Good Samaritan Society - Stillwater: Safety Hazards - MN
Nobody had assessed whether she needed them. Nobody had told her about the risks. Nobody had asked her permission.
The resident, identified in inspection records only as R12, has multiple sclerosis and chronic kidney disease. Her cognition is intact. Inspectors who visited on February 9, 2026 found the grab bars installed on both sides of her bed and noted she was capable of repositioning herself without them. R12 told the inspector directly: she didn't use the bars and could reposition on her own.
Her care plan, dated January 12, 2026, told a different story. It described grab bars as tools staff used to help reposition her, noting she could roll side to side with extensive assistance from one staff member using the bars while staff guided her lower extremities. A nursing assistant confirmed to inspectors that R12 used the grab bars to help staff reposition her.
But the physical device assessment form where nurses are supposed to document that they identified alternatives before installing grab bars, evaluated the resident's entrapment risk, and obtained informed consent, was blank on all of those points. The assessment lacked any indication the facility had tried other approaches first, educated R12 on risks versus benefits, checked whether she could become trapped, or gotten her agreement to the device.
Grab bar entrapment is a recognized safety hazard. A resident can become caught between a bar and the mattress, between bars, or between a bar and the bed frame, with serious or fatal results.
The director of nursing told inspectors that nurses were responsible for completing these assessments before grab bars go in, that the process requires collaboration with the provider, and that consent is required. She confirmed the documentation should appear on the physical device assessment. "This was important to ensure resident safety," she said.
Two nurses said the same thing independently. A licensed practical nurse told inspectors nurses were responsible for assessing residents for grab bars and documenting it on the physical device assessment. A registered nurse said the same, then went further: she verified that R12's grab bars had not been assessed and acknowledged they should have been.
The facility's own bed safety policy, updated as recently as September 30, 2025, states that a physical device and restraint assessment must be completed before grab bars are used. The policy existed. The assessment form existed. Neither was applied to R12.
The inspection cited the deficiency at a level of minimal harm or potential for actual harm, affecting few residents. Inspectors reviewed one resident for grab bar use. That resident had no documented assessment.
What R12 said to the inspector is worth sitting with. She has a disease that progressively strips the protective covering from her nerves, leaving her with significant weakness in both legs and requiring substantial help to move in bed. She is cognitively sharp. She noticed the bars. She formed a view about why they were there. "She thinks the facility uses them to keep us in bed," the inspection report states.
Whether that interpretation is accurate is not what the record resolves. What the record resolves is simpler: the facility made a decision about her body, installed equipment on her bed, and wrote it into her care plan without once sitting down with her to explain what the bars were for, what could go wrong, or whether she agreed.
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 5, 2026 · Our methodology
Good Samaritan Society - Stillwater in STILLWATER, MN was cited for violations during a health inspection on February 12, 2026.
Nobody had assessed whether she needed them.
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.