Stillwater Health Care

In the surveyor’s words

From the most serious findings on record at Stillwater Health Care, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 16, 2025

  Based on record review and interviews, the facility failed to provide interventions outlined in the resident's care plan to ensure that two-person assist was provided during activities of daily living (ADL) for 1 of 2 sampled residents (Resident #12 [R12]), reviewed for falls. The failure to have supervision (two-person assist) as directed by the care plan resulted in an avoidable accident; R12 falling out of bed during evening ADL care, requiring transfer to the emergency room [ER] with admission to the hospital, sustaining a laceration to the head, and rib fractures with increased pain. […]

• Actual harm, isolatedF600Aug 9, 2023

  Based on interviews, review of the facility reportable incident form, and review of the medical record, the facility failed remove a bed pan timely from 1 of residents reviewed. This resulted in harm when a resident was left on a bed pan for approximately 45 minutes and sustained a Stage 2 pressure ulcer (Resident 1). Finding: A Nursing Facility Reportable Incident form was faxed to Division of Licensing and Certification office indicating on 7/25/23 at approximately 4:00 a.m., a Certified Nurse Aide (CNA) placed a resident on a bed pan, left resident on bedpan and failed to monitor the resident per policy. […]

• Actual harm, isolatedF689Feb 19, 2021

  Based on review of the Nursing Facility Reportable Incident Form, the facility's internal investigation, the facility transfer policy and procedure, and interviews, the facility failed to ensure a resident's safety during a Hoyer lift transfer which caused harm to the resident. The facility failed to follow their Hoyer lift policy and procedure which resulted in the resident falling to the floor from the Hoyer lift. From this fall, the resident sustained [REDACTED].#1). Finding: A review of the Nursing Facility Reportable Incident Form submitted to the Division of Licensing and Certification on 2/8/21 stated that on 2/7/21 at 11:55 a.m., Certified Nursing Assistants #1 (C.N.A.#1) and C.N.A. […]

• No harm, potential for more than minimal, widespreadF812Jul 13, 2022

  Based on observations, interviews, facility policy reviews, and temperature monitoring logs, the facility failed to ensure that the High Temperature Dishwasher consistently reached 180 degrees Fahrenheit (F) during the rinse cycle for 3 of 3 months reviewed (May, June, and July). In addition, the facility failed to label and remove expired items in the Resident Refrigerator and food storage area in the dining room for 2 of 3 days of survey ([DATE] and [DATE]), and failed to monitor temperatures in the Resident Refrigerator located in the dining room for 6 of 11 days in July. Findings: 1. […]

• No harm, potential for more than minimal, patternF761Feb 27, 2026

  Based on observations and interviews, the facility failed to ensure expired medications were removed from the available for use supply, for 2 of 3 Medication Storage Areas reviewed (A Wing Treatment Cart and B Wing Treatment Cart).Findings:On 2/25/26 at 3:16 p.m., a surveyor and the Director of Nursing Services (DON) observed and confirmed the following were in the A Wing treatment cart and available for use:-1 box of 12 rectal Acetaminophen Suppositories 650 milligrams (mg) with an expiration date of 01/2026-1 multi-use vial containing 10 milliliter (ml) of Insulin glargine 100 units (u)/10ml, open but unlabeled with an open date or an expiration date. […]