Stillwater Health Care

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired medications were removed from the available for use supply, for 2 of 3 Medication Storage Areas reviewed (A Wing Treatment Cart and B Wing Treatment Cart).

Inspectors wroteBased on observations and interviews the facility failed to ensure the kitchen was maintained in a clean manner on 2 of 3 days of survey (2/24/26 and 2/25/26), the facility failed to ensure that dented cans were removed from use and the facility failed to discard expired products in the reach-in refrigerator and the walk in refrigerator located in the kitchen that were available for use on 1 of 3 days of survey (2/24/26)

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that clinical record(s) contained complete and accurate information for 6 of 10 sampled residents reviewed on survey (Resident #7 [R7], R8, R51, R2, R36, and R17).

Inspectors wroteBased on facility policy review, record review, and interviews, the facility failed to ensure allegations of abuse and neglect was investigated for 1 of 4 complaints reviewed.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that a physician ordered medication was available for use to meet the needs for 1 of 4 residents observed during medication administration pass (Resident #64 [R64]).

Inspectors wroteBased on review of the facility Infection Control Program (ICP) and interview, the facility failed to complete an annual review of the ICP and update/revise the program if needed for 1 of 1 ICP.

Inspectors wroteBased on employee record reviews and interviews, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on dementia management by failing to ensure that 1 of 5 Certified Nursing Assistant (CNA) staff employed completed their required training (CNA3).

Inspectors wroteBased on record reviews and interviews, the facility failed to notify (at least monthly) the Ombudsman office of transfer/discharges for 1 of 1 resident reviewed for discharge (Resident #63 [R63]), and the facility failed to issue a written transfer/bed hold notice to a resident and their legal representative for a facility-initiated transfer/discharge for 1 of 1 resident reviewed for hospitalization (R61).

Inspectors wroteBased on record reviews and interviews, the facility failed to provide resident/resident representative's with a summary of their baseline care plan for 3 of 4 residents reviewed for baseline care plans (Resident #3 [R3], R5, R61).

Inspectors wroteBased on record review and interviews, the facility failed to provide interventions outlined in the resident's care plan to ensure that two-person assist was provided during activities of daily living (ADL) for 1 of 2 sampled residents (Resident #12 [R12]), reviewed for falls. The failure to have supervision (two-person assist) as directed by the care plan resulted in an avoidable accident; R12 falling out of bed during evening ADL care, requiring transfer to the emergency room [ER] with admission to the hospital, sustaining a laceration to the head, and rib fractures with increased pain. In addition, based on record review, and interview, the facility failed to adequately supervise a fall risk resident for 1 of 2 sampled residents (R30), reviewed for falls.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a comfortable air temperature for 3 of 4 days of survey.

Inspectors wroteBased on record review, review of the facility's 'Fall Policy and Procedure' and interview, the facility failed to re-evaluate fall interventions and the relevance of the current fall interventions for 1 of 2 sampled residents (Resident #30 [R30]) reviewed for 7 falls within 8 months timeframe.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain oxygen filled tanks while in use, failed to maintain a physician ordered oxygen setting on an air concentrator, and failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 3 of 4 residents reviewed for respiratory care (Resident #10 [R10], R15 and R1).

Inspectors wroteBased on record review and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility. This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's).

Inspectors wroteBased on observations and interviews, the facility failed to ensure the proper storage and labeling of foods in the walk-in refrigerator located in the kitchen, failed to ensure a vegetable sink had the proper air gap and failed to ensure kitchen staff properly wore hairnets by leaving hair uncovered and unrestrained for 2 of 4 days of survey (1/13/25, 1/15/25).

Inspectors wroteBased on the observations, facility policy reviews, and interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and during two medication administration observations and for a Resident on Enhanced Barrier Precautions (Resident #25 [R25] on 2 of 4 days of survey (1/14/25 and 1/15/25).

Inspectors wroteBased on employee record reviews and interviews, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, and on dementia management by failing to ensure that 5 of 5 Certified Nursing Assistant (CNA) staff employed completed their required training (CNA1, CNA2, CNA4, CNA5, and CNA6).

Inspectors wroteBased on observations and interview, the facility failed to post the nurse staffing information in an area visible to residents for 4 of 4 days of survey (1/13/25, 1/14/25, 1/15/25, and 1/16/25).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that a resident's record contained the Power of Attorney paperwork, 2 months after admission, for 1 of 2 residents reviewed for Advance Directives (Resident #55 [R55]).

Inspectors wroteBased on interviews and facility policy review, the facility failed to ensure an alleged violation involving fall with major injury was thoroughly investigated for 1 of 2 facility reported incidents reviewed (Resident #1 (R1).

Inspectors wroteBased on record review and interview, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 2 residents reviewed for fall with major injury (Resident #1 (R1)).

Inspectors wroteBased on record review and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 22 of 31 treatment opportunities for Resident #1's treatment for Nitroglycerin ointment application.

Inspectors wroteBased on record review and interviews, the facility failed to ensure physician ordered medications with parameters to hold were followed for 1 of 1 residents reviewed with medication parameters (Resident [R]1). Findings; 1. On 3/26/24, R1's clinical record was reviewed and included a physician order, dated 2/28/24, for scheduled Acetaminophen, 325 milligrams (mg) tablets x 3 tablets (975 mg) to be administered at 6:00 a.m., 2:00 p.m., and 10:00 p.m. The clinical record also included an as needed (PRN) order for Acetaminophen, dated 2/27/24, 500 mg every 4 hours as needed for pain/fever, with parameters not to exceed 3 grams (3000 milligrams) in a 24 hour period. A review of the Medication Administration Record indicated at on 3/10/24 at 10:00 p.m., R1 received 975 mg of Acetaminophen; on 3/11/24, R1 received 975 mg of Acetaminophen at 6:00 a.m. and 2:00 p.m. and 500 mg at 8:43 a.m. [...]

Inspectors wroteBased on clinical record reviews, review of the electronic Medication Administration Record (eMAR) and interviews, the facility failed to ensure physician orders were followed for 2 of 5 sampled residents for unnecessary medications (Resident #152 (R152) and R11)).

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to follow their own policy in obtaining a resident's Pneumococcal vaccination status and providing a vaccination if needed, for 1 of 5 residents reviewed for immunizations Resident #18 (R 18).

Inspectors wroteBased on review of annual evaluations and interviews, the facility failed to complete an annual performance evaluation for a nurse aide at least every 12 months, for 4 of 5 sampled Certified Nursing Assistants (CNA) employed greater than 1 year (CNA1, CNA2, CNA3, CNA4).

Inspectors wroteBased on observations and interview, the facility failed to post the nurse staffing information in an area visible to residents and visitors for 3 of 3 days of survey.