Health inspection·October 28, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility staff failed to identify, assess, and notify the attending physician for one of three sampled residents (Resident 1) when Resident 1 had no urine output (UO) for more than 24 hours and no stool output (bowel movement, BM) from her colostomy (stools moving through the intestine draining into a bag that is attached to the skin of the abdomen) bag. In addition, Resident 1 ' s output was not documented consistently in Resident 1 ' s clinical record. This failure had the potential for Resident 1 to have urinary tract infection (UTI) and went untreated. Findings: On 10/7/24 and on 10/15/24, the Department received complaints related to quality of care for Resident 1. On 10/21/24, an unannounced visit to the facility was conducted. Resident 1 was admitted to the facility on [DATE], with diagnoses which included stroke, pressure ulcer (areas of damage to the skin and the tissue underneath), and rectal cancer, per the facility's admission Record. On 10/21/24, a review of Resident 1 ' s minimum data set (MDS – a federally mandated assessment tool), dated 9/16/24, indicated Resident 1 had a brief interview for mental status (BIMS, ability to recall) score of 15/15 which indicated Resident 1 had an intact cognition. Per MDS, Resident 1 had a colostomy upon admission. On 10/21/24 at 1:11 P.M., a concurrent review of Resident 1 ' s clinical record and an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 1 was on bladder training (the goals are to increase the amount of time between emptying the bladder and the amount of fluids the bladder can hold) and had colostomy. CNA 1 stated for residents with colostomy, the CNAs monitor the resident ' s BM and documented the size and consistency of the BM. CNA 1 stated one of the responsibilities of the CNAs was to ensure the colostomy bags were emptied and the site was not infected. CNA 1 stated the CNAs were to report to the charge nurse when the resident did not have UO or BM. Per Resident 1 ' s clinical record, Resident 1 ' s BM in the colostomy bag were documented in the following dates and shifts. Page 1 of 4 555076 555076 10/28/2024 Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020

F 0690 On 10/1/24, Level of Harm - Minimal harm or potential for actual harm - Nocturnal Shift (Noc, 11 P.M. to 7 A.M.) – Large, soft. CNA 1 stated Resident 1 had a bowel movement. Residents Affected - Few - Morning (AM) Shift (7 A.M. to 3 P.M.) – No documentation, CNA 1 stated the assigned CNA did not enter an entry on Resident 1 ' s clinical record. - Afternoon (PM) Shift (3 P.M. to 11 P.M.) – No documentation On 10/2/24, - Noc Shift – No documentation - AM Shift – Medium soft/ normal. CNA 1 stated Resident 1 had a bowel movement. - PM Shift – No BM On 10/3/24, - Noc Shift – No documentation - AM Shift – No BM - PM Shift – No BM On 10/4/24, - Noc Shift – No BM - AM Shift – No BM - PM Shift – No documentation On 10/5/24, - Noc Shift – No BM - AM Shift – No BM, CNA 1 stated Resident 1 was sent to the acute care hospital on [DATE]. CNA 1 stated the last BM documented in Resident 1 ' s clinical record was on 10/2/24 in the AM shift. On 10/21/24 at 3:10 P.M., a concurrent review of Resident 1 ' s clinical record and an interview was conducted with CNA 2 and with the Director of Nursing (DON). Per Resident 1 ' s clinical record, Resident 1 ' s UO were documented in the following dates and shifts. 555076 Page 2 of 4 555076 10/28/2024 Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020

F 0690 On 10/1/24, Level of Harm - Minimal harm or potential for actual harm - Noc Shift – Not applicable (N/A), CNA 2 stated CNAs documented N/A when the resident did not have urine output. Residents Affected - Few - AM Shift – No documentation - PM Shift – two (2), CNA 2 stated Resident 1 ' s incontinence brief was changed twice. On 10/2/24, - Noc Shift - No documentation - AM Shift – two (2), CNA 2 stated Resident 1 ' s incontinence brief was changed twice. - PM Shift – No documentation On 10/3/24, - Noc Shift – No documentation - AM Shift – N/A - PM Shift – N/A On 10/4/24, - Noc Shift – N/A - AM Shift – N/A - PM Shift – N/A On 10/5/24, - Noc Shift – 150 milliliters (ml), the DON stated, How did that happen? Unless the CNA squeezed the resident ' s brief and measured it in a cylindrical cup or the urinal? - AM Shift – N/A The DON stated the process was when the residents did not have UO for eight hours, and no BM for 2-3 days, the LNs were to assess the resident and call the attending physician. The DON stated the residents could have had urinary retention or blockage and or bowel obstruction that could potentially cause UTI and sepsis (a life-threatening condition that occurs when the body damages its own tissues and organs in response to an infection). Per the facility ' s policy, titled Urinary Continence and Incontinence – Assessment and Management, revised August 2022, indicated, .5. Identification and management of urinary tract infections will follow relevant clinical guidelines .Policy Interpretation and Implementation .2 .d. 555076 Page 3 of 4 555076 10/28/2024 Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020

F 0690 observations, including .evidence of abdominal .surgery . Level of Harm - Minimal harm or potential for actual harm Per the facility ' s policy, titled Bowel Management, revised September 2017, indicated, .This facility will provide measures to help eliminate and/or alleviate constipation .2. Monitor for signs and symptoms of constipation, including: a) Bowel movements, including frequency, consistency, shape, volume, and color, as appropriate, b) Physician notification as indicated . Residents Affected - Few 555076 Page 4 of 4