director of Nursing acknowledged that proper protocols should have been established when the resident began using the device three months earlier. A hastily created care plan was added only after inspectors identified the violation, raising questions about systematic monitoring procedures.
Choking Incident Exposes Supervision Failures
A separate violation involved inadequate mealtime supervision for a Parkinson's disease patient with documented swallowing difficulties. During the inspection, surveyors observed the resident experiencing a choking episode while eating breakfast alone in his room.
The resident, who has dysphasia and left-side weakness following a stroke, was found "attempting to cough loudly" with "his face red" while trying to breathe. No staff members were present in the room despite facility protocols requiring supervision during meals for residents at aspiration risk.
Nursing staff had identified this resident as requiring constant supervision due to his tendency to "inhale food and gulp as he drinks." However, investigators discovered no formal care plan addressing aspiration precautions or documenting the need for mealtime assistance.
Aspiration presents life-threatening risks for residents with swallowing disorders. Parkinson's disease commonly affects the muscles involved in swallowing, increasing the likelihood of food or liquid entering the airway. Without proper supervision and positioning, residents can develop aspiration pneumonia, a leading cause of death in nursing home populations.
The facility's Assistant Director of Nursing confirmed that supervision requirements existed but acknowledged the absence of formal documentation to ensure all staff understood the resident's needs.
Delayed Podiatric Care for Diabetic Patient
Inspectors also documented failure to follow established care plans for specialized medical services. A resident with insulin-dependent diabetes and peripheral vascular disease had not received required podiatric care for over seven months, despite having a care plan specifying visits every two months.
The resident reported waiting "months" to see a podiatrist and was observed with "long, thick toenails that were approximately a quarter inch in length" along with "dry, cracked feet." His last documented podiatry visit occurred in September 2024, despite the care plan requiring regular professional foot care.
For diabetic patients, delayed foot care can have serious consequences. Diabetes impairs blood circulation and nerve function in the extremities, making patients more susceptible to infections, ulcers, and slow-healing wounds. Overgrown toenails can cause pressure points and ingrown nails, potentially leading to serious infections that may require amputation in severe cases.
Peripheral vascular disease further compounds these risks by reducing blood flow to the feet, making early detection and prevention of foot problems essential for maintaining mobility and overall health.
Industry Standards and Best Practices
Federal regulations require nursing homes to develop comprehensive, person-centered care plans within seven days of resident assessment. These plans must address all identified health conditions and specify the frequency and type of services needed to maintain resident well-being.
Effective care planning involves several critical components: regular interdisciplinary team meetings, ongoing assessment of resident needs, clear communication protocols between staff members, and systematic monitoring of care plan implementation. When facilities fail to establish or follow these protocols, residents face increased risks of complications, emergency interventions, and deteriorating health outcomes.
The Centers for Medicare & Medicaid Services emphasize that care plans serve as communication tools ensuring all staff members understand each resident's specific needs and required interventions. Without proper documentation and protocols, critical care elements may be overlooked during shift changes or staff rotations.
Additional Issues Identified
The inspection narrative revealed other areas requiring attention, including incomplete documentation in the facility's electronic health records and insufficient coordination between different departments regarding resident care protocols. Staff members demonstrated varying levels of awareness about specific resident needs, suggesting potential gaps in training and communication systems.
The facility's policies acknowledge the importance of comprehensive care planning and resident participation in care decisions, but implementation appeared inconsistent across different areas of operation.
These violations underscore the critical importance of systematic care planning and staff communication in maintaining resident safety and health outcomes in skilled nursing facilities.
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.
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