Health inspection·July 3, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which include paraplegia (loss of the ability to move the lower part of the body and osteoarthritis of hip according to the facility ' s admission Record. On 6/20/24 AT 9:46 A.M., a concurrent observation and interview was conducted with Resident 1 in his bedroom. Resident 1 ' s bed was observed with half side rails to the left and right side of the bed. Resident 1 stated the side rails were installed to help him turn and/or reposition in bed. Resident 1 stated he had a fall on 6/14/24, and the side rails were provided to him after his fall. Resident 1 stated he thinks side rails will prevent future falls. On 6/20/24, a review of Resident 1 ' s IDT (Interdisciplinary Team) /COC (Change of Condition) note indicated Resident 1 sustained a fall on 6/14/24. The note indicated side rails were recommended by the IDT as an intervention to promote mobility. On 6/20/24, a review of Resident 1 ' s physician ' s orders dated 2/24/24 was conducted. The physician ' s orders indicated half siderails to bilateral sides. On 6/21/24 at 1P.M., a concurrent interview and record review was conducted with Licensed Nurse (LN) 1. LN1 confirmed Resident 1 sustained a fall on 6/14/24, and prior to the fall resident did not have side rails. LN1 stated the side rails were provided to Resident 1 after the fall (on 6/14/24) to aid in bed mobility. LN1 stated the physician ordered side rails for Resident 1 on 2/24/24. LN1 stated the side rails should have been installed on Resident 1 ' s bed when it was ordered by the physician on 2/24/24. On 7/3/24 at 10:05 A.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated the side rails would have helped Resident 1 with positioning and mobility. The ADON acknowledged that the order for side rails were not followed as ordered by the physician. The ADON acknowledged the side rails should have been installed on Resident 1 ' s bed when ordered on 2/24/24. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555076 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)