ElderGrade

Inspection citations at Stillwater Post-Acute

62 citations on record, 0 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 1 0
2025 23 0
2024 25 0
2022 13 0
D March 19, 2026 Tag F0656 Complaint investigation Corrected Apr 2026

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0919 Corrected May 2025

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0881 Corrected May 2025

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0761 Corrected May 2025

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0757 Corrected May 2025

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0755 Corrected May 2025

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0694 Corrected May 2025

Quality of Life and Care Deficiencies

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0692 Corrected May 2025

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0689 Corrected May 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0688 Corrected May 2025

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0687 Corrected May 2025

Quality of Life and Care Deficiencies

Provide appropriate foot care.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0679 Corrected May 2025

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0657 Corrected May 2025

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0655 Corrected May 2025

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0644 Corrected May 2025

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0584 Corrected May 2025

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

D April 18, 2025 Tag F0550 Corrected May 2025

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E April 18, 2025 Tag F0812 Corrected May 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E April 18, 2025 Tag F0804 Corrected May 2025

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

E April 18, 2025 Tag F0725 Corrected May 2025

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

No actual harm, potential for more than minimal harm

E April 18, 2025 Tag F0656 Corrected May 2025

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D April 3, 2025 Tag F0684 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D January 29, 2025 Tag F0689 Complaint investigation Corrected Feb 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D January 2, 2025 Tag F0921 Complaint investigation Corrected Jan 2025

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

No actual harm, potential for more than minimal harm

D December 27, 2024 Tag F0698 Complaint investigation Corrected Jan 2025

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D October 28, 2024 Tag F0690 Complaint investigation Corrected Nov 2024

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D July 3, 2024 Tag F0656 Complaint investigation Corrected Aug 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D April 26, 2024 Tag F0842 Corrected May 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D April 26, 2024 Tag F0806 Corrected May 2024

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

No actual harm, potential for more than minimal harm

D April 26, 2024 Tag F0698 Corrected May 2024

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

D April 26, 2024 Tag F0697 Corrected May 2024

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

D April 26, 2024 Tag F0689 Corrected May 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D April 26, 2024 Tag F0685 Corrected May 2024

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

No actual harm, potential for more than minimal harm

D April 26, 2024 Tag F0609 Corrected May 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

E April 26, 2024 Tag F0880 Corrected May 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E April 26, 2024 Tag F0804 Corrected May 2024

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

E April 26, 2024 Tag F0803 Corrected May 2024

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

No actual harm, potential for more than minimal harm

E April 26, 2024 Tag F0699 Corrected May 2024

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

No actual harm, potential for more than minimal harm

E April 26, 2024 Tag F0695 Corrected May 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

E April 26, 2024 Tag F0677 Corrected May 2024

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.