Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stillwater Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
An LPN found six loose pills of different sizes, shapes, and colors at the bottom of a medication cart drawer under resident med cards. The LPN confirmed the pills were loose in the drawer and stated meds should remain in their original containers or be discarded if they fall into the drawer. Facility policy required drugs and biologicals to be stored in a safe, secure, and orderly manner in the containers in which they were received.
Care Plan Missing Resident Preferences and Refusals for Laryngectomy Tube Care: A resident with a laryngectomy tube, tracheostomy status, COPD, and chronic respiratory failure was observed managing the tube independently, with no trach ties in place and no replacement tube at the bedside. The care plan addressed tube care and skin monitoring but did not document the resident’s refusal of trach ties, preference to perform tube care independently, or refusal to allow staff access to the tube at bedside; the DON confirmed the omissions.
A resident with a laryngectomy tube, COPD, chronic respiratory failure with hypoxia, and tracheostomy status was observed completing his own tube care, but no replacement tube was at the bedside. The resident confirmed he did not have a replacement tube available, an LPN confirmed staff had no tube to use if needed, and the DON stated the tube was in a locked box that staff could not access. The facility policy required a replacement tube to be available at the bedside at all times.
Unnecessary Long-Term Azithromycin Use: A resident with COPD, chronic respiratory failure, and lung cancer remained on Azithromycin 250 mg three times weekly for infection/COPD. A pharmacist recommended a stop date, but the PA declined because the pulmonologist had written the order. The DON confirmed staff did not contact the pulmonologist to review the ongoing antibiotic use, and the IP did not monitor or evaluate the long-term Azithromycin after the pharmacy recommendation.
Medication pass error rate exceeded the 5% threshold after an LPN failed to administer all ordered morning meds to a resident. The resident had diagnoses including HTN, atherosclerotic heart disease, asthma, and anxiety disorder, and was cognitively intact. During observation, the LPN prepared and gave 10 meds instead of the 12 ordered, omitting amlodipine besylate and carvedilol despite the resident's BP being checked before administration. The facility's medication error rate was 7.4% based on 2 errors out of 27 opportunities.
Failure to Monitor Long-Term Antibiotic Use: A resident with COPD, chronic respiratory failure, and lung cancer was ordered Azithromycin three times weekly for infection/COPD. The pharmacist recommended a stop date, but the PA declined because the pulmonologist wrote the order. The DON confirmed staff did not contact the pulmonologist to review the ongoing antibiotic use, and the IP did not monitor or evaluate the long-term Azithromycin or suggest a dose reduction or stop date after the pharmacy recommendation.
The facility failed to protect residents’ controlled substances when an LPN diverted Oxycodone 5 mg tablets prescribed for four residents with chronic conditions and varying cognitive status. During a routine narcotic count, the DON discovered altered bubble packaging and unstamped white pills that did not match the manufacturer markings of Oxycodone. An audit identified 11 affected Oxycodone cards containing a total of 42 substituted pills. The LPN later admitted to replacing the Oxycodone with Melatonin 1 mg tablets over approximately one month and documented in a police statement that she intentionally used a similar-looking medication to imitate the narcotic, resulting in confirmed misappropriation of residents’ medications.
The facility did not follow its policy for Enhanced Barrier Precautions, as rooms of multiple residents requiring EBP lacked clear signage or instructions about required PPE and care activities. Staff demonstrated inconsistent understanding of EBP protocols, and care plans indicated EBP needs without corresponding physician orders. The deficiency was identified through record review, staff interviews, and observation.
A resident with moderate cognitive impairment and multiple medical conditions underwent several room changes, but the facility did not notify the resident's representative prior to all moves as required. Documentation of notification was delayed, and interviews confirmed that the representative was only informed of one of the recent room changes, contrary to facility policy.
Improper Storage of Resident Medications in Medication Cart
Penalty
Summary
The facility failed to properly store resident medications in the [NAME] Hall medication cart. During observation of the cart, six loose pills of different sizes, shapes, and colors were found at the bottom of the cart drawer under the resident medication cards. An LPN confirmed the loose pills were in the drawer and stated that medications should be stored in their original containers and discarded if they fall to the bottom of the drawer. Review of the facility policy on Storage of Medications stated that drugs and biologicals should be stored in a safe, secure, and orderly manner and kept in the packing, container, or dispensing systems in which they were received.
Care Plan Missing Resident Preferences and Refusals for Laryngectomy Tube Care
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan for Resident #8 included the resident’s preferences and refusals related to laryngectomy tube care. Resident #8 was admitted with diagnoses including malignant neoplasm of the larynx, COPD, chronic respiratory failure with hypoxia, and tracheostomy status. The MDS dated 01/07/26 indicated the resident was cognitively intact, required staff assistance with ADLs, and received tracheostomy care. The care plan dated 06/25/25 documented that the resident had a laryngeal tube with a history of cutting the edge/lip of the tube because it was too long, and included interventions such as ensuring tube ties were secured, suctioning as needed, and monitoring for skin breakdown. The care plan did not document that the resident refused trach ties, preferred to complete laryngeal tube care independently, or refused to allow staff access to the tube at bedside. During observation on 04/14/26 at 11:37 A.M., the resident had a laryngectomy tube in the neck stoma with no trach ties noted, removed the tube from the stoma, and replaced it independently; there was no replacement tube at the bedside. In interview at 11:39 A.M., the resident confirmed he completed his laryngectomy tube care independently, did not want trach ties around the tube, and did not have a replacement tube at the bedside. The DON later confirmed the care plan did not document the resident’s independent care, refusal of trach ties, or refusal to allow staff access to the laryngectomy tube at bedside.
Replacement Laryngectomy Tube Not Accessible at Bedside
Penalty
Summary
The facility failed to ensure that a replacement laryngectomy tube was at the bedside or otherwise easily accessible for staff use for one resident with a laryngectomy tube. Resident #8 was admitted with diagnoses including malignant neoplasm of the larynx, COPD, chronic respiratory failure with hypoxia, and tracheostomy status. The resident’s MDS indicated he was cognitively intact, required staff assistance with ADLs, and received tracheostomy care. A physician order directed staff to remove the laryngectomy tube from the stoma, cleanse the stoma site with normal saline, and clean and replace the tube every shift and as needed. During observation, the resident had a laryngectomy tube in the neck stoma and removed it independently, then placed it back independently. No replacement tube was at the bedside. The resident confirmed he completed his laryngectomy tube care independently and did not have a replacement tube at the bedside. An LPN confirmed there was no replacement laryngectomy tube at bedside and no tube available for staff use if needed. The DON stated the resident had a laryngectomy tube in a locked box at the bedside, but staff were not able to get into the locked box. The facility policy stated a replacement tube must be available at the bedside at all times.
Unnecessary Long-Term Azithromycin Use
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs. Resident #22 was admitted with diagnoses including COPD, chronic respiratory failure with hypoxia, and malignant neoplasm of the bronchus and lung. The resident had an order for Azithromycin 250 mg by mouth on Monday, Wednesday, and Friday for infection, and the care plan identified the resident as having signs and symptoms of respiratory infection/COPD exacerbation and being on a long-term antibiotic for COPD. A pharmacist recommended a stop date for the Azithromycin, but the physician’s assistant refused the recommendation because the pulmonologist had written the order. The resident’s record also showed a later episode of pneumonia treated with Augmentin and Doxycycline, with Azithromycin held for seven days, and then the pulmonologist again ordered the Azithromycin to continue on Monday, Wednesday, and Friday. The DON confirmed staff had not called the pulmonologist to review the ongoing use of Azithromycin and ask for a possible stop date, and the facility IP had not monitored or evaluated the long-term use of the medication or suggested a dose reduction or stop date after the pharmacy recommendation.
Medication pass error rate exceeded threshold
Penalty
Summary
The facility failed to ensure a medication error rate of 5% or lower. Based on medical record review, observation, staff interview, and review of facility policy, the medication error rate was 7.4% from two errors out of 27 medication opportunities. This involved one resident observed during medication administration, and the facility census was 46 residents. Resident #34 was admitted on 07/26/24 with diagnoses including hypertension, atherosclerotic heart disease, asthma, and anxiety disorder. The resident's MDS assessment dated 01/31/26 indicated the resident was cognitively intact and required staff assistance with ADLs. Physician orders for April 2026 included 12 morning medications, including Eliquis, Claritin, Norco, Lasix with a blood pressure hold parameter, Wellbutrin, amlodipine besylate with a blood pressure hold parameter, allopurinol, clonidine with a systolic blood pressure hold parameter, spironolactone, aspirin, and pantoprazole. During observation of the morning medication pass, an LPN prepared 10 medications for the resident and later administered them after checking the resident's blood pressure at 150/88. The LPN confirmed that amlodipine besylate and carvedilol were not administered as ordered, and confirmed the resident should have received 12 medications during the morning pass. The facility policy stated medications were to be administered in accordance with prescriber orders and within the required timeframe.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship plan and failed to properly monitor antibiotic use for one resident. Resident #22 was admitted with COPD, chronic respiratory failure with hypoxia, and malignant neoplasm of the bronchus and lung. The resident had an order for Azithromycin 250 mg by mouth on Monday, Wednesday, and Friday for infection, and the care plan identified the resident as having signs and symptoms of respiratory infection/COPD exacerbation and being on a long-term antibiotic for COPD. The pharmacist recommended a stop date for the Azithromycin, but the physician's assistant refused the recommendation because the pulmonologist had written the order. The resident later developed pneumonia and was ordered Augmentin and Doxycycline for five days, with Azithromycin held for seven days, then the pulmonologist again ordered the Azithromycin to continue on Monday, Wednesday, and Friday. The DON confirmed staff had not called the pulmonologist to review the three-times-weekly Azithromycin use or ask for a possible stop date, and the IP had not monitored or evaluated the long-term use of Azithromycin or suggested a dose reduction or stop date after the pharmacy recommendation.
Misappropriation and Diversion of Resident Oxycodone by LPN
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their controlled substances, specifically Oxycodone 5 mg tablets prescribed for four residents with conditions including COPD, type 2 diabetes, vascular dementia, chronic pain, chronic kidney disease, and inflammatory spondylopathy. These residents had active physician orders for Oxycodone and varying cognitive statuses, with some cognitively intact and others cognitively impaired. During a routine narcotic count, the DON identified alterations in the packaging of multiple controlled substances, including nicks and tears on the backs of bubble packs. When the compromised medications were popped for waste, the pills inside were found to be unstamped white tablets that did not match the manufacturer markings of the legitimate Oxycodone tablets in other narcotic cards. Further review showed that 11 Oxycodone 5 mg cards were affected, with a total of 42 unstamped pills discovered in place of the ordered narcotic. Each compromised card was associated with residents who had active Oxycodone orders, and these residents were identified as potentially affected by the misappropriation of their medications. Interviews and subsequent investigation revealed that an LPN admitted responsibility for the drug discrepancy and diversion of controlled substances. The LPN confirmed that she had been replacing Oxycodone 5 mg tablets with Melatonin 1 mg tablets in all 11 affected packages and that this diversion had been occurring within the last month. A police statement written by the LPN corroborated that she intentionally substituted the narcotic with a similar-looking medication to imitate the Oxycodone. The facility’s investigation substantiated misappropriation of residents’ controlled substances, confirming that four residents were affected by this diversion.
Failure to Implement Enhanced Barrier Precautions Signage and Staff Awareness
Penalty
Summary
The facility failed to implement its policy regarding Enhanced Barrier Precautions (EBP) for residents requiring such precautions. Specifically, there was a lack of clear signage or instructions on resident doors indicating the required personal protective equipment (PPE) and care activities necessitating PPE use. Observations revealed that rooms of nine residents on EBP only had a magnetic square labeled 'EP' without further information, and some rooms lacked any signage or had incorrect precaution signs. Staff interviews indicated inconsistent understanding of what PPE to use for EBP, with some staff stating they would don full PPE but lacking specific guidance at the point of care. The Director of Nursing confirmed that there was no signage at the door, and staff would need to look inside the room or in the resident's chart to determine PPE requirements. Medical record reviews for several residents showed that while care plans indicated the need for EBP due to conditions such as complex wounds, laryngostomy tubes, urinary catheters, and PICC lines, there were no corresponding physician orders for EBP. The facility's policy required staff training and posting of signs outside resident rooms to alert staff to EBP requirements, but this was not consistently followed. The deficiency was identified through medical record review, staff interviews, and direct observation during the survey.
Failure to Notify Resident Representative Prior to Room Change
Penalty
Summary
The facility failed to ensure that a resident's representative was notified prior to room changes, as required by both resident rights and facility policy. Medical record review showed that a resident with moderate cognitive impairment and multiple diagnoses, including dementia and depression, experienced several room moves. Documentation indicated that notification to the resident's representative was either delayed or not completed prior to the moves. Specifically, nurses' notes included late entries documenting notification after the fact, and the Director of Nursing confirmed that documentation of room changes was not made until a later date. Interviews revealed that the resident's representative was only notified of one of the recent room changes, despite multiple moves occurring. Facility policy requires that residents and their families be informed of room changes and that this information be documented in the medical record, including details such as the date and time of the move, who assisted, and how the resident tolerated the move. The failure to notify and properly document notification to the resident's representative prior to room changes led to the identified deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Covington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Piqua Manor | 4.8 mi | ★★★★★ | 14 | 0 |
| Vancrest-upper Valley | 6.9 mi | ★★★★★ | 0 | 0 |
| Ayden Healthcare Of Piqua | 8 mi | ★★★★★ | 0 | 0 |
| Troy Rehabilitation And Healthcare Center | 8.5 mi | ★★★★★ | 18 | 0 |
| Versailles Rehabilitation And Health Care Center | 10.3 mi | ★★★★★ | 1 | 0 |
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