Health inspection·January 29, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide resident ' s (Resident 1) safety when Resident 1 eloped (leave without notice) from a facility ' s entrance/exit without their knowledge. As a result, Resident 1 had a successful elopement (leaving the facility unsafely and unescorted) on 1/28/25, and was not found as of today, 1/30/25. The facility did not know Resident 1 ' s exit point and his whereabouts. Findings: On 1/29/25 at 9:57 A.M., an unannounced onsite to the facility was conducted related to a facility reported incident on resident safety. On 1/29/25, a review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (serious mental illness with disorganized thinking). On 1/29/25, a review of Resident 1 ' s minimum data set (MDS - a federally mandated resident assessment tool), dated 9/11/24, Resident 1 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 6/15, (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 1/29/25, a review of Resident 1 ' s history and physical examination completed by Resident 1 ' s attending physician, dated 10/15/24, indicated Resident 1 could make his needs known but could not make medical decision. On 1/29/25 at 10:46 A.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 was ambulatory and was independent. CNA 1 stated Resident 1 resided in their station and his usual behavior was to go to another station to socialize. On 1/29/25 at 10:59 A.M., an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 1 could make his needs known but could not make a medical decision. LN 1 stated she had seen Resident 1 pushed other residents to the smoking patio and went to different stations to socialize with other residents. LN 1 stated Resident 1 was not in his room during meal tray pass and medication pass on 1/28/25. LN 1 stated Resident 1 had no wander guard (wearable bracelet that alerts the staff when the doors are opened) because he was low risk of elopement. LN 1 stated Resident had not Page 1 of 7 555076 555076 01/29/2025 Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020

F 0689 exhibited an exit seeking behavior (a resident who leaves a safe area under the care of a facility). Level of Harm - Minimal harm or potential for actual harm On 1/29/25 at 1:28 P.M., a telephone interview with LN 2 was conducted. LN 2 stated Resident 1 was assigned to her on 1/28/25. LN 2 stated Resident 1 had some cognitive deficiencies related to his diagnosis. LN 2 stated Resident 1 helped pushed other residents to the smoking patio. LN 2 stated Resident 1 was not always available in his room . LN 2 stated she did not see Resident 1 in his room from the beginning of her shift until the end of her shift on 1/28/25. Residents Affected - Few On 1/29/25 at 2:04 P.M., a telephone interview with CNA 2 was conducted. CNA 2 stated Resident 1 was assigned under her care on 1/28/25. CNA 2 stated Resident 1 goes to his friends in another station. Per CNA 2, Resident 1 would stand in the nurses ' station to wait for his breakfast, but on 1/28/25 at around 7:30 in the morning, Resident 1 was not in the nurses ' station and was not in his bed. CNA 2 stated I did not think that was unusual for him. CNA 2 stated she informed LN 2 and LN 2 informed CNA 2 to check Resident 1 ' s vital signs when he gets back to his bed. CNA 2 stated on 1/28/25 at around 10 in the morning, Resident 1 was still not back in his bed, the staff went to check his whereabouts and a yellow code for missing person was initiated. CNA 2 stated Resident did not exhibit exit seeking behavior. CNA 2 stated she did not see Resident 1 on her shift on 1/28/25. On 1/29/25 at 2:49 P.M., a joint telephone interview with Unit Clerk (UC) and LN 3 was conducted. UC and LN 3 stated Resident 1 resided in one station, was last seen in another station on 1/28/25 at around 9:30 AM to 10 A.M. UC stated she saw Resident 1 while she was on the telephone. LN 3 stated she saw Resident 1 getting some coffee and she did not know where Resident 1 headed after preparing some coffee. LN 3 stated that was around 10ish. On 1/30/25, a review of Resident 1 ' s interdisciplinary (IDT, group of professionals who plan, coordinate and deliver personalized health care) notes was conducted. The information was as followed: - 12/29/22 - IDT notes. The IDT notes indicated Resident 1 was initially placed in the facility ' s secured unit (having doors that set off an alarm if opened without a code and secure windows to make sure residents do not end up anywhere dangerous) due to his history of leaving his previous facility. Per the IDT notes, since admission on [DATE], Resident 1 had remained in his room, and had not exhibited an interest in eloping or had an exit seeking behavior. Resident 1 was then placed in a non-secured unit and the plan was to monitor Resident 1. On 1/30/25, a review of Resident 1 ' s wandering and elopement assessment was conducted. - 10/14/22 - 60, at risk for elopement. - 1/17/23 - 60, at risk for elopement. - 3/3/23 - 60, at risk for elopement. - 4/11/23 - 60, at risk for elopement. - 7/5/23 - 10, not at risk for elopement. - 9/27/23 - 10, not at risk for elopement. 555076 Page 2 of 7 555076 01/29/2025 Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020

F 0689 - 12/18/23 - 10, not at risk for elopement. Level of Harm - Minimal harm or potential for actual harm - 3/19/24 - low risk for wandering. - 6/19/24 - low risk for wandering. Residents Affected - Few - 9/20/24 - low risk for wandering. - 12/20/24 - low risk for wandering. On 1/30/25 at 1:24 P.M., a conference call with CDPH facility supervisor and the Nursing Home Administrator (NHA) was conducted. The NHA stated the facility staff did not know where Resident 1 exited and was still not found as of 1/30/25. A review of the facility ' s policy titled, Routine Residents Checks, revised July 2013, indicated, Staff shall make routine resident checks to help maintain resident safety and well-being . Based on interview, and record review, the facility failed to provide resident's (Resident 1) safety when Resident 1 eloped (leave without notice) from a facility's entrance/exit without their knowledge. As a result, Resident 1 had a successful elopement (leaving the facility unsafely and unescorted) on 1/28/25, and was not found as of today, 1/30/25. The facility did not know Resident 1's exit point and his whereabouts. Findings: On 1/29/25 at 9:57 A.M., an unannounced onsite to the facility was conducted related to a facility reported incident on resident safety. On 1/29/25, a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (serious mental illness with disorganized thinking). On 1/29/25, a review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), dated 9/11/24, Resident 1 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 6/15, (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 1/29/25, a review of Resident 1's history and physical examination completed by Resident 1's attending physician, dated 10/15/24, indicated Resident 1 could make his needs known but could not make medical decision. On 1/29/25 at 10:46 A.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated Resident 1 was ambulatory and was independent. CNA 1 stated Resident 1 resided in their station and his usual behavior was to go to another station to socialize. On 1/29/25 at 10:59 A.M., an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated 555076 Page 3 of 7 555076 01/29/2025 Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 could make his needs known but could not make a medical decision. LN 1 stated she had seen Resident 1 pushed other residents to the smoking patio and went to different stations to socialize with other residents. LN 1 stated Resident 1 was not in his room during meal tray pass and medication pass on 1/28/25. LN 1 stated Resident 1 had no wander guard (wearable bracelet that alerts the staff when the doors are opened) because he was low risk of elopement. LN 1 stated Resident had not exhibited an exit seeking behavior (a resident who leaves a safe area under the care of a facility). On 1/29/25 at 1:28 P.M., a telephone interview with LN 2 was conducted. LN 2 stated Resident 1 was assigned to her on 1/28/25. LN 2 stated Resident 1 had some cognitive deficiencies related to his diagnosis. LN 2 stated Resident 1 helped pushed other residents to the smoking patio. LN 2 stated Resident 1 was not always available in his room . LN 2 stated she did not see Resident 1 in his room from the beginning of her shift until the end of her shift on 1/28/25. On 1/29/25 at 2:04 P.M., a telephone interview with CNA 2 was conducted. CNA 2 stated Resident 1 was assigned under her care on 1/28/25. CNA 2 stated Resident 1 goes to his friends in another station. Per CNA 2, Resident 1 would stand in the nurses' station to wait for his breakfast, but on 1/28/25 at around 7:30 in the morning, Resident 1 was not in the nurses' station and was not in his bed. CNA 2 stated I did not think that was unusual for him. CNA 2 stated she informed LN 2 and LN 2 informed CNA 2 to check Resident 1's vital signs when he gets back to his bed. CNA 2 stated on 1/28/25 at around 10 in the morning, Resident 1 was still not back in his bed, the staff went to check his whereabouts and a yellow code for missing person was initiated. CNA 2 stated Resident did not exhibit exit seeking behavior. CNA 2 stated she did not see Resident 1 on her shift on 1/28/25. On 1/29/25 at 2:49 P.M., a joint telephone interview with Unit Clerk (UC) and LN 3 was conducted. UC and LN 3 stated Resident 1 resided in one station, was last seen in another station on 1/28/25 at around 9:30 AM to 10 A.M. UC stated she saw Resident 1 while she was on the telephone. LN 3 stated she saw Resident 1 getting some coffee and she did not know where Resident 1 headed after preparing some coffee. LN 3 stated that was around 10ish . On 1/30/25, a review of Resident 1's interdisciplinary (IDT, group of professionals who plan, coordinate and deliver personalized health care) notes was conducted. The information was as followed: - 12/29/22 - IDT notes. The IDT notes indicated Resident 1 was initially placed in the facility's secured unit (having doors that set off an alarm if opened without a code and secure windows to make sure residents do not end up anywhere dangerous) due to his history of leaving his previous facility. Per the IDT notes, since admission on [DATE], Resident 1 had remained in his room, and had not exhibited an interest in eloping or had an exit seeking behavior. Resident 1 was then placed in a non-secured unit and the plan was to monitor Resident 1. On 1/30/25, a review of Resident 1's wandering and elopement assessment was conducted. - 10/14/22 - 60, at risk for elopement. - 1/17/23 - 60, at risk for elopement. - 3/3/23 - 60, at risk for elopement. - 4/11/23 - 60, at risk for elopement. 555076 Page 4 of 7 555076 01/29/2025 Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020

F 0689 - 7/5/23 - 10, not at risk for elopement. Level of Harm - Minimal harm or potential for actual harm - 9/27/23 - 10, not at risk for elopement. - 12/18/23 - 10, not at risk for elopement. Residents Affected - Few - 3/19/24 - low risk for wandering. - 6/19/24 - low risk for wandering. - 9/20/24 - low risk for wandering. - 12/20/24 - low risk for wandering. On 1/30/25 at 1:24 P.M., a conference call with CDPH facility supervisor and the Nursing Home Administrator (NHA) was conducted. The NHA stated the facility staff did not know where Resident 1 exited and was still not found as of 1/30/25. A review of the facility's policy titled, Routine Residents Checks, revised July 2013, indicated, Staff shall make routine resident checks to help maintain resident safety and well-being . Based on interview, and record review, the facility failed to provide resident's (Resident 1) safety when Resident 1 eloped (leave without notice) from a facility's entrance/exit without their knowledge. As a result, Resident 1 had a successful elopement (leaving the facility unsafely and unescorted) on 1/28/25, and was not found as of today, 1/30/25. The facility did not know Resident 1's exit point and his whereabouts. Findings: On 1/29/25 at 9:57 A.M., an unannounced onsite to the facility was conducted related to a facility reported incident on resident safety. On 1/29/25, a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (serious mental illness with disorganized thinking). On 1/29/25, a review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool), dated 9/11/24, Resident 1 had a Brief Interview for Mental Status (BIMS, ability to recall) score of 6/15, (a score of 13 to 15 suggests the patient is cognitively [process of acquiring knowledge and understanding] intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). On 1/29/25, a review of Resident 1's history and physical examination completed by Resident 1's attending physician, dated 10/15/24, indicated Resident 1 could make his needs known but could not make medical decision. On 1/29/25 at 10:46 A.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 555076 Page 5 of 7 555076 01/29/2025 Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1 stated Resident 1 was ambulatory and was independent. CNA 1 stated Resident 1 resided in their station and his usual behavior was to go to another station to socialize. On 1/29/25 at 10:59 A.M., an interview with Licensed Nurse (LN) 1 was conducted. LN 1 stated Resident 1 could make his needs known but could not make a medical decision. LN 1 stated she had seen Resident 1 pushed other residents to the smoking patio and went to different stations to socialize with other residents. LN 1 stated Resident 1 was not in his room during meal tray pass and medication pass on 1/28/25. LN 1 stated Resident 1 had no wander guard (wearable bracelet that alerts the staff when the doors are opened) because he was low risk of elopement. LN 1 stated Resident had not exhibited an exit seeking behavior (a resident who leaves a safe area under the care of a facility). On 1/29/25 at 1:28 P.M., a telephone interview with LN 2 was conducted. LN 2 stated Resident 1 was assigned to her on 1/28/25. LN 2 stated Resident 1 had some cognitive deficiencies related to his diagnosis. LN 2 stated Resident 1 helped pushed other residents to the smoking patio. LN 2 stated Resident 1 was not always available in his room . LN 2 stated she did not see Resident 1 in his room from the beginning of her shift until the end of her shift on 1/28/25. On 1/29/25 at 2:04 P.M., a telephone interview with CNA 2 was conducted. CNA 2 stated Resident 1 was assigned under her care on 1/28/25. CNA 2 stated Resident 1 goes to his friends in another station. Per CNA 2, Resident 1 would stand in the nurses' station to wait for his breakfast, but on 1/28/25 at around 7:30 in the morning, Resident 1 was not in the nurses' station and was not in his bed. CNA 2 stated I did not think that was unusual for him. CNA 2 stated she informed LN 2 and LN 2 informed CNA 2 to check Resident 1's vital signs when he gets back to his bed. CNA 2 stated on 1/28/25 at around 10 in the morning, Resident 1 was still not back in his bed, the staff went to check his whereabouts and a yellow code for missing person was initiated. CNA 2 stated Resident did not exhibit exit seeking behavior. CNA 2 stated she did not see Resident 1 on her shift on 1/28/25. On 1/29/25 at 2:49 P.M., a joint telephone interview with Unit Clerk (UC) and LN 3 was conducted. UC and LN 3 stated Resident 1 resided in one station, was last seen in another station on 1/28/25 at around 9:30 AM to 10 A.M. UC stated she saw Resident 1 while she was on the telephone. LN 3 stated she saw Resident 1 getting some coffee and she did not know where Resident 1 headed after preparing some coffee. LN 3 stated that was around 10ish . On 1/30/25, a review of Resident 1's interdisciplinary (IDT, group of professionals who plan, coordinate and deliver personalized health care) notes was conducted. The information was as followed: - 12/29/22 – IDT notes. The IDT notes indicated Resident 1 was initially placed in the facility's secured unit (having doors that set off an alarm if opened without a code and secure windows to make sure residents do not end up anywhere dangerous) due to his history of leaving his previous facility. Per the IDT notes, since admission on [DATE], Resident 1 had remained in his room, and had not exhibited an interest in eloping or had an exit seeking behavior. Resident 1 was then placed in a non-secured unit and the plan was to monitor Resident 1. On 1/30/25, a review of Resident 1's wandering and elopement assessment was conducted. - 10/14/22 – 60, at risk for elopement. - 1/17/23 – 60, at risk for elopement. 555076 Page 6 of 7 555076 01/29/2025 Stillwater Post-Acute 510 E. Washington Avenue El Cajon, CA 92020

F 0689 - 3/3/23 - 60, at risk for elopement. Level of Harm - Minimal harm or potential for actual harm - 4/11/23 – 60, at risk for elopement. - 7/5/23 – 10, not at risk for elopement. Residents Affected - Few - 9/27/23 - 10, not at risk for elopement. - 12/18/23 - 10, not at risk for elopement. - 3/19/24 – low risk for wandering. - 6/19/24 - low risk for wandering. - 9/20/24 - low risk for wandering. - 12/20/24 - low risk for wandering. On 1/30/25 at 1:24 P.M., a conference call with CDPH facility supervisor and the Nursing Home Administrator (NHA) was conducted. The NHA stated the facility staff did not know where Resident 1 exited and was still not found as of 1/30/25. A review of the facility's policy titled, Routine Residents Checks, revised July 2013, indicated, Staff shall make routine resident checks to help maintain resident safety and well-being . 555076 Page 7 of 7