Stillwater Post-Acute

CMS lists this as a complaint inspection.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on August 26, 2026.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on August 26, 2026.

  CMS has cited this home for F0656 5 times since 2024.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on April 11, 2026.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation K0111. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

  CMS lists it as corrected on February 16, 2026.

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CMS lists this as a standard inspection.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 11, 2025.

• Citation F0725. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 11, 2025.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on May 11, 2025.

  CMS has cited this home for F0804 3 times since 2022.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 11, 2025.

  CMS has cited this home for F0812 3 times since 2022.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on May 11, 2025.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 11, 2025.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on May 11, 2025.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on May 11, 2025.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on May 11, 2025.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on May 11, 2025.

• Citation F0687. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate foot care.

  CMS lists it as corrected on May 11, 2025.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 11, 2025.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 11, 2025.

  CMS has cited this home for F0689 4 times since 2024.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on May 11, 2025.

  CMS has cited this home for F0692 2 times since 2022.

• Citation F0694. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  CMS lists it as corrected on May 11, 2025.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on May 11, 2025.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on May 11, 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 11, 2025.

• Citation F0881. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on May 11, 2025.

  CMS has cited this home for F0881 2 times since 2022.

• Citation F0919. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on May 11, 2025.

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CMS lists this as a standard inspection.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on May 5, 2025.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on May 5, 2025.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on May 5, 2025.

  CMS has cited this home for K0353 2 times since 2024.

• Citation K0511. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on May 5, 2025.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on May 5, 2025.

• Citation K0345. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on May 5, 2025.

  CMS has cited this home for K0345 2 times since 2024.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on May 5, 2025.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on May 5, 2025.

  CMS has cited this home for K0363 3 times since 2022.

• Citation K0372. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on May 5, 2025.

• Citation K0741. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on May 5, 2025.

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CMS lists this as a complaint inspection.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on April 23, 2025.

  CMS has cited this home for F0684 3 times since 2022.

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• Changed ownership in the last 12 months

  CMS no longer shows a change of ownership in the past 12 months.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on February 20, 2025.

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CMS lists this as a complaint inspection.

• Citation F0921. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on January 3, 2025.

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CMS lists this as a complaint inspection.

• Citation F0698. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on January 24, 2025.

  CMS has cited this home for F0698 3 times since 2022.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on November 26, 2024.

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• Health citation

  CMS removed citation F0692 from the health inspection on April 26, 2024.

• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS lists this home under a new chain.

• Ownership

  CMS ownership records list new owners for this home.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on August 1, 2024.

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• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Changed ownership in the last 12 months

  CMS records show a change of ownership in the past 12 months.

CMS lists this as a standard inspection.

• Citation F0802. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

  CMS lists it as corrected on May 17, 2024.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on May 17, 2024.

• Citation F0558. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on May 17, 2024.

• Citation F0656. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on May 17, 2024.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on May 17, 2024.

  CMS has cited this home for F0677 2 times since 2024.

• Citation F0695. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on May 17, 2024.

• Citation F0699. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care or services that was trauma informed and/or culturally competent.

  CMS lists it as corrected on May 17, 2024.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 17, 2024.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on May 17, 2024.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on May 17, 2024.

  CMS has cited this home for F0880 4 times since 2022.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on May 17, 2024.

• Citation F0685. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.

  CMS lists it as corrected on May 17, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 17, 2024.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on May 17, 2024.

  CMS has cited this home for F0697 2 times since 2022.

• Citation F0698. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on May 17, 2024.

• Citation F0806. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on May 17, 2024.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on May 17, 2024.

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CMS lists this as a standard inspection.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on May 10, 2024.

• Citation K0345. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on May 10, 2024.

• Citation K0347. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly provide smoke detection systems in areas open to corridors.

  CMS lists it as corrected on May 10, 2024.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on May 10, 2024.

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CMS lists this as a complaint inspection.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on May 2, 2024.

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• Name

  CMS lists a new name for this home. It was AVOCADO POST ACUTE.

CMS lists this as a complaint inspection.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on March 27, 2024.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 27, 2024.

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• Star rating

  The CMS quality measures star rating changed from not rated by CMS to 1 of 5.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on February 17, 2024.

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CMS lists this as a complaint inspection.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on January 25, 2024.

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CMS lists this as a standard inspection.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

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

  CMS lists it as corrected on July 18, 2022.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on July 18, 2022.

• Citation F0636. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

  CMS lists it as corrected on July 18, 2022.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on July 18, 2022.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on July 18, 2022.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on July 18, 2022.

• Citation F0697. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate pain management for a resident who requires such services.

  CMS lists it as corrected on July 18, 2022.

• Citation F0698. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on July 18, 2022.

• Citation F0732. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on July 18, 2022.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on July 18, 2022.

• Citation F0804. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on July 18, 2022.

• Citation F0809. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

  CMS lists it as corrected on July 18, 2022.

• Citation F0881. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on July 18, 2022.

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CMS lists this as a standard inspection.

• Citation K0346. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  CMS lists it as corrected on July 18, 2022.

• Citation K0354. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  CMS lists it as corrected on July 18, 2022.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on July 18, 2022.

• Citation K0161. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on July 18, 2022.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on July 18, 2022.

• Citation K0521. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  CMS lists it as corrected on July 18, 2022.

• Citation K0912. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have power receptacles that are properly grounded.

  CMS lists it as corrected on July 18, 2022.

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