Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stillwater Assisted Living And Skilled Nursing Com during CMS and state inspections, most recent first.
A resident receiving IV Ertapenem had the order transcribed incorrectly as 1 gram instead of 500 mg, and the MAR showed the higher dose was administered for several days. Another resident with HF and CKD had a Bumetanide increase ordered for fluid overload, but the order was entered with a delayed start date and the resident missed 12 doses. The RN, physician, and DON/DNS acknowledged the transcription and administration errors.
Inaccurate medication transcription led to two residents not receiving ordered therapy as documented in the MAR. One resident with ESBL UTI received Ertapenem at 1 g IV daily instead of 500 mg IV daily, and another resident with HF and CKD missed multiple Bumetanide doses after the order was entered with the wrong start date. The RN and DON/DNS acknowledged the transcription errors.
A facility failed to maintain its infection prevention and control program when two residents were placed in the same room even though one resident had MRSA and was on contact precautions. Staff were unsure of the other resident’s MRSA status, the record did not show MRSA for that resident, and the DON later acknowledged the resident should not have been roomed with the MRSA-positive roommate.
The facility failed to provide required in-service training for staff related to the QAPI program and for a nurse aide’s annual competency training. Record review did not show evidence that two cooks, one NA, and one nurse aide completed the required training, and the Administrator could not provide proof of completion during interview.
Surveyors found that the facility did not follow physician orders for lab monitoring for two residents. One resident with a history of acute pulmonary edema had an order for periodic BNP testing, but the scheduled BNP was not completed as documented on the MAR or elsewhere in the record, despite the resident reporting ongoing leg swelling. Another resident with hypertension had a physician order for a repeat BMP in one week, but there was no evidence in the record that this lab was obtained as ordered. These omissions show that physician-directed lab tests were not carried out as required.
The facility failed to maintain proper food safety standards, with food items stored at incorrect temperatures and lacking a certified Food Safety Manager during meal preparations. Observations revealed food items like salads and sandwiches were not kept at the required cold holding temperatures, and a cook without the necessary certification was responsible for evening meals.
The facility breached residents' privacy by posting a resident's name and weight visibly at their room entrance and failing to close a privacy curtain during a wound dressing change for another resident. The incidents were confirmed by staff interviews and surveyor observations.
A facility failed to conduct necessary laboratory tests for a resident on Atorvastatin, despite a physician's order and pharmacist's recommendation for a lipid panel and hepatic function panel. The DON could not provide evidence that these tests were performed.
A resident readmitted with surgical wounds did not receive proper wound assessment or treatment upon re-admission. The facility's initial skin assessment lacked detailed wound descriptions, and no treatment orders were in place until two days later. Staff interviews confirmed the oversight in wound assessment and treatment inquiry.
A facility failed to follow professional standards for administering IV antibiotics via a PICC line for a resident with MRSA. The resident, receiving Vancomycin, did not have a physician's order for the required 10 ml saline flush before and after medication administration, as per facility policy. Both a nurse and the facility's pharmacist confirmed the absence of this order, highlighting a deficiency in adhering to established protocols.
The facility failed to ensure nursing staff had the necessary competencies to manage a PICC line for a resident with sepsis due to MRSA. Discrepancies in catheter length measurements were noted, with staff unable to accurately measure or explain the process. The Nursing Staff Educator expected staff to use the lines on the catheter for measurement, indicating a lack of competency in PICC line management.
The facility was found to have several deficiencies related to food storage and sanitation in the main kitchen and two kitchenettes. Issues included unlabeled and undated food items in the walk-in freezer, expired food in refrigerators, and improper labeling of food from external sources. Additionally, food-contact surfaces of equipment had encrusted grease and soil accumulations, and equipment such as a microwave contained dried food particles and debris. The facility also did not comply with the Rhode Island Food Code regarding the air gap requirement for the ice machine, posing potential food safety risks. These observations, along with record reviews and staff interviews, indicated systemic issues in maintaining professional standards for food service safety.
A resident with type 2 diabetes mellitus did not receive their prescribed insulin on multiple occasions, and there was no evidence of an order to hold the insulin or notification to the provider. Interviews confirmed the facility's failure to follow professional standards of practice.
A resident with pressure ulcers did not receive necessary treatment as per physician's orders. The resident had an unstageable pressure ulcer on the left posterior calf, which required daily dressing changes. However, the dressing changes were incorrectly scheduled for Monday, Wednesday, and Friday, leading to 9 missed dressing changes. The error was acknowledged by the Infection Preventionist and the Regional Infection Preventionist.
A resident with a history of traumatic subdural hemorrhage and Down syndrome experienced multiple falls due to the facility's failure to use a prescribed gait belt for transfers and ambulation. Despite clear instructions from the Rehabilitation Department, staff did not utilize the gait belt, leading to repeated falls and injuries.
A facility failed to provide appropriate care for a resident with a suprapubic catheter. The resident's drainage bag was repeatedly observed hung above the level of their bladder, contrary to facility policy. Staff acknowledged the improper positioning during interviews.
The facility failed to establish an IPCP that includes an antibiotic stewardship program with protocols and monitoring systems. Two residents were prescribed antibiotics without evidence of urine culture and sensitivity tests to confirm appropriateness. Interviews revealed a lack of processes for reviewing or obtaining necessary diagnostic tests.
Medication Orders Were Transcribed Incorrectly, Resulting in Wrong Dose and Missed Doses
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for two residents receiving ordered medications. One resident was readmitted with a diagnosis of a urinary tract infection with ESBL and had a hospital order for Ertapenem 500 mg IV daily for 8 days. The order was transcribed incorrectly as Ertapenem 1 gram IV daily, and the MAR showed the 1 gram dose was signed off as administered on three consecutive days, indicating the resident received double the ordered dose. An RN acknowledged that she transcribed the order incorrectly, and the DNS stated that the admission orders should have been reviewed by the nurse working with her to ensure accuracy. A second resident with diagnoses including heart failure and chronic kidney disease had a physician order to increase Bumetanide to 2 mg twice daily after being assessed for fluid volume overload, weight gain, and bilateral lower extremity edema. The order was incorrectly transcribed with a start date several days later, and the June and July MARs did not show the medication being initiated as ordered. The resident therefore missed 12 doses of Bumetanide. The physician stated he was unaware the resident had not received the medication since the order date and expected the new order to start the next day, and the DNS acknowledged the missed doses.
Inaccurate Medication Order Transcription and MAR Documentation
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for two residents who experienced significant medication errors. One resident was readmitted with a diagnosis of a urinary tract infection with ESBL and had a hospital Continuity of Care document dated 6/26/2026 that ordered Ertapenem 500 mg IV once daily for 8 days. The June 2026 MAR showed the order was transcribed incorrectly as 1 gram IV daily, and the resident received double the intended dose for three days. During interview, the RN acknowledged that she inaccurately transcribed the order, and the DNS also acknowledged the transcription error. A second resident, with diagnoses including heart failure and chronic kidney disease, had a physician order dated 6/22/2026 for Bumetanide 2 mg twice daily every Monday, Wednesday, and Friday through 6/26/2026. A provider progress note dated 6/26/2026 documented that the physician assessed the resident for fluid volume overload and heart failure symptoms and increased Bumetanide to 2 mg twice daily with a repeat BMP in one week. The June and July 2026 MARs showed the order was transcribed with a start date of 7/3/2026, resulting in missed doses on 6/27 through 7/2, for a total of 12 missed doses. The physician stated he expected the increased dose to start on 6/27/2026, and the DNS acknowledged the inaccurate transcription.
Improper Room Placement for Residents on Contact Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for residents on contact precautions. Resident #87 was admitted with diagnoses including vascular dementia and acute respiratory failure, was diagnosed with MRSA in the nares, and had physician orders for contact precautions requiring gowns and gloves upon room entry, along with a face mask and eye protection if splashes or sprays were anticipated. Resident #91 was readmitted with diagnoses including vascular dementia and urinary tract infection, and the census report showed that this resident was placed in the same room with Resident #87 upon readmission. During surveyor observation, Resident #91 was seen residing in the same room as Resident #87, and signage at the doorway indicated the room was under contact precautions. A registered nurse stated she was unsure whether Resident #91 had MRSA on readmission, while the clinical record did not show evidence that Resident #91 had a MRSA diagnosis. A progress note later documented that Resident #91's spouse was educated about exposure to a roommate with MRSA, that a room change was initiated, and that Resident #91 was placed on contact precautions due to exposure to the roommate with MRSA. The DON later stated that hospital paperwork had been interpreted as showing MRSA for Resident #91, but review of the hospital records failed to confirm MRSA on readmission, and the DON acknowledged that Resident #91 should not have been placed with Resident #87.
Missing Required Staff In-Service Training
Penalty
Summary
The facility failed to provide mandatory in-service training related to the QAPI program for 3 of 10 staff reviewed, including two cooks and one nursing assistant. Record review did not show evidence that Staff C, Staff D, and Staff E received QAPI training within the last year, and during interview the Administrator was unable to provide evidence that these staff members had completed the required training. The facility also failed to provide required in-service training for one nurse aide, Staff F, to ensure continuing competence, including the required annual 12 hours of training with dementia management and resident abuse prevention. Record review did not reveal evidence that Staff F completed any mandatory in-service training within the last year, and the Administrator was unable to provide evidence of completion during interview.
Failure to Follow Physician Orders for Laboratory Testing for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents received treatment and care in accordance with professional standards of practice by not following physician orders for laboratory testing. For one resident with a history of acute pulmonary edema and intact cognition, the physician ordered a Brain Natriuretic Peptide (BNP) test to be obtained every second Monday in February and August. The February Medication Administration Record showed the BNP was scheduled but not signed off as completed on the specified date, and further record review did not show evidence that the BNP was obtained as ordered. During an interview, the resident reported being given a fluid pill for leg swelling that had not helped, and the Assistant Director of Nursing Services acknowledged that the ordered BNP test was not completed. For a second resident admitted with hypertension, the physician documented a new order in a progress note for a repeat Basic Metabolic Panel (BMP) to be obtained in one week. Record review failed to show that this repeat BMP was completed within the ordered timeframe. In an interview, the Assistant Director of Nursing Services was unable to provide evidence that the repeat BMP had been obtained as ordered. These missed laboratory tests, despite clear physician orders, constitute the failure to provide care and services in accordance with professional standards of quality.
Food Safety and Certification Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by surveyor observations and staff interviews. During a lunch meal tray service, it was observed that certain food items, such as bean salad and turkey salad sandwiches, were not maintained at the required cold holding temperature of 41°F or below. Further inspection of the walk-in refrigerator revealed additional food items, including turkey salad and egg salad, also stored at temperatures above the required limit. The Food Service Director (FSD) and the cook acknowledged these discrepancies and discarded the improperly stored food items. A follow-up visit revealed a similar issue with chicken salad, which was also stored at an inappropriate temperature. Additionally, the facility did not ensure the presence of a certified food protection manager during all meal preparation times. The surveyor found that a cook responsible for preparing and serving evening meals did not possess the necessary Food Safety Manager certification. The kitchen staff schedule confirmed that this uncertified cook was the only one working during several evening meal services. The FSD was unable to provide evidence of a certified Food Safety Manager being present during these times, as required by the Rhode Island Food Code.
Privacy Breaches in Resident Care
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information, as evidenced by two separate incidents. In the first incident, a resident's name and weight were visibly posted at the entrance of their room, which was accessible to anyone passing by in the hallway. This was observed by surveyors on multiple occasions, and the Assistant Director of Nursing Services confirmed the visibility of the information during an interview. In the second incident, a registered nurse did not ensure privacy during a wound dressing change for a resident with a stage 3 pressure ulcer on the left heel. The nurse failed to close the privacy curtain between the resident and their roommate, leaving the resident exposed during the medical procedure. The Director of Nursing Services later stated that staff are expected to provide privacy for residents, indicating a lapse in adherence to the facility's privacy policy.
Failure to Monitor Atorvastatin Therapy with Required Lab Tests
Penalty
Summary
The facility failed to ensure that a resident receiving Atorvastatin, a medication prescribed to treat high cholesterol, received appropriate monitoring through laboratory tests as per professional standards of practice. A pharmacist recommended an annual lipid panel and hepatic function panel to monitor the therapeutic effects and potential side effects of Atorvastatin. The provider agreed to this recommendation, and a physician's order was issued to obtain these laboratory tests. However, a review of the records revealed no evidence that the lipid panel and hepatic function panel were conducted as ordered. During an interview, the Director of Nursing Services was unable to provide documentation that these tests were obtained.
Failure to Assess and Treat Resident's Surgical Wounds
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. The resident, who was readmitted to the facility with a history of a right ankle fracture and surgical wounds, did not have their wounds assessed or described in detail upon re-admission. The facility's Admission Skin assessment, completed by a registered nurse, did not include an assessment or description of the surgical wounds, and the admission nursing progress note failed to document any wound assessment or treatment implementation. Additionally, there was no evidence of a treatment order for the resident's right lower extremity wounds from the time of admission until two days later. The Director of Nursing Services later documented the presence of multiple wounds on the resident's right lower extremity and a pressure wound on the right heel. During interviews, staff acknowledged the failure to assess the wounds upon re-admission and the lack of inquiry about treatment orders, which contributed to the deficiency.
Failure to Follow PICC Line Protocol for IV Antibiotic Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of intravenous (IV) fluids for a resident receiving antibiotics via a peripherally inserted central catheter (PICC) line. The resident, admitted in March 2025 with a diagnosis of sepsis due to methicillin-resistant Staphylococcus aureus (MRSA), had a PICC line placed on March 6, 2025, and was receiving Vancomycin intravenously every 12 hours. However, the facility did not have a physician's order for a 10 ml saline flush before and after administering the Vancomycin, as required by the facility's pharmacy policy. During interviews, both a registered nurse and the facility's contracted pharmacist confirmed the absence of the necessary saline flush order. The pharmacist further indicated that a 10 ml saline flush should be administered before and after medication administration via the PICC line, as well as an additional flush on shifts when the antibiotic is not administered. This oversight in following the established protocol for PICC line maintenance and medication administration led to the identified deficiency.
Inadequate PICC Line Management by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets to manage a peripherally inserted central catheter (PICC) for a resident diagnosed with sepsis due to methicillin-resistant Staphylococcus aureus (MRSA). The resident was admitted with a PICC line, and discrepancies in the external catheter length measurements were noted. Initially, the external catheter length was recorded as 0 cm, but a subsequent measurement by RN Staff D during a dressing change showed an 8 cm length. Staff D later acknowledged an error in his initial measurement and admitted to not reviewing previous measurements before documenting the new one. Further interviews with other nursing staff, including RN Staff C and RN Staff A, revealed that they were unable to accurately explain how to measure the external catheter length of a PICC line. The Nursing Staff Educator, Staff E, indicated that the external portion of a PICC line has small lines for measurement, which staff are expected to use. This deficiency highlights a lack of competency among the nursing staff in managing PICC lines, which is critical for ensuring resident safety.
Food Storage and Sanitation Deficiencies Identified in Main Kitchen and Kitchenettes
Penalty
Summary
The facility failed to ensure that food was stored and distributed in accordance with professional standards for food service safety in the main kitchen and two kitchenettes observed. The deficiencies included unlabeled and undated food items in the walk-in freezer, expired food items in refrigerators, and improper labeling of food brought from external sources. Additionally, food-contact surfaces of equipment were found to have encrusted grease deposits and other soil accumulations, indicating a lack of proper cleaning and maintenance practices. The report also highlighted issues with the cleanliness of equipment, such as a microwave with dried food particles and debris. Furthermore, the facility was found to be non-compliant with the Rhode Island Food Code regarding the air gap requirement for the ice machine in the main kitchen. The absence of an adequate air gap and the overflowing drain posed potential risks to food safety and sanitation. The observations made during the survey, along with record reviews and staff interviews, revealed a pattern of deficiencies in food storage, labeling, cleanliness, and equipment maintenance across the main kitchen and kitchenettes, indicating a systemic failure in ensuring compliance with professional standards for food service safety.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Resident ID #65, who was admitted with diagnoses including type 2 diabetes mellitus and a urinary tract infection, had a care plan indicating an increased risk for hypo/hyperglycemia with an intervention to administer medication as ordered. However, the Medication Administration Report revealed that the resident's insulin was not administered on four specific dates between March and April 2024, without any evidence of an order to hold the insulin or notification to the provider. Interviews with the Nurse Practitioner and the Assistant Director of Nursing Services confirmed that the facility did not notify the provider or administer the insulin as per the physician's order.
Failure to Provide Necessary Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. The resident, who was readmitted in February 2024 with diagnoses including pressure-induced deep tissue damage and a Methicillin Resistant Staphylococcus Aureus infection, had a physician's order dated 3/26/2024 for daily dressing changes on an unstageable pressure ulcer on the left posterior calf. However, the Medication Administration Records for March and April 2024 indicated that the dressing changes were scheduled for Monday, Wednesday, and Friday instead of daily, resulting in 9 missed dressing changes. During an interview on 4/10/2024, the Infection Preventionist and the Regional Infection Preventionist acknowledged that the wound order was transcribed incorrectly.
Failure to Use Assistive Devices for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident received appropriate assistive devices to prevent accidents. The resident, who was admitted with diagnoses including traumatic subdural hemorrhage and Down syndrome, experienced multiple falls. These incidents occurred on various dates, including falls on 2/4/2024, 2/24/2024, 3/17/2024, and 3/23/2024. The resident's care plan included an order for safe patient handling, which required the use of a gait belt for transfers and ambulation. However, surveyor observations on 4/9/2024 revealed that staff did not use a gait belt during ambulation and transfers with the resident, despite this requirement being communicated in multiple ways by the Rehabilitation Department. Interviews with the Director of Rehabilitation and a Physical Therapist confirmed that the expectation was for staff to use a gait belt for all transfers and ambulation when assisting the resident. The Physical Therapist was unable to explain why the staff did not utilize the gait belt during the observed instances. This failure to use the prescribed assistive device contributed to the resident's repeated falls and subsequent injuries, including a readmission to the hospital for an acute subdural hematoma.
Improper Positioning of Suprapubic Catheter Drainage Bag
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a suprapubic catheter. The resident, admitted in February 2024 with diagnoses including obstructive and reflux uropathy and chronic kidney disease stage 3, was observed multiple times on 4/10/2024 with their drainage bag hung on the back of their wheelchair near their shoulders, above the level of their bladder. This was contrary to the facility's policy, which states that the drainage bag should be kept below the resident's waist/bladder. During interviews, both a registered nurse and the infection preventionists acknowledged that the drainage bag was improperly positioned and should be moved below the resident's waist/bladder.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. This deficiency was identified for two residents. Resident ID #124 was admitted with diagnoses including a urinary tract infection and vascular dementia. The resident was prescribed Macrobid, but there was no evidence of a urine culture and sensitivity test to determine if the antibiotic was appropriate. Similarly, Resident ID #129 was admitted with diagnoses including a urinary tract infection and cough and was prescribed cefuroxime axetil. Again, there was no evidence of a urine culture and sensitivity test to confirm the appropriateness of the antibiotic. Interviews with the Nurse Practitioner and Infection Preventionist revealed that the facility lacked a process for reviewing or obtaining laboratory or diagnostic testing to determine if the prescribed antibiotics were still indicated or if adjustments were needed. The Nurse Practitioner stated that staff should call the hospital for results or repeat cultures in-house if no sensitivities are available. The Infection Preventionist was unable to provide evidence of such a process, highlighting a gap in the facility's antibiotic stewardship program.
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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 Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenville Operations Ri Llc Dba Greenville Skille | 1.1 mi | ★★★★★ | 16 | 1 |
| Cedar Haven Operations Llc Dba Lake Forest Health | 2.4 mi | ★★★★★ | 20 | 2 |
| Heritage Hills Nursing & Rehabilitation Center | 4.4 mi | ★★★★★ | 7 | 0 |
| Lincolnwood Rehabilitation And Healthcare Center | 4.5 mi | ★★★★★ | 15 | 0 |
| Cherry Hill Manor | 4.7 mi | ★★★★★ | 7 | 0 |
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