Stillwater Skilled Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Stillwater Skilled Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF802Mar 24, 2023

  Based on observation and staff interview, the facility failed to ensure there was sufficient dietary staff to carry out functions of the nutrition services. This affected four (Residents #46, #23, #19, and #31) and had the potential to affect all residents residing in the facility, as all residents received their meals from the facility's kitchen. The facility's census was 56. Findings include: Interview on 03/13/23 at 9:05 A.M. with Dietary Manager (DM) #24 stated there were two aides and one cook working in the facility's kitchen, which was not enough staff to serve residents in the main dining room and halls. DM #24 verified the dining room was closed due to insufficient kitchen staffing. […]

• No harm, potential for more than minimal, patternF761Apr 16, 2026

  Based on observation, staff interview, and review of the facility policy, the facility failed to properly store the resident medications. This had the potential to affect the seven residents with medications stored in the [NAME] Hall cart. The facility census was 46 residents.Findings include: Observation 04/15/26 at 8:20 A.M. of [NAME] Hall medication cart with Licensed Practical Nurse (LPN) #160 revealed there were six loose pills of different sizes, shapes, and colors at the bottom of the cart drawer under the resident medication cards. Interview on 04/15/26 at 8:20 A.M. with LPN #160 confirmed the medication cart drawer had six loose pills at the bottom of the drawer. […]

• No harm, potential for more than minimal, patternF602Feb 23, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, review of Self-Reported Incident (SRI), review of the incident log, review of police statement, review of staff drug screening results, and policy review, the facility failed to ensure resident's controlled substances were not misappropriated. This affected four (#18, #31, #50 and #78) of five residents reviewed for misappropriation. The facility census was 49. Findings include: Review of the medical record for Resident #18 revealed an admission date of 09/29/23 with diagnoses including chronic obstructive pulmonary disease, type two diabetes, and vascular dementia. […]

• No harm, potential for more than minimal, patternF880Nov 26, 2025

  Based on medical record review, observations, staff interviews and policy review, the facility failed to implement their policy to ensure residents with enhanced barrier precautions (EBP) have clear signage and/or instruction on their doors indicating required personal protective equipment (PPE) and care activities that require PPE. Additionally, the facility failed to ensure staff have awareness of the EBP policy and what PPE to use. This affected nine (#13, #18, #20, #30, #34, #39, #42, #43 and #56) out of nine residents reviewed for EBP. The facility census was 57. Findings include: Medical record review for Resident #34 revealed an admission date of 12/19/24. Medical diagnoses included acute embolism and thrombosis of left femoral vein. […]

• No harm, potential for more than minimal, patternF584Mar 24, 2023

  Based on medical record review, observations, resident and staff interviews, review of facility water temperature logs and review of invoices, the facility failed to ensure comfortable water temperatures were maintained for residents bathrooms and shower room. This affected three (#31, #45, and #46) of three residents reviewed for the physical environment and had the potential to affect 13 (#2, #6, #9, #11, #14, #23, #31, #32, #38, #45, #46, #118, and #309) residents residing on the West-hall. The current census is 56. Findings include: 1. Record review of Resident #45 revealed the resident was admitted to the facility on [DATE]. Diagnoses include conversion disorder with seizures, bipolar disorder, autism, and adjustment disorder. […]