Inspection·June 6, 2025

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based on medical record review, interviews with staff and Resident Representative, and facility policy review, the facility failed to ensure Resident Representative was notified of room change prior to a room change. This affected one resident (#54) out of the three residents reviewed for room change notification. The facility census was 55. Findings include: Review of the medical record for Resident #54 revealed an admission date of 10/19/23 with medical diagnoses of mild neurocognitive disorder due to known physiological condition with behavioral disturbances, degenerative disease of the nervous system, depression, dementia, and cerebral atherosclerosis. Review of the medical record for Resident #54 revealed a quarterly Minimum Data Set (MDS) assessment, dated 04/09/25, which indicated Resident #54 had moderate cognitive impairment and was dependent upon staff for all Activities of Daily Living (ADLs). Review of the medical record for Resident #54 revealed the resident had room moves on 01/01/25, 02/27/25 and on 04/14/25. Review of the medical record for Resident #54 revealed a nurses' note dated 02/28/25 which stated notified resident/family of room move. Review of the medical record revealed a late entry note on 06/06/25 at 12:48 P.M. for 01/01/25 at 12:46 P.M. which stated the resident was moved rooms due to bed reductions. The note stated Resident Representative aware of room moves and of bed reductions. Further review of the nurses' notes revealed a late entry note on 06/06/25 at 1:02 P.M. for 04/14/25 at 12:58 P.M. which stated the resident was moved from a rehab hall to a long-term private room where the resident would be more visible to staff to visualize due to the need for frequent checks and large space for family to visit. Discussed with Resident Representative in advance and in agreement with change. Physician Assistant was notified. Interview on 06/06/25 at 2:08 P.M. with Director of Nursing (DON) stated Resident #54's husband was aware of the room changes but the facility staff had not documented the room changes in the medical record until 06/06/25. DON confirmed the medical record for Resident #54 indicated on 02/28/25 that Resident #54's husband was notified of room change that occurred on 02/27/25. Interview on 06/06/25 at 2:53 P.M. with Resident #54's Representative stated the facility notified him of one of Resident #54's room changes but was not notified of the other recent room changes. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365483 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365483 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Stillwater Skilled Nursing and Rehabilitation 75 Mote Drive Covington, OH 45318 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)