Federal inspectors found Stillwater Post-Acute failed to follow basic care requirements for multiple residents during an April inspection, documenting violations that put vulnerable patients at risk for depression, infection, and medical complications.
Resident 141, who has diabetes and peripheral vascular disease, told inspectors on April 15 that he had been "on a list to see the podiatrist for months." When inspectors observed his feet, they found long, thick toenails approximately a quarter-inch in length, along with dry, cracked skin.
His doctor had ordered podiatry visits every two months starting in February 2024. The last time he actually saw the podiatrist was September 5, 2024.
"Yeah, that's bad and [Resident 141] should have been seen immediately," Assistant Director of Nursing 66 told inspectors after examining the resident's feet herself.
The breakdown occurred at multiple levels. Certified nursing assistants knew they couldn't cut residents' toenails and were supposed to report long nails to nurses. Nurses were supposed to contact the social worker to schedule podiatry visits. But Social Worker 65 admitted she wasn't aware Resident 141 had an order to be seen every two months and didn't have him on the rolling schedule for the podiatrist.
"Resident 141 should have been seen regularly as his orders indicated," the social worker told inspectors.
For diabetic patients like Resident 141, proper foot care prevents serious complications including infections and amputations. The facility's own policy states that residents with foot disorders or medical conditions associated with foot complications should be referred to qualified professionals.
Director of Nursing acknowledged that "Resident 141's order for podiatry care every two months should have been followed and implemented."
Meanwhile, Resident 67 lay in bed staring blankly at the ceiling for days without receiving the activities prescribed in her care plan. The 67-year-old woman has dementia and a history of adult failure to thrive, conditions that make social engagement crucial for preventing further decline.
Her care plan, initiated in April 2024, specifically called for one-on-one room visits three times per week to reduce behavioral and psychological symptoms of dementia.
Inspectors observed her on five separate occasions between April 15 and April 18. Each time, she was in bed wearing a facility gown, either asleep or staring blankly at the ceiling without speaking.
Activity records showed the facility consistently failed to meet her care plan requirements. During the last week of January 2025, she received no activities at all. The entire month of February passed without a single documented activity. In March, she received activities on only five days out of 31.
Activities Director told inspectors that Resident 67 "liked music and would sing with her" during music activities. She also enjoyed lotion massages, listening to radio, and balloon toss. But the director admitted she was aware the resident wasn't getting activities three times a week and blamed her own absence for audits and evaluations.
"If Resident 67 did not engage with activities according to his plan of care, Resident 67 could have declined and became more depressed and lonelier," the activities director said.
The Director of Nursing agreed that dependent residents like Resident 67 should be visited regularly per their care plan "because it was their right to participate with activities." She acknowledged that not engaging with activities according to the care plan "could have caused depression that did not promote their highest physical, mental and psychosocial well-being."
The facility's own policy requires staff to review activity records regularly to determine changes in resident participation that might indicate declining condition and lead to care plan reviews.
A third violation involved Resident 183, a stroke patient on long-term antibiotics who lacked a specific care plan for medication monitoring. Both the Director of Nursing and Infection Preventionist acknowledged the oversight during interviews with inspectors.
"Care plans drive the resident care, they should be resident specific," the Director of Nursing told inspectors. "If it [a resident's care plan] is not specific, the resident might not get the appropriate care."
The Infection Preventionist confirmed that Resident 183 "has been on this medication since admission" but agreed that "the care plan is not specific to this medication. It should be."
These violations occurred despite the facility's own policies emphasizing individualized, person-centered care plans designed to prevent or reduce decline in residents' functional status.
For Resident 67, the consequences of missed activities compound over time. Dementia patients who lack regular engagement face accelerated cognitive decline, increased agitation, and social withdrawal. For Resident 141, delayed foot care could lead to infections, ulcers, or worse complications common in diabetic patients.
The Activities Director planned to train an assistant to help when she was unavailable, acknowledging that Resident 67 "should try and have more social events." But for the months of isolation already endured, no remedy can restore the lost opportunities for engagement and human connection.
Resident 141 continues waiting for the podiatry care his doctor ordered eight months ago.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stillwater Post-acute from 2025-04-18 including all violations, facility responses, and corrective action plans.