F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure Licensed Nurses (LNs) assessed a resident prior to
sending the resident to the general acute care hospital (GACH), for one of three sampled residents
(Resident 1).
Residents Affected - Few
This deficient practice had the potential in a delay in the resident receiving treatment to address the onset
of infection and placed Resident 1's health at risk.
Findings:
On 2/28/25, the Department received a complaint related to quality of care.
On 3/4/25 at 10:40 A.M., an unannounced onsite visit to the facility was conducted.
Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive
pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) and congestive heart
failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting
in leg swelling), per the facility's admission Record.
A review of Resident 1's history and physical dated 10/10/24, indicated Resident 1 had the capacity to
understand and make decisions.
A review of Resident 1's GACH record dated 12/1/24 was conducted. Resident 1's clinical record indicated
the clinical impression for Resident 1 at the GACH was pneumonia (an infection/inflammation in the lungs)
due to an infectious organism and acute (unwelcome situation) respiratory failure with hypoxia (when the
tissues of your body don't have enough oxygen). Resident 1's clinical record indicated Resident 1 was
transferred to another GACH in critical care.
On 3/4/25 at 12:16 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1
stated she remembered Resident 1 to have respiratory problems and received breathing treatments.
On 3/4/25 at 1:17 P.M., a joint review of Resident 1's clinical record and an interview was conducted with
Licensed Nurse (LN) 2. LN 2 stated Resident 1 had respiratory diagnosis. LN 2 stated LN 2 worked with
Resident 1 during the last few days he (Resident 1) was at the facility. LN 2 stated Resident 1's responsible
party (RP, is usually a friend, family member or guardian who looks out for the interests of a resident of the
nursing home, making major decisions for the resident) requested the LNs to send Resident 1 out to
GACH.
(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
04/03/2025
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 3/4/25 at 2:09 P.M., a telephone interview was conducted with LN 3. LN 3 stated, He (Resident 1) did
not appear to be in distress. I didn't see any reason for him (Resident 1) to be sent out. It was not a doctor's
order, so we don't document.
On 3/4/25 at 3:04 P.M., a joint review of Resident 1's clinical record and an interview was conducted with
the Director of Nursing (DON). The DON read LN 3's change of condition (COC) charting/ notes dated
11/29/24 for Resident 1. The DON stated LNs did not assess Resident 1 per the COC notes as Resident
1's transfer to GACH was per the RP's request. The DON stated the LNs should have assessed Resident 1
when the RP requested Resident 1 to be sent out and prior to sending Resident 1 to GACH.
A review of the facility's policy, titled Change in a Resident's Condition or Status, revised 5/2017, indicated,
Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor)
of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care,
billing/payments, resident rights, etc.) . 1. The nurse will notify the resident's Attending Physician or
physician on call when there has been a(an) .d. significant change in the resident's
physical/emotional/mental condition .d. Ultimately is based on the judgment of the clinical staff .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555076
If continuation sheet
Page 2 of 2
