Stillwater Post-Acute

In the surveyor’s words

From the most serious findings on record at Stillwater Post-Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF610Sep 1, 2021

  Based on observation, interview and record review, the facility failed to protect one of 2 residents (Resident 2) from potential abuse when Resident 2 was transferred to Resident 1's room after Resident 1 was involved in an altercation with previous roommate (Resident 5). Resident 1 was identified by staff as unpredictable and territorial and had been involved in 3 resident to resident altercations. This failure had the potential to result in an altercation between Resident 1 and Resident 2 which may result in a serious injury, harm, impairment, or death to Resident 2. […]

• Actual harm, patternF600Dec 10, 2021

  Based on observation, interview and record review, the facility failed to ensure three of three residents (Resident 1, Resident 2, and Resident 3) were free from abuse when: 1. Certified nursing assistant (CNA) 5 became upset with Resident 1 and pushed the resident into the wall. In addition, CNA 5 forced care upon Resident 1 when the resident was refusing care. 2. CNA 10 yelled at Resident 2 and told the resident not to speak. 3. CNA 10 yelled at Resident 3 and slapped the resident's legs. These deficient practices resulted in: -Resident 1 experiencing rough handling and sustaining a head injury that caused pain and required a hospital evaluation. -Resident 2 feeling upset, having a knot in my stomach, and reliving previous abuse committed by her mother. […]

• Actual harm, isolatedF689Apr 5, 2022

  Based on interview and record review, the facility failed provide one to one (1:1) feeding (when a staff member assist the resident throughout the meal, with verbal queing), according to the facility's policy and the physician's order for RNA (restorative nursing assistant-a certified nursing assistant {CNA} with advanced training and skills such as feeding residents at high risk for aspiration), feeding for one of five residents (Resident 1), reviewed for Quality of Care. As a result, Resident 1 expired after she was left unsupervised to eat her lunch, and she aspirated (when food enters the lung), food into her lungs causing asphyxiation (deprived of oxygen). […]

• Actual harm, isolatedF609Dec 10, 2021

  Based on observation, interview and record review, the facility failed to ensure reported allegations of abuse were reported according to mandated reporting timeframes of 24 hours, when: 1. Certified nursing assistant (CNA) 1, reported an incident of verbal and physical abuse occurring between one resident (Resident 3) and CNA 10, approximately two months after witnessing the event (Cross reference F600 # 2 and #3). 2. The acting administrator (AA) failed to report an allegation of physical abuse that was allegedly witnessed by a resident's (Resident 5) family member (FM) 2 to the California Department of Public Health (CDPH-regulates the facility for compliance) within 24 hours of having knowledge of the allegation. […]

• Actual harm, isolatedF684Dec 10, 2021

  Based on observation, interview and record review, the facility failed to ensure care was provided to one of three residents (Resident 4) in a manner consistent with the Resident 4's comprehensive assessment and according to professional standards of nursing practice, when: 1. Certified nursing assistant (CNA) 13 did not receive report (information about a resident's level of care) prior to providing care to Resident 4. 2. CNA 15 did not perform Resident 4's bed mobility (how a resident moves to and from lying position and turns side to side while in bed) with two or more staff as indicated in the resident's Minimum Data Set Assessment (MDS, a comprehensive assessment tool) and according to professional standards of practice. […]