STILWELL NURSING AND REHAB

509 W LOCUST ST, STILWELL, OK 74960 (918) 696-7715
For profit - Limited Liability company 120 Beds Independent Data: November 2025
Trust Grade
70/100
#74 of 282 in OK
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Last Inspection: April 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Stilwell Nursing and Rehab has a Trust Grade of B, indicating it is a good choice among nursing homes, suggesting a solid level of care. It ranks #74 out of 282 facilities in Oklahoma, placing it in the top half, and it is the only nursing home in Adair County, making it the local option. The facility is improving, with issues decreasing from 11 in 2023 to just 4 in 2025. Staffing is average, rated 3 out of 5 stars, with a turnover rate of 39%, which is better than the Oklahoma average of 55%. Notably, there have been no fines, which is a positive sign regarding compliance. However, there are some concerns. For example, one incident involved a resident not receiving their prescribed insulin according to their doctor’s orders, which could be harmful. Additionally, the facility failed to follow the menu for meals, causing inconsistencies in what residents were served. While there are strengths, such as no fines and a good Trust Grade, families should be aware of these specific issues when considering this facility for their loved ones.

Trust Score
B
70/100
In Oklahoma
#74/282
Top 26%
Safety Record
Low Risk
No red flags
Inspections
Getting Better
11 → 4 violations
Staff Stability
○ Average
39% turnover. Near Oklahoma's 48% average. Typical for the industry.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Oklahoma facilities.
Skilled Nurses
⚠ Watch
Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for Oklahoma. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
24 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 11 issues
2025: 4 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (39%)

    9 points below Oklahoma average of 48%

Facility shows strength in fire safety.

The Bad

Staff Turnover: 39%

Near Oklahoma avg (46%)

Typical for the industry

The Ugly 24 deficiencies on record

Apr 2025 4 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to ensure there was a care plan intervention for tracheostomy self care for 1 (#60) of 1 sampled resident whose care plan was re...

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Based on observation, record review, and interview, the facility failed to ensure there was a care plan intervention for tracheostomy self care for 1 (#60) of 1 sampled resident whose care plan was reviewed. The DON reported one resident with a tracheostomy resided at the facility. Findings: On 04/07/25 at 12:18 p.m., Resident #60 was observed to have a tracheostomy. A treatment administration record, dated 03/01/25 through 03/31/25, showed Resident #60 had diagnoses which included malignant neoplasm of the lung. Resident #60's care plan was reviewed. The care plan did not include self care for their tracheostomy. On 04/08/25 at 2:55 p.m., MDS coordinator #2 reviewed Resident #60's care plan. They stated Resident #60's self care of their tracheostomy was not care planned. They stated self care should have been added to their care plan. On 04/08/25 at 3:15 p.m., the DON stated Resident #60 performing self care for their tracheostomy should have been care planned.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0848 (Tag F0848)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a binding arbitration agreement did not require mediation be...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a binding arbitration agreement did not require mediation be held in a specific county of the state of Oklahoma for 1 (#45) of 3 sampled residents reviewed for binding arbitration agreements. The DON stated 76 residents at the facility were offered the opportunity to sign the facility's arbitration agreement. Findings: An undated facility document titled Mediation and Arbitration Agreement, read in part, It is understood and agreed by [blank line for resident's name] ('Resident' or 'Resident Authorized Representative') that in the event of any legal dispute, controversy, demand or claim that arises out of or related to the admission Agreement or any service or health care provided by [NAME] Nursing Home (the 'Facility') to the Resident, such shall first be submitted to mediation, and not a lawsuit or resort to court process. Such mediation will be held in Tulsa County, Oklahoma in a place agreed to by the parties. A facility policy titled Binding Arbitration Agreements, dated November 2023, read in part, Residents (or representatives) are given the opportunity to suggest an arbitrator and a venue. If the facility disagrees with the resident's suggested arbitrator(s) and/or venue, the facility will document the reason and provide that documentation to the resident (or representative).Arbitration agreements provide for the selection of venue that is convenient to and suitably meets the needs of both parties. When selecting a venue for consideration, convenience for the resident (or representative) (sic) may be determined by his or her ability to get to the venue. An admission assessment for Res #45, dated 03/05/25, showed in Section C the resident had a BIMS score of 15 which indicated their cognition was intact. On 04/08/25 at 11:31 a.m., Res #45 was shown the binding arbitration agreement from their admission packet. They stated they had no recollection of signing the arbitration agreement, but agreed it was their signature. They stated they did not believe traveling to the required mediation site listed in the agreement would be convenient for them. On 04/09/25 at 08:20 a.m., the administrator was asked to review the facility's binding arbitration agreement and comment on any issues related to federal regulations. After looking at the arbitration agreement they stated the first paragraph mandated the arbitration occur in Tulsa County, Oklahoma and that did not meet the requirements. They stated they agreed the place for arbitration would be agreed upon by both parties. They stated they would have the part about arbitration being required to occur in Tulsa County removed from the current agreement. The administrator stated every resident was offered the opportunity to sign the current binding arbitration agreement.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of infections for 1 (#40) of 3 sampled ...

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Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program to help prevent the transmission of infections for 1 (#40) of 3 sampled residents reviewed for wound care. The DON identified 12 residents received wound care. Findings: On 04/09/25 at 12:00 p.m., LPN #1 gathered supplies to complete wound care for the Res #40. LPN #1 donned a gown, mask, and a pair of gloves for the wound care. LPN #1 cleaned the resident's wounds to both lower extremities with wet gauze and disposed of the gauze in the trash container on the side of the treatment cart in the hall. LPN #1 did not change their gloves or wash their hands. LPN #1 applied calcium alginate (wound dressing) and a Kerlix (bandage roll) dressing to both lower legs and wrapped with Coban (a self-adherent wrap). LPN #1 removed their gown, mask, and gloves then placed them in a trash container on the side of the treatment cart in the hall. LPN #1 did not change their gloves or wash their hands during the wound care. A policy titled Wound Care, Revised October 2010, read in part, Wash and dry hands thoroughly .Put on exam gloves. Loosen tape and remove dressing .Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly .Put on gloves .Pour liquid solutions directly on gauze sponges on their papers .Remove dry gauze. Apply treatments as indicated .Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into soiled laundry container. Remove disposable gloves and discard them into designated container. Wash and dry your hands thoroughly. An undated diagnoses list showed Res #40 had diagnoses which included congestive heart failure and pulmonary edema. Res #40's care plan, dated 07/05/24, showed the resident had potential/actual impairment to skin integrity related to fragile skin and impaired mobility. Res #40's quarterly assessment, dated 01/20/25, showed the resident was moderately impaired for decision making with a brief interview for mental status 12. The assessment showed the resident did not have pressure ulcers. A physician order, dated 04/04/25, showed the staff was to cleanse the right lower extremity of Res #40 with wound cleaner, pat dry, apply calcium alginate to the wound bed, cover with Kerlix, and wrap with Coban daily. On 04/09/25 at 12:10 p.m., LPN #1 stated they should change gloves and wash their hands before the wound care and after wound care. On 04/09/25 at 12:20 p.m., the DON stated LPN #1 should have changed their gloves and washed their hands between dirty and clean surfaces with wound care.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected multiple residents

Based on record review and interview, the facility failed to ensure the estimated costs of services was included on form CMS-10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage)...

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Based on record review and interview, the facility failed to ensure the estimated costs of services was included on form CMS-10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage) for 3 (#37, 78, and #79) of 3 sampled residents reviewed for beneficiary notifications reviews. MDS Coordinator #1 stated there had been 28 discharges from Part A services in the past six months (09/01/24 through 04/01/25). Findings: A facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated September 2022, read in part, If the director of admissions or benefits coordinator believes (upon admission or during the resident's stay) that Medicare (Part A of the Fee for Service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s). 1. A document titled Form CMS-10055, dated 2024, showed Res #79 had signed the form on 10/28/24. The section of the document designated for the cost of skilled services the resident would be required to pay was blank. 2. A document titled Form CMS-10055, dated 2024, showed Res #78 had signed the form on 11/24/24. The section of the document designated for the cost of skilled services the resident would be required to pay was blank. 3. A document titled Form CMS-10055, dated 2024, showed Res #37's representative had signed the form on 01/29/25. The section of the document designated for the cost of skilled services the resident would be required to pay was blank. On 04/09/25 at 8:03 a.m., MDS coordinator #1 was asked the purpose for CMS form 10055. They stated it was to inform residents they were running out of Part A service coverage and to inform them of their rights to appeal the loss of coverage or to assume the costs themselves. They were asked to review the CMS-10055 forms for Residents #37, 78, and #79 and identify any missing information. They stated they did not see any. They were asked about the costs of services. They stated they were unaware of the need to put the costs of the services on the form. MDS Coordinator #1 stated they were still new at filling out the forms. They stated they were unaware if the facility had a policy and procedure for filling out the beneficiary notices. On 04/09/25 at 8:14 a.m., the DON stated the CMS-10055 purpose of the form was to inform residents of their rights to appeal the non-coverage and the type of services that would end along with their costs. After reviewing the CMS-10055 forms Res #39, 78, and Res #79 had signed, they stated the forms did not provide the cost of the skilled services. They stated the residents and their representatives needed that information to make their decision.
Dec 2023 11 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, it was determined the facility failed to ensure the code status was identified and correct for one (#40) of five resident whose code status was revi...

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Based on observation, record review, and interview, it was determined the facility failed to ensure the code status was identified and correct for one (#40) of five resident whose code status was reviewed. The administrator identified 74 residents who resided in the facility. Findings: Res #40 had diagnoses which included acute embolism and thrombosis or unspecified deep veins of left lower extremity, vascular dementia, Alzheimer's disease, and sarcopenia. On 06/07/23, a DNR was signed by the primary care physician. A significant change assessment, dated 06/09/23, documented the resident's cognitive skills were severely impaired and was dependent with ADLs. On 06/19/23, Res #40 was admitted to hospice. A physician order, dated 09/09/23, documented the resident's code status was DNR. On 12/11/23 at 10:55 a.m., an observation was made of a green sticker by resident's name on doorway, indicating the resident was a full code. On 12/13/23 at 2:30 p.m., CNA #3 stated the green sticker on the door meant the resident was a full code.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify OHCA of a new diagnoses of serious mental illness for two (#...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify OHCA of a new diagnoses of serious mental illness for two (#3 and #66) of three sampled residents whose PASARR records were reviewed. The DON identified 74 residents who residents in the facility. Findings: 1. Res #3 was admitted to the facility on [DATE] with diagnoses which included diabetes, atherosclerotic heart disease, hypertension, dementia, depression, and repeated falls. A PASARR I form, dated 01/09/23, documented the resident did not have a diagnosis of a serious mental illness. The EHR documented on 01/30/23 the resident received a diagnosis of major depressive disorder. On 12/13/23 at 3:04 p.m., the DON reviewed the resident's clinical record and stated a new diagnosis of serious mental illness was added to the resident's diagnoses list on 01/30/23. The DON stated a referral should have been made to the OHCA. 2. Res #66 was admitted on [DATE] with diagnoses which included depression and anxiety. A level I PASARR was completed on 04/26/23. On 08/28/23, Res #66 was diagnosed with bipolar disorder. There was no documentation OHCA was notified of Res #66's new diagnosis of bipolar disorder. On 12/14/23 at 8:00 a.m., the DON reported OHCA was not called when Res #66 was diagnosed with bipolar disorder and should have been.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify OHCA of a serious mental illness for one (#17) of three samp...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify OHCA of a serious mental illness for one (#17) of three sampled resident whose Level I PASARR was reviewed. The administrator identified 74 resident who resided in the facility. Findings: Res #17 was admitted on [DATE] with diagnoses which included dementia, schizophrenia, bipolar disorder, and Parkinson's. A Level I PASARR was completed on 12/12/23, and OHCA was notified of Res #17's diagnoses of dementia and Parkinson's. There was no documentation to show OHCA was notified of Res #17's diagnoses of schizophrenia and bipolar disorder. On 12/14/23 at 10:15 a.m., the DON reported Res #17's diagnoses of schizophrenia and bipolar should have been communicated to OHCA and were not.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to update a comprehensive care plan when a resident developed a urinary tract infection for one (#54) of one sampled resident who was reviewed...

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Based on record review and interview, the facility failed to update a comprehensive care plan when a resident developed a urinary tract infection for one (#54) of one sampled resident who was reviewed for an indwelling urinary catheter. The DON identified three residents who had an indwelling urinary catheter. Findings: Res #54 was admitted with an indwelling urinary catheter and had diagnoses which included neuromuscular dysfunction of the bladder and obstructive reflec uropathy. A review of the medical record showed Res #54 developed a urinary tract infection which was treated with antibiotics on the following dates: 07/14/23, 08/18/23, 09/22/23, and 09/28/23. The indwelling urinary catheter care plan for Res #54 did not address the resident's urinary tract infections. On 12/14/23 at 10:15 a.m., the DON reported the care plan should have been updated when Res #54 developed a urinary tract infection but it was not.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, the facility failed to keep a urinary drainage bag off the floor to prevent infection for one (#54) of one sampled resident who was reviewed for an ...

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Based on observation, record review, and interview, the facility failed to keep a urinary drainage bag off the floor to prevent infection for one (#54) of one sampled resident who was reviewed for an indwelling urinary catheter. The DON identified three residents who had indwelling urinary catheters. Findings: A Catheter Care, Urinary policy, last revised in September 2014, read in part, .Infection Control: .b. Be sure the catheter tubing and drainage bag are kept off the floor . Res #54 was admitted with an indwelling urinary catheter and diagnoses which included neuromuscular dysfunction of the bladder and obstructive reflux uropathy. On 12/11/23 at 11:45 a.m., Res #54's urinary drainage bag was on floor with the bedside table wheel on top of it. On 12/12/23 at 11:00 a.m., Res #54's urinary drainage bag was flat on floor underneath their bed. On 12/13/23 at 10:20 a.m., Res #54's urinary drainage bad was on the floor underneath bed. A progress note, dated 12/02/23 at 3:14 p.m., read in part, Foley catheter bag changed due to hole in the bag . A review of the medical record showed Res #54 developed a urinary tract infections, which was treated with antibiotics, on 07/14/23, 08/18/23, 09/22/23, and 09/28/23. On 12/13/23 at 10:25 a.m., Res #54 reported they tried to keep the drainage bag up off the floor but could not always lift the mattress to secure the drainage bag to the bed frame. Res #54 reported the staff did not consistently try to keep drainage bag up off the floor. On 12/14/23 at 10:15 a.m., the DON reported the staff should attempt to secure the drainage bag off the floor anytime it is on the floor to prevent infections.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

Based on observation and interview, the facility failed to post the required information related to staffing and retain daily staffing information for the past 18 months. The administrator identified ...

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Based on observation and interview, the facility failed to post the required information related to staffing and retain daily staffing information for the past 18 months. The administrator identified 74 residents who resided in the facility. Findings: On 12/11/23 at 10:30 a.m. and throughout the survey the staffing boards at both nursing stations did not include the facility name, census, and hours each employee worked. On 12/14/23 at 2:20 p.m., the DON reported they were not aware of the requirements regarding what information needed to be documented on the staffing board and did not retain the staffing information for 18 months.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Based on record review and interview, it was determined the facility failed to ensure residents did not receive psychotropic medication, unless for a specific diagnosed condition, for one (#48) of fiv...

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Based on record review and interview, it was determined the facility failed to ensure residents did not receive psychotropic medication, unless for a specific diagnosed condition, for one (#48) of five residents reviewed for unnecessary medication. The DON identified 17 residents who received psychotropic medication. Findings: Res #48 was admitted to the facility with diagnoses which included alcoholic cirrhosis of the liver, alcohol dependence with withdrawal, dementia, epilepsy, and hemiplegia and hemiparesis after non-traumatic intracranial hemorrhage. A physician order, dated 03/02/23, documented the resident was to receive Remeron (a antidepressant medication) 15 mg at bedtime for dementia. A physician order, dated 08/30/23, documented the resident was to receive Seroquel (a antipsychotic medication) 25 mg tablet with one 50 mg tablet totaling 75 mg three times a day for alcohol dependence with withdrawal and dementia. The quarterly assessment, dated 09/25/23, documented the resident was moderately impaired cognitively. The assessment documented the resident had a diagnosis of non-Alzheimer's dementia. The assessment did not document psychiatric/mood disorders for the resident. The assessment documented the resident received a antipsychotic and antidepressant medication seven times the last seven days. The care plan, dated 03/28/23, documented the resident used psychotropic medication related to behavior management. The staff were to educate the resident and/or family about risks, benefits, and the side effects of toxic symptoms. On 12/14/23 at 10:36 a.m., the DON stated the diagnoses identified for the use of the psychotropic medications was not appropriate.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Based on record review and interview, the facility failed to follow physician's orders for a diabetic for one (#17) of one sampled resident whose record was reviewed for insulin usage. The DON identif...

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Based on record review and interview, the facility failed to follow physician's orders for a diabetic for one (#17) of one sampled resident whose record was reviewed for insulin usage. The DON identified 24 residents who required insulin. Findings: Res #17 was admitted with diagnoses which included diabetes. A physician order, dated 04/11/23, read in part, Novolog Solution, inject as per sliding scale .for glucose over 450, recheck in 1 hour, if glucose is still above 401 call physician . The TAR for October 2023 was reviewed with the following findings: On 10/02/23 at 8:00 p.m., Res #17's blood sugar was 468. No documentation blood sugar was rechecked an hour later. On 10/03/23 at 6:00 a.m., Res #17's blood sugar was 571. No documentation blood sugar was rechecked an hour later. On 10/09/23 at 4:00 p.m., Res #17's blood sugar was 571. No documentation blood sugar was rechecked an hour later. On 10/10/23 at 11:00 a.m., Res #17's blood sugar was 500. No documentation blood sugar was rechecked an hour later. On 10/15/23 at 8:00 p.m., Res #17's blood sugar was 454. No documentation blood sugar was rechecked an hour later. On 10/29/23 at 8:00 p.m., Res #17's blood sugar was 470. No documentation blood sugar was rechecked an hour later. On 10/31/23 at 8:00 p.m., Res #17's blood sugar was 475. No documentation blood sugar was rechecked an hour later. The TAR for November 2023 was reviewed with the following findings: On 11/19/23 at 11:00 a.m., Res #17's blood sugar was 490. No documentation blood sugar was rechecked an hour later. On 11/22/23 at 4:00 p.m., Res #17's blood sugar was 524. No documentation blood sugar was rechecked an hour later. On 11/23/23 at 6:00 a.m., Res #17's blood sugar was 505. No documentation blood sugar was rechecked an hour later. On 12/13/23 at 10:40 a.m., the DON reported there was no documentation to show the nurses were rechecking Res #17's blood sugar as per physician's orders. The DON reported the physician's orders should have been followed and weren't.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

Based on record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week. The administrator identified 74 residents wh...

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Based on record review and interview the facility failed to ensure the services of an RN was available in the facility eight hours daily seven days a week. The administrator identified 74 residents who resided in the facility. Findings: A document titled, Time Care Report, documented an RN was not present in the building on the dates of 09/16/23 and 09/17/23 for the month of September. A document titled Time Care Report documented an RN was not present in the building on the dates of 10/08/23 for the month of October. A document titled Time Care Report documented an RN was not present in the building on the dates of 11/18/23, 11/19/23, 11/25/23, and 11/26/23 for the month of November. On 12/14/23 at 1:37 p.m., the DON stated they did have an RN in the facility every day for at least 8 hours per day. On 12/14/23 at 1:40 p.m., the administrator stated there was an RN in the facility every day. On 12/14/23 at 1:56 p.m., the BOM stated they were not aware that an RN was not here on certain days related to the corporate nurse never said anything about no RN coverage.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

2. On 12/13/23 at 1:24 p.m., a test tray was obtained as the last tray on Hall 6. The tray included black eyed peas with a temperature of 119 degrees; green beans at 111 degrees and did not taste seas...

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2. On 12/13/23 at 1:24 p.m., a test tray was obtained as the last tray on Hall 6. The tray included black eyed peas with a temperature of 119 degrees; green beans at 111 degrees and did not taste seasoned; pork chop at 98 degrees which tasted lukewarm to cool; a roll at 109 degrees; and ice cream. On 12/14/23 at 11:35 a.m., CNA #1 reported the food was cold all the time and the residents complained of cold food. On 12/14/23 at 11:36 a.m., the DA reported the residents always complained of cold food. On 12/14/23 at 11:38 a.m., the DM stated. they had tried everything they could to help keep the food warm or hot and it still got cold. They stated the residents complained of cold food. Based on observation, record review, and interview, the facility failed to ensure food was palatable and at an appetizing temperature. The administrator identified 74 residents resided in the facility. Findings: 1. On 12/12/23 at 11:45 a.m., Res #24 stated they ate meals in their room. The resident stated the food was usually cold. On 12/12/23 at 9:03 a.m., Res #51 stated they ate in the dining room sometimes and sometimes in their room. The resident stated the food was always cold.
CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation and interview the facility failed to ensure trash cans were clean and in working order. The DON identified 73 residents who receive meals from the kitchen. Findings: On 12/11/23...

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Based on observation and interview the facility failed to ensure trash cans were clean and in working order. The DON identified 73 residents who receive meals from the kitchen. Findings: On 12/11/23 at 9:30 a.m., there were three sensor trash cans in the kitchen. None of the trash cans were working and did not have foot pedals. All three trash can lids were covered with dried liquid, brown stains, and food debris. On 12/11/23 at 9:45, the DM reported the batteries in the trash cans were low and needed to be replaced. The DM reported the staff would have to raise the trash can lid with their hands to dispose of trash. The DM reported the trash cans were supposed to be cleaned on the weekend but they were not. On 12/13/23 at 11:45 a.m., the trash can beside the handwashing sink was covered in dried liquid and had food substances/debris on the outside lid, underneath the lid, and around the inside rim of the trash can. On 12/13/23 at 12:00 p.m., the DM reported the trash can beside the handwashing sink was not clean.
Aug 2022 9 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

Based on record review and interview, it was determined the facility failed to provide residents with beneficiary notices for one (#20) of three sampled residents for beneficiary notices. The Discharg...

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Based on record review and interview, it was determined the facility failed to provide residents with beneficiary notices for one (#20) of three sampled residents for beneficiary notices. The Discharge Summary Report documented 39 residents had been discharged in the past six months. Findings: A SNF Beneficiary Protection Notification Review for Res #20, dated 03/11/22 read in parts, .Medicare Part A Skilled Services Episode Start Date: 02/01/22 .Last covered day of Part A Services 03/11/22 .The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted The document showed Res #20 was neither provided a SNF ABN, nor a NOMNC. The document did not contain explanation why the forms were not provided. On 08/02/22 at 1:45 p.m., MDS #2 reported Res #20 had not been provided a beneficiary notice.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notice of discharge for one (#63) resident of 39 re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide written notice of discharge for one (#63) resident of 39 residents reviewed for discharge notices. The Discharge Summary Report documented 39 residents had been discharged from the facility in the past six months. Findings: Res #63 was admitted on [DATE] with diagnoses which included diabetes mellitus. A Discharge Summary, dated 06/17/22 documented Res #63 was discharged to acute care on 05/08/22. On 08/04/22 at 8:32 a.m., the DON reported the facility had not provided written notice of Res #63's discharge to the resident's representative, or the ombudsman. She further stated she was unaware of the requirement to provide written notice for transferred or discharged residents. On 08/04/22 at 8:40 a.m., the administrator reported he was unaware of the requirement to provide written notice for transferred or discharged residents. .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to properly document a fall on the resident assessment for one (#16) o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to properly document a fall on the resident assessment for one (#16) of one residents reviewed for falls. The DON reported the facility had 79 residents with falls since 01/22. Findings: A nursing note, dated 01/26/22 documented a fall for Res #16 resulting in four skin tears. A quarterly assessment dated [DATE] did not document the fall on 01/26/22. On 08/02/22 at 3:30 p.m., the MDS Coordinator #1 reported the fall should have been documented on the resident assessment. The MDS Coordinator reported she had not received formal training regarding resident assessments.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#65) of two resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#65) of two residents reviewed for discharge summaries. The Resident Census and Conditions of Residents documented 68 residents were in the facility. Findings: Resident #65 was admitted to the facility on [DATE] and was discharged from the facility on 06/08/22. There was no discharge nursing note or discharge summary in the medical record. On 08/03/22 at 4:15 p.m., the DON stated There should have been a nursing note and discharge summary. I didn't think about writing a discharge summary.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on record review and interview, the facility failed to coordinate care with hospice for one (#37) of one resident who was reviewed for hospice services and to follow physician's orders related t...

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Based on record review and interview, the facility failed to coordinate care with hospice for one (#37) of one resident who was reviewed for hospice services and to follow physician's orders related to diabetic care for two (#39 and #45) of four residents reviewed for diabetic care. The Resident Census and Conditions of Residents report, dated 08/01/22, documented there were seven residents with hospice services. The DON reported 16 residents who required diabetic care resided in the facility. Findings: #1. Res #37 was admitted to the facility on hospice services for congestive heart failure. There were no nursing or nurse aide visit notes in the hospice chart. 08/02/22 at 4:25 p.m., the DON reported she didn't have access to hospice nursing and aide visit notes. She wasn't aware there needed to be visit notes in the hospice chart, nor was she aware of what documentation was needed in the hospice chart. #2. Res #39 was admitted with diagnoses which included diabetes mellitus with ketoacidosis. An order dated 01/17/22, read in parts, If blood sugar is less than 70, call MD If blood sugar is greater than 499, call MD. The Insulin/FSBS Administration History form documented from May 2022 to July 2022, Res #39's blood sugar was out of parameters 13 times and there was no documentation of physician notification. An Insulin/FSBS Administration History form, dated 06/01/22, read in parts, .at 7:28 p.m. Blood sugar 503 . Comment: administer 12 units and recheck. There was no documentation the blood sugar was rechecked. A nursing note, dated 07/07/22 at 6:54 a.m., read in parts, .CBG 45 this AM. This nurse held long-acting insulin. This nurse gave resident orange juice with sugar in it in hopes to bring it up. After about 10 minutes this nurse checked again while monitoring resident. CBG continued to be 45. This nurse gave resident another glass of OJ and rechecked CBG 5 minutes later and it was at 72 at that time. Will continue to monitor resident and meet needs . There was no documentation of physician notification for the out of parameter blood sugar. On 08/02/22 at 2:30 p.m., the DON reported the physician's orders should have been followed and the physician should have been notified of the out of parameter blood sugar results. #3. Res #45 was admitted with diagnoses which included diabetes mellitus. A physician's order dated 01/03/21, read in parts, .for sliding scale insulin .If blood sugar is greater than 400, give 10u. A physician's order dated 01/03/21, read in parts, .if administering 10u, wait 1 hour and recheck. If still high call MD. The Insulin/FSBS Administration History form documented from May 2022 to July 2022, Res #45's blood sugar was over 400 mg/dL (measurement for blood glucose level), 20 times. There was no documentation Res #39's blood sugar was rechecked. On 08/02/22 at 2:30 p.m., the DON reported the Res #45's blood sugar should have been rechecked and the physician notified if required.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to update a care plan regarding smoking for one (#14) of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to update a care plan regarding smoking for one (#14) of ten residents reviewed for care plans. The DON reported the facility had ten residents who smoked. Findings: Res #14 was admitted with diagnoses which included schizoaffective disorder. A care plan last revised on 06/15/22, documented in part .Smoking attendant to be in smoke room at all times when resident is present. An assessment dated [DATE], documented Res #14 was moderately impaired with cognition. A nurse's note, dated 07/29/22, documented in parts .This nurse was given in report that this resident had a blister to her finger from smoking .Staff to monitor resident when she is smoking. A physician's order, dated 07/29/22, read in part, BEHAVIORS - MONITOR FOR THE FOLLOWING: Resident has behaviors related to smoking such [sic] burning self. Document: .findings every day and night shift. A physician's order, dated 08/01/22, read in part, clean right second finger with wound cleanser and pat dry, apply ATB [sic] and cover with bandage every day shift until resolved. On 08/01/22 at 10:50 a.m., Res #14 was observed in the dining area with a bandage on their right second finger. On 08/02/22 at 8:25 a.m., Res #14 was observed in bed with a bandage on their right second finger. On 08/02/22 at 3:30 p.m., the DON reported Res #14's care plan should have been updated on 07/29/22 when the burn occurred, on 08/01/22 when orders were received for wound care, and on 08/02/22 when the Smoking Safety Assessment was done.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

Based on record review, observation, and interview, the facility failed to prevent injury by assessing smoking safety for one (#14) of ten residents reviewed for smoking safety. The DON identified ten...

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Based on record review, observation, and interview, the facility failed to prevent injury by assessing smoking safety for one (#14) of ten residents reviewed for smoking safety. The DON identified ten residents were smokers. Findings: A care plan, revised on 06/15/22, read in part, .Attendant to be with res when smoking . A nurse's note, dated 07/29/22, read in parts, .This nurse was given in report that this resident had a blister to her finger from smoking . Staff to monitor resident when she is smoking. A physician's order, dated 07/29/22, read in part, .BEHAVIORS - MONITOR FOR THE FOLLOWING: Resident has behaviors related to smoking such [sic] burning self. Document: .findings every day and night shift. A physician's order, dated 08/01/22, read in part, .clean right second finger with wound cleanser and pat dry, apply ATB [sic] and cover with bandage every day shift until resolved. An undated Smoking Policy - Resident, read in part, .A smoking risk assessment of a resident's cognitive ability, judgement, manual dexterity and mobility will be utilized to determine if a resident is deemed safe to smoke without supervision. The smoking risk assessment is done upon admission, annually, and more often if necessary. A Smoking Safety Screen, dated 08/02/22, read in parts, .had cognitive loss, smoked 5-10 cigarettes per day, in the morning, afternoon, and eve .Res cannot light own cigarette, res needs supervision, staff lights cigarette, facility needs to store lighter and cigarettes. all cigarette breaks are supervised by staff, safe to smoke with supervision. On 08/01/22 at 10:50 a.m., Res #14 was observed in the dining area with a bandage on their right second finger. On 08/02/22 at 8:25 a.m., Res #14 was observed in bed with a bandage on their right second finger. On 08/02/22 at 11:45 a.m., MDS coordinator #2 reported Res #14 had not had a Smoking Safety Screen completed prior to 08/02/22.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

Based on record review and interview, the facility failed to implement and maintain an antibiotic stewardship program. The Resident Census and Conditions of Residents form documented 68 residents res...

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Based on record review and interview, the facility failed to implement and maintain an antibiotic stewardship program. The Resident Census and Conditions of Residents form documented 68 residents resided in the facility. Findings: The Antibiotic Stewardship policy, revised 12/16, read in parts, .the IP will monitor over time and report .measures of antibiotic use .antibiotic susceptibility patterns .and negative outcomes or events related to antibiotic use . The Antibiotic Stewardship - Review and Surveillance of Antibiotic Use and Outcomes policy, revised 12/16, read in parts, .Antibiotic usage and outcome data will be collected and documented .The data will be used to guide decisions for improvement of .facility-wide antibiotic stewardship. The Infection Control Summary forms from 01/22 to 05/22 contained no documentation. On 08/03/22 at 10:47 a.m., Corp RN #1 reported the IP had collected data on antibiotic use and resident infections, but the data had not been trended. She reported the IP had not been provided training on how to apply the data. On 08/03/22 at 11:00 a.m., the IP reported she had collected data on antibiotic use and had not utilized the data.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Menu Adequacy (Tag F0803)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to follow the menu provided for one meal of five meals r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to follow the menu provided for one meal of five meals reviewed for menu accuracy. The Resident Census and Conditions of Residents form documented 67 residents ate meals from the menu. Findings: A Menu: [NAME] SS 2022 documented the evening meal for Sunday, 07/31/22, was garden vegetable soup, deli sandwich on bun, potato chips, sugar cookies and beverage of choice. On 07/31/22 at 4:30 p.m. meal trays were observed to contain baked macaroni and cheese with ham, buttered peas, and frosted gelatin poke cake. On 08/01/22 at 12:05 p.m. the RD reported the menu for 07/31/22 evening meal wasn't followed and should have been.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Oklahoma facilities.
  • • 39% turnover. Below Oklahoma's 48% average. Good staff retention means consistent care.
Concerns
  • • 24 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 70/100. Visit in person and ask pointed questions.

About This Facility

What is Stilwell Nursing And Rehab's CMS Rating?

CMS assigns STILWELL NURSING AND REHAB an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Oklahoma, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Stilwell Nursing And Rehab Staffed?

CMS rates STILWELL NURSING AND REHAB's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 39%, compared to the Oklahoma average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Stilwell Nursing And Rehab?

State health inspectors documented 24 deficiencies at STILWELL NURSING AND REHAB during 2022 to 2025. These included: 24 with potential for harm.

Who Owns and Operates Stilwell Nursing And Rehab?

STILWELL NURSING AND REHAB is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 120 certified beds and approximately 79 residents (about 66% occupancy), it is a mid-sized facility located in STILWELL, Oklahoma.

How Does Stilwell Nursing And Rehab Compare to Other Oklahoma Nursing Homes?

Compared to the 100 nursing homes in Oklahoma, STILWELL NURSING AND REHAB's overall rating (4 stars) is above the state average of 2.6, staff turnover (39%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Stilwell Nursing And Rehab?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Stilwell Nursing And Rehab Safe?

Based on CMS inspection data, STILWELL NURSING AND REHAB has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Oklahoma. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Stilwell Nursing And Rehab Stick Around?

STILWELL NURSING AND REHAB has a staff turnover rate of 39%, which is about average for Oklahoma nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Stilwell Nursing And Rehab Ever Fined?

STILWELL NURSING AND REHAB has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Stilwell Nursing And Rehab on Any Federal Watch List?

STILWELL NURSING AND REHAB is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

STILWELL NURSING AND REHAB

509 W LOCUST ST, STILWELL, OK 74960 | (918) 696-7715

B
Trust Grade (70/100)
4.0
CMS Rating
24
Deficiencies

Strengths

  • Licensed facility

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025