Good Samaritan Society - Stillwater: Pressure Ulcer Care Gaps - MN
Federal inspectors visiting Good Samaritan Society - Stillwater on February 9, 2026, found bilateral grab bars installed on the bed of a resident identified in records as R12, a woman with intact cognition, multiple sclerosis, and chronic kidney disease. She had significant weakness in both legs and needed substantial help moving in bed. She also had no idea, in any documented sense, that the bars had been formally assessed for her safety, explained to her in terms of their risks, or consented to by her in writing. None of that had happened.
When inspectors asked R12 about the bars that afternoon, she said she didn't actually use them and that she could reposition herself. Then she said what she said about the facility using them to keep residents in bed.
That comment sat alongside a care plan that told a more complicated story. The plan, dated January 12, 2026, said R12 could "use her bilateral assist bars to help with turning and repositioning" and that she could "roll side to side with extensive assist of one staff using grab/assist bars." A nursing assistant told inspectors on February 12 that R12 used the bars to help staff reposition her.
So the bars were in the care plan. Staff were using them. R12 had them on her bed. What didn't exist was the paperwork that was supposed to come first.
The facility's own policy, dated September 30, 2025, required that before grab bars are used, a physical device and restraint assessment be completed. R12's assessment form showed no indication that staff had tried other approaches before installing the bars, no documentation that anyone had walked R12 through the risks and benefits, no record of an entrapment risk evaluation, and no consent.
A licensed practical nurse told inspectors that nurses were responsible for completing those assessments and that it should be documented on the physical device form. A registered nurse said the same thing, then confirmed directly that R12's bars had never been assessed and should have been. The director of nursing, interviewed just before noon on February 12, said nurses were responsible for ensuring residents meet criteria for safe use, that provider collaboration and consent were required, and that documentation belonged on the physical device assessment. She called it important for resident safety.
The word "entrapment" is not bureaucratic filler. Gaps between bed rails and mattresses have trapped residents before, including residents whose bodies became wedged in ways that cut off breathing. The assessment process exists because the risk is real and specific to each person's body, mattress, and movement patterns. R12's assessment form was blank on all of it.
What makes this harder to dismiss is what R12 said she believed. She had intact cognition. She was aware the bars were there. She had formed her own theory about why. And nobody had sat with her, explained what the bars were for, gone through what could go wrong, and asked her whether she agreed to have them.
The facility had a policy. The nurses knew who was responsible. The director of nursing knew what the process required. The form existed. It just wasn't filled out, not for the one resident inspectors checked.
R12 could reposition herself, she said. She didn't use the bars. She thought they were there to keep her in.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society - Stillwater from 2026-02-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
Good Samaritan Society - Stillwater in STILLWATER, MN was cited for violations during a health inspection on February 12, 2026.
She had significant weakness in both legs and needed substantial help moving in bed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.