Stillwater Skilled Nursing And Rehabilitation
STILLWATER SKILLED NURSING AND REHABILITATION in COVINGTON, OH — inspection on February 23, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the observed drug screen completed on 02/05/26 revealed LPN #89 tested
verified that she found the alterations int he narcotic packaging. DON #100 verified that LPN #89 confessed to diverting the narcotic medication.
All residents were assessed with no concerns found.
All residents had their medications replaced. DON #100 confirmed four (#18, #31, #50 and #78) residents were affected by the misappropriation.
Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021, revealed residents have a right to be free from abuse, neglect, misappropriation and exploitation.
The deficient practice was corrected on 02/05/25 when the facility implemented the following corrective actions: On 02/05/26 at from 7:43 A.M., DON #100 identified packages of narcotics with impaired package integrity. On 02/05/26 from 7:45 A.M. to 9:00 A.M. a full narcotic audit of all medication carts was conducted. 11 Oxycodone 5 mg cards for 5 residents with a total of 42 unstamped white pills were found in place of the oxycodone. On 02/05/26 between 9:00 A.M. and 7:00 P.M. drug testing of all nursing staff was completed. On 02/05/26 at 10:22 A.M the Medical Director, Chief Medical Director, Nurse Practitioner and Pharmacist were notified. On 02/05/26 at 10:56 A.M. the facility notified law enforcement and State Survey Agency of suspected drug diversion. On 02/05/26 at 11:00 A.M. DON #100 and Pharmacy Consultant completed the following audits: all current narcotics sheets, Electronic Medication Administration Records, Pyxis/Omnicell reports, shift-to-shift count documents, and waste documents. No additional discrepancies were found. On 02/05/26 at 11:00 A.M. the facility provided the following education to all staff: controlled substance handling, narcotic procedures, waste witnessing requirements, reporting discrepancies immediately, abuse/neglect and misappropriation policy. On 02/05/26 at 12:27 P.M. the facility had a QAPI meeting regarding narcotic discrepancy and abatement plan. On 02/05/26 at 7:40 P.M. the facility notified Ohio Board of Nursing suspected drug diversion. On 02/05/26 Social Services Director interviewed all cognitively intact residents.
All residents denied concerns about receiving proper medication or knowledge of misappropriation. On 02/05/26 DON #100 interviewed all cognitively intact residents.
All residents denied unmanaged pain or inadequate pain control. On 02/05/26 DON #100 assessed all cognitively impaired residents for presence of pain.
All residents presented absent of abnormal findings. On 02/05/26 DON #100 began daily audits of medication storage and narcotic sheets.
This deficiency represents non-compliance investigated under Complaint Number 2744451.