Above 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 Stilwell Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to include estimated service costs on CMS-10055 forms for three residents, which are necessary to inform them of potential liabilities for non-covered services. Interviews revealed that staff were unaware of the requirement to specify costs, impacting residents' ability to make informed decisions.
A facility failed to include a care plan intervention for tracheostomy self-care for a resident with a tracheostomy. The resident, diagnosed with malignant neoplasm of the lung, was observed with a tracheostomy, but their care plan lacked self-care instructions. The MDS coordinator and DON confirmed that this aspect should have been included in the care plan.
The facility's arbitration agreement mandated mediation in Tulsa County, Oklahoma, without allowing for mutual agreement on the venue, violating federal regulations. A resident with intact cognition expressed inconvenience with the specified site. The administrator acknowledged the non-compliance and confirmed that all residents were offered the current agreement.
An LPN failed to follow proper infection control procedures during wound care for a resident with fragile skin and impaired mobility. The LPN did not change gloves or wash hands between handling dirty and clean surfaces, contrary to the facility's policy. The DON confirmed the lapse in protocol.
Failure to Include Service Costs on Beneficiary Notices
Penalty
Summary
The facility failed to ensure that the estimated costs of services were included on the CMS-10055 forms for three residents reviewed for beneficiary notifications. The forms, which are intended to inform residents of their potential liability for services not covered by Medicare, were missing the section that specifies the cost of skilled services. This omission was identified during a review of the forms signed by the residents, where it was noted that the cost section was left blank. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed a lack of awareness regarding the requirement to include service costs on the CMS-10055 forms. The MDS Coordinator, who was new to filling out these forms, was unaware of the need to specify costs and did not know if there was a facility policy for completing beneficiary notices. The DON confirmed that the purpose of the form is to inform residents of their rights to appeal non-coverage and the costs of services, acknowledging that the omission of cost information could impact residents' decision-making.
Failure to Include Tracheostomy Self-Care in Resident's Care Plan
Penalty
Summary
The facility failed to ensure that a care plan intervention for tracheostomy self-care was included for a resident with a tracheostomy. On April 7, 2025, the resident was observed with a tracheostomy, and a review of their treatment administration record from March 1 to March 31, 2025, indicated a diagnosis of malignant neoplasm of the lung. However, the resident's care plan did not address self-care for their tracheostomy. On April 8, 2025, the MDS coordinator confirmed that the self-care aspect should have been included in the care plan. The DON also acknowledged that the resident's self-care for their tracheostomy should have been care planned.
Non-compliant Arbitration Agreement Venue Requirement
Penalty
Summary
The facility failed to ensure that its binding arbitration agreement did not mandate mediation to be held in a specific county, which is a violation of federal regulations. The arbitration agreement required mediation to occur in Tulsa County, Oklahoma, without allowing for mutual agreement on the venue. This was identified during a review of the facility's documents and interviews with staff and residents. The facility's policy stated that residents should have the opportunity to suggest an arbitrator and venue, and any disagreement by the facility should be documented. However, the agreement in question did not adhere to this policy, as it predetermined the location for mediation. A resident with an intact cognition, as indicated by a BIMS score of 15, was shown the arbitration agreement they had signed. The resident did not recall signing the agreement and expressed that the specified mediation site would not be convenient for them. The facility's administrator acknowledged that the agreement's requirement for mediation to occur in Tulsa County did not comply with federal regulations and agreed that the venue should be mutually agreed upon by both parties. The administrator also confirmed that all residents were offered the opportunity to sign the current binding arbitration agreement.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during wound care for a resident. On April 9, 2025, an LPN was observed performing wound care on a resident with diagnoses including congestive heart failure and pulmonary edema. The LPN donned a gown, mask, and gloves, and proceeded to clean the resident's wounds on both lower extremities. However, the LPN did not change gloves or wash hands after disposing of the used gauze, which is contrary to the facility's wound care policy that requires handwashing and glove changes between handling dirty and clean surfaces. The resident's care plan indicated potential or actual impairment to skin integrity due to fragile skin and impaired mobility. Despite the physician's order to cleanse the right lower extremity and apply specific dressings, the LPN failed to adhere to proper infection control practices. The Director of Nursing acknowledged that the LPN should have changed gloves and washed hands between handling dirty and clean surfaces during wound care.
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 5 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stilwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sequoyah Pointe Skilled Nursing And Therapy | 19.7 mi | ★★★★★ | 0 | 0 |
| Cherokee County Nursing Center | 20 mi | ★★★★★ | 0 | 0 |
| University Park Skilled Nursing And Therapy Memory | 20.6 mi | ★★★★★ | 0 | 0 |
| Prairie Grove Health And Rehabilitation, Llc | 20.9 mi | ★★★★★ | 5 | 0 |
| Sequoyah Manor, Llc | 25.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.