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.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.