Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 1 | 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 | — | 8 | 0 |
| Versailles Rehabilitation And Health Care Center | 10.3 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 August 2026) and official state health department websites.