Stillwater Post-acute
STILLWATER POST-ACUTE in EL CAJON, CA — inspection on April 18, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Survey team observations conducted on 4/15/25 included:
- 9:00 A.M., Sometimes there is a long wait.
Roommate stated he had poop since 7:30 A.M.
- 11:15 A.M., Soiled diapers were changed about an hour ago.
- 3:05 P.M., Waits for staff for over an hour every time he called then yelled out.
Waited for pain management for a long time.
- 9:55 A.M., 3-11 shift that it takes a long time to answer call light due to not having enough staff
- 10:58 A.M., Don't answer call lights for hours.
On 4/17/25 at 9:47 A.M., an interview was conducted with the Staffing Coordinator (SC).
The SC stated there were weekend shortages during the holidays along with the month of January and February and staff call offs due to sickness.
On 4/17/25 at 1:30 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 22. CNA 22 stated during staff shortage that this definitely affected resident care. CNA 22 stated the facility residents would complain about getting changed and yell out.
On 4/18/25 at 7:45 A.M., an interview was conducted with Resident 37, in Resident 37's room. Resident 37 stated there aren't enough staff that run the facility which stressed the nursing staff having to fill in for the shortage. Resident 37 stated she did not think the facility scheduled enough people to care for residents because they had nursing staff who floated from other sections and were overworked to cover a shortage. Resident 37 stated that influenced how the care was unmet when she waited hours to get changed. Resident 37 stated meals were always given an hour late and thought the kitchen staff may also have been short staffed. Resident 37 stated that happened on all shifts and all days.
555076
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555076 B.
Wing 04/18/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Stillwater Post-Acute 510 E.
Washington Avenue El Cajon, CA 92020
Findings
A review of Resident 183's Admission Record indicated Resident 183 was admitted to the facility on [DATE] with diagnoses which included a history of metabolic encephalopathy (a brain disorder that caused problems with the body's chemistry due to lack of oxygen, blood sugar level and essential nutrients).
On 4/15/25 at 2:46 P.M., a clinical chart review was conducted on Resident 183's physician's order sheet (POS). Resident 183 was taking Rifaximin (an antibiotic medication that worked by killing the bacteria and preventing its growth) for encephalopathy ordered 3/4/24.
On 4/18/25 at 7:06 A.M., a record review was conducted on Resident 183's MRR.
There was no MRR conducted on Resident 183's medication for Rifaximin for the month of January 2025-March 2025.
On 4/18/25 at 8:49 A.M., an interview and record reviews were conducted on Resident 183's clinical chart and MRR with the Infection Control Prevention Nurse (ICPN).
The ICPN stated Resident 183 was no longer on antibiotic.
The ICPN stated she tracked the infection control log/antibiotic tracking to determine which residents were on antibiotics.
The ICPN reviewed Resident 183's POS and stated Resident was on Rifaximin for encephalopathy ordered on 3/4/24.
The ICPN reviewed the MRR for the month of January 2025-March 2025 and stated Resident 183's Rifaximin was not reviewed.
The ICPN stated that she only kept track on residents with infections as part of her antibiotic stewardship log as to why Resident 183's antibiotic was not tracked.
The ICPN stated Resident 183's Rifaximin should have included routine monitoring for the medication use and appropriateness to be included monthly.
The ICPN stated antibiotics (such as Rifaximin) were used for bacterial infections but Resident 183 was using the medication for encephalopathy and that there was no stop date for the medication.
The ICPN stated she was unable to find any side effect monitoring or documentation in Resident 183's clinical chart for Rifaximin.
The ICPN stated they should have been monitoring the side effects for Resident 183's antibiotics use and indications so that the physician can reassess with the information gathered to determine appropriateness of long-term use.
The ICPN stated complications from taking antibiotics for long term use can lead to antibiotic resistance and cause other infections.
555076
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555076 B.
Wing 04/18/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Stillwater Post-Acute 510 E.
Washington Avenue El Cajon, CA 92020
During an interview and observation on 4/15/25 at 8:55 A.M., Resident 141 stated he had long toenails and a fungal condition, and had been on a list to see the podiatrist (healthcare provider specializing in foot care) for months. Resident 141 was observed to have long, thick toenails that were approximately a quarter inch in length. Resident 141 also had dry, cracked feet.
555076
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555076 B.
Wing 04/18/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Stillwater Post-Acute 510 E.
Washington Avenue El Cajon, CA 92020
During a concurrent interview and record review on 4/18/25 at 1:55 P.M., with the Director of Nursing (DON), the DON stated, Care plans drive the resident care, they should be resident specific.
The DON further stated, if it [a resident's care plan] is not specific, the resident might not get the appropriate care. Resident 183's care plans were reviewed.
The DON stated there is no care plan for antibiotic monitoring.
There should be one.
During an interview on 4/18/25 at 2:10 P.M., with the Infection Preventionist (IP), the IP stated Resident 183 has been on this medication since admission.
The IP further stated Yes, the care plan is not specific to this medication. It should be.
During a review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised December 2016, the document indicated .8.
The comprehensive, person-centered care plan will aid in preventing or reducing decline in the resident's functional status and/or functional levels .
555076
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555076 B.
Wing 04/18/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Stillwater Post-Acute 510 E.
Washington Avenue El Cajon, CA 92020