Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Creek Skilled Nursing And Therapy during CMS and state inspections, most recent first.
A facility failed to notify a physician when a resident with multiple health issues left AMA with all medications. The administrator confirmed no documentation of physician notification, and a corporate nurse consultant stated there was no policy for handling AMA situations.
The facility failed to notify the physician when a resident's fingerstick blood sugar results exceeded 501 on multiple occasions, despite the requirement to do so. Interviews and record reviews confirmed the absence of documentation for physician notification, constituting a deficiency in care.
A resident with quadriplegia and existing pressure ulcers developed new pressure ulcers due to the facility's failure to ensure heel lift boots and other pressure-relieving devices were in place as per the care plan. Staff admitted to noticing the absence of these devices but did not take appropriate action.
The facility failed to obtain proper physician orders for continuous oxygen and did not ensure that oxygen tubing and humidifier bottles were changed and dated as required for two residents with COPD. Observations revealed discrepancies in oxygen flow rates and undated tubing and humidifier bottles, with residents indicating a need for continuous oxygen.
The facility failed to ensure ongoing assessment for a resident on dialysis, missing required checks for AVF thrill and bruit, monitoring for trauma or infection, and timely dressing changes as per physician orders. Documentation inconsistencies were confirmed by the ADON and a corporate nurse consultant.
A facility failed to administer medications according to physician orders for a resident with diabetes, coronary artery disease, and hypertension. The MAR and insulin administration records documented multiple instances of late or missed doses, and blood pressure medications were given despite readings being out of prescribed parameters. Staff confirmed these discrepancies, leading to a deficiency in pharmaceutical services.
The facility failed to monitor for side effects related to the use of Warfarin for a resident with hemiplegia and hemiparesis following cerebral infarction. The resident was administered Warfarin from September through January without documented monitoring for side effects until January.
The facility failed to monitor behavior and side effects for a resident on psychotropic medication and did not limit PRN antianxiety medications to 14 days for another resident. One resident with dementia was prescribed quetiapine without proper monitoring, and another resident with anxiety received Ativan without a required stop date, exceeding the 14-day limit.
The facility failed to obtain laboratory studies as ordered for a resident with hypokalemia. Despite orders to repeat a CMP on a specific date, the facility was unable to locate documentation for the repeat lab.
The facility failed to complete a significant change assessment for a resident who experienced declines in ADLs, including range of motion impairments and increased dependency on assistance for daily activities. The corporate MDS coordinator acknowledged the oversight.
The facility failed to update the care plan with smoking interventions for a resident with heart failure and type two diabetes mellitus. Despite the resident being identified as a smoker and having signed a smoking contract, the care plan lacked necessary interventions and safety measures. Interviews confirmed the oversight, which was against the facility's Smoking Policy and Procedure.
The facility failed to ensure a timely response to a pharmacist's recommendation for a gradual dose reduction of medications for a resident with bipolar disorder, insomnia, and depression. The recommendation was made in a monthly medication review, but the facility did not document a response until nearly two months later, when the physician declined the GDR.
Failure to Notify Physician of Resident Leaving AMA
Penalty
Summary
The facility failed to notify the physician when a resident left against medical advice (AMA). The resident, who had diagnoses including alcohol abuse, psychoactive substance abuse with intoxication, chronic heart failure, anxiety, depression, and anemia, left the facility under the care of a friend with all medications in their possession. A late entry progress note documented the resident's departure on 11/25/24, but there was no evidence that the resident's physician was informed of this event. During an interview on 03/04/25, the administrator confirmed the absence of documentation regarding physician notification. Additionally, a corporate nurse consultant indicated that the facility lacked a policy or procedure for handling situations where a resident leaves AMA.
Failure to Notify Physician of Elevated Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician when a resident's fingerstick blood sugar (FSBS) results were greater than 501, as required by the physician's order. The resident, who had diagnoses including heart failure and type two diabetes mellitus, had multiple instances where FSBS readings exceeded 501. Specifically, on five separate occasions, the FSBS readings were 528, 501, 545, 556, 501, and 544, but there was no documentation indicating that the physician had been notified of these elevated results. The facility's policy required consultation with the resident's physician in such events, but this was not adhered to in these instances. Interviews with facility staff, including an LPN and a corporate nurse consultant, confirmed that there was no documentation in the resident's clinical health record or progress notes indicating that the physician had been notified of the elevated FSBS results. The corporate nurse consultant reviewed the January and February Medication Administration Records (MAR) and confirmed the absence of documentation for physician notification on the specified dates. This failure to notify the physician as required by the facility's policy and the physician's order constitutes a deficiency in the care provided to the resident.
Failure to Prevent New Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of new pressure ulcers for a resident with quadriplegia and existing pressure ulcers. Despite physician orders and a care plan requiring heel lift boots and floating heels with pillows, the resident was observed multiple times without any pressure-relieving devices in place. On one occasion, the resident's bare feet were pressed against the footboard of the bed, causing the toes to curl under from pressure. This lack of adherence to the care plan led to the development of new purple discolorations on the resident's right great toe and left great toe, as well as a new purple area on the right heel. Staff interviews revealed that both CNAs and nurses were responsible for ensuring the pressure reduction devices were in place. However, a CNA could not recall if the boots were in place the previous day, and an LPN admitted to noticing the boots were not in place but failed to take action or notify anyone. This inaction directly contributed to the resident developing new pressure ulcers, as documented in the nurse progress notes and observed by the wound nurse.
Failure to Obtain Proper Oxygen Orders and Change Tubing
Penalty
Summary
The facility failed to obtain proper physician orders for continuous oxygen and did not ensure that oxygen tubing and humidifier bottles were changed and dated as required for two residents. Resident #1, diagnosed with COPD, had a physician order to administer oxygen at 2 liters per minute as needed and to change the oxygen tubing and humidifier bottle monthly. However, observations revealed that the oxygen tubing and humidifier bottle were not dated, and the oxygen concentrator was set at 4 liters per minute without an order for continuous oxygen. The resident stated they needed oxygen most of the time but were unsure when the tubing and humidifier bottle were last changed. LPN #1 confirmed the absence of an order for continuous oxygen and noted the discrepancy in the oxygen flow rate settings. Similarly, Resident #9, also diagnosed with COPD, had a physician order for oxygen at 2 liters per minute as needed and to change the oxygen tubing and humidifier bottle monthly. Observations showed that the oxygen tubing and humidifier bottle were not dated, and the oxygen concentrator and portable oxygen tank were set at higher flow rates than ordered. The resident indicated they required oxygen continuously and pointed out that their oxygen tubing had never been changed, with the cannula showing discoloration. LPN #1 later confirmed that an order for continuous oxygen was obtained after noting the resident's increased need for oxygen.
Failure to Ensure Ongoing Assessment for Dialysis Resident
Penalty
Summary
The facility failed to ensure ongoing assessment of a resident on dialysis, specifically for Resident #54, who had diagnoses including end-stage renal disease (ESRD). Physician orders required the resident to undergo dialysis on specific days and mandated checks for arteriovenous fistula (AVF) thrill and bruit every shift, monitoring for signs and symptoms of trauma or infection every shift, and removal of the AVF dressing four hours post-dialysis. However, documentation revealed that out of 58 opportunities, the AVF was not checked for thrill and bruit 20 times, and out of 13 opportunities, the AVF dressing was not removed seven times as required by the physician's orders. This lack of documentation indicated a failure to follow the prescribed monitoring and care procedures for the resident's dialysis access site. The Assistant Director of Nursing (ADON) and a corporate nurse consultant confirmed that while they documented dialysis management in daily skilled nurses' notes, they did not consistently follow the physician's orders for monitoring each shift. The ADON acknowledged that the dialysis communication form used did not include documentation of the required checks for thrill and bruit, monitoring for trauma or infection, or dressing changes after dialysis. This inconsistency in documentation and adherence to physician orders led to the identified deficiency in providing appropriate dialysis care for Resident #54.
Failure to Administer Medications According to Physician Orders
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders for one of the five sampled residents reviewed for unnecessary medications. The resident had diagnoses including diabetes, coronary artery disease, and hypertension. The physician orders included specific instructions for administering insulin glargine, insulin aspart, Victoza, amlodipine besylate, losartan potassium, and carvedilol. However, the Medication Administration Records (MAR) and insulin administration records for January, February, and March 2024 documented multiple instances where medications were administered late or not at all, and blood pressure medications were given despite the resident's blood pressure being out of the prescribed parameters. The resident confirmed that they often received their medications late, and staff interviews corroborated the findings of late administration and failure to hold medications as required by the physician orders. On specific dates, the resident's blood pressure readings were below the parameters set for holding the medications, yet the medications were still administered. Additionally, insulin and Victoza were frequently administered more than one hour after the prescribed times, and in some instances, doses were missed entirely. The staff acknowledged these discrepancies, with a Certified Medication Aide (CMA) and a Licensed Practical Nurse (LPN) confirming that the medications should have been held or were administered late. These actions and inactions led to the deficiency in providing pharmaceutical services according to physician orders, potentially compromising the resident's health and safety.
Failure to Monitor Warfarin Side Effects
Penalty
Summary
The facility failed to monitor for side effects related to the use of Warfarin for a resident with diagnoses including hemiplegia and hemiparesis following cerebral infarction. The resident had been administered Warfarin as ordered by the physician from September through January, but the clinical health record did not document any monitoring for side effects during this period. The resident's Treatment Administration Record (TAR) dated January 22 indicated that monitoring for side effects such as nose/gum bleeding, coughing or blood-tinged sputum, hematuria, black/tarry stools, vomiting of blood or coffee ground-like material, abnormal or excessive bruising, low blood pressure, change in cognition, and cyanosis should occur every shift for anticoagulation therapy. However, the Corporate Nurse Consultant confirmed that there were no orders to monitor for side effects until January 2024.
Failure to Monitor Psychotropic Medications and Limit PRN Antianxiety Medications
Penalty
Summary
The facility failed to ensure proper behavior and side effect monitoring for the use of psychotropic medications for one resident and did not limit PRN antianxiety medications to 14 days for another resident. Resident #127, who had a diagnosis of dementia with behavioral disturbances, was prescribed quetiapine fumarate at varying dosages over a period of time. However, there was no documentation of behavior and side effect monitoring from 03/04/24 through 03/12/24. The administrator confirmed that the monitoring was overlooked and not conducted as required by the facility's policy dated 10/25/21. Resident #9, diagnosed with an anxiety disorder, had a physician's order for Ativan oral tablet 0.5 mg every 12 hours as needed for anxiety. Despite a pharmacist's request to add a stop date to the PRN Ativan order in May 2023, the order continued without a stop date until August 2023. During this period, the resident received the medication multiple times each month, far exceeding the 14-day limit for PRN antianxiety medications. The corporate nurse consultant acknowledged that the 14-day stop date was not added to the order as required.
Failure to Obtain Ordered Laboratory Studies
Penalty
Summary
The facility failed to obtain laboratory studies as ordered for a resident diagnosed with hypokalemia. A lab result dated 06/20/23 indicated the resident had a low potassium level, and a new order was received to administer potassium and repeat a comprehensive metabolic panel (CMP) on 06/26/23. A nurse progress note on 06/23/23 documented a focused assessment related to labs and new orders to give potassium chloride (KCL) and repeat the CMP on 06/26/23. However, on 03/12/24, the missing labs were requested from the Assistant Director of Nursing (ADON), and by 03/15/24, the administrator confirmed that the facility was unable to locate documentation for the repeat lab on 06/26/23.
Failure to Complete Significant Change Assessment
Penalty
Summary
The facility failed to complete a significant change assessment for a resident who experienced declines in activities of daily living (ADLs). An annual Minimum Data Set (MDS) documented that the resident had no functional impairments in range of motion and required minimal assistance with upper body dressing and supervision with walking. However, a subsequent quarterly MDS revealed that the resident had declined in range of motion, had impairments in both upper and lower extremities, and had become newly dependent on assistance for toileting hygiene, showering/bathing, upper and lower body dressing, and walking. The corporate MDS coordinator acknowledged that the significant change assessment had been missed and should have been completed.
Failure to Update Care Plan with Smoking Interventions
Penalty
Summary
The facility failed to update the care plan with smoking interventions for a resident diagnosed with heart failure and type two diabetes mellitus. Despite the resident having signed a smoking contract and being identified as a smoker in a smoking assessment, the care plan did not include any interventions or safety measures related to smoking. Interviews with the resident, the Administrator, and the corporate nurse confirmed that the resident was a smoker and that the care plan should have included smoking-related interventions. The facility's Smoking Policy and Procedure required physicians to update care plans and set goals for residents regarding smoking habits, but this was not done for the resident in question.
Failure to Respond Timely to Medication Regimen Review
Penalty
Summary
The facility failed to ensure a timely response to a medication regimen review for a resident diagnosed with bipolar disorder, insomnia, and depression. The resident had physician orders for Zoloft, Abilify, and Trazodone. A monthly medication review conducted on 12/18/23 by the pharmacist recommended a gradual dose reduction (GDR) of one of these medications. However, the facility did not document a response to this recommendation until 02/12/24, when the physician declined the GDR. According to a corporate consult RN, the facility should have escalated the issue to the medical director if there was no response within 30 days.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 15 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stillwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westhaven Nursing Home | 1.3 mi | ★★★★★ | 6 | 0 |
| Perry Green Valley Nursing Center, Llc | 17.7 mi | ★★★★★ | 0 | 0 |
| Linwood Village Nursing & Retirement Apts | 19.8 mi | ★★★★★ | 0 | 0 |
| Southern Oaks Care Center | 21.1 mi | ★★★★★ | 9 | 0 |
| Golden Age Nursing Home Of Guthrie, Llc | 25.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.