Good Samaritan Society - Stillwater: Care Standards Gap - MN
The resident, identified in inspection records as R12, has multiple sclerosis and chronic kidney disease. Inspectors noted she requires substantial assistance with bed mobility and has impairment in both legs. When an inspector observed her room on February 9, 2026, the grab bars were there, one on each side of her bed.
R12 said she didn't actually use them. She said she could reposition herself. Then she offered her own theory about why they were there: she thinks the facility uses them to keep us in bed.
Federal inspectors flagged the situation as a violation during a February 12 survey. The core problem wasn't that grab bars existed. It was that the facility had skipped every required step before putting them there.
The facility's own bed safety policy, dated September 30, 2025, required a Physical Device and Restraint Assessment before any grab bar, assist bar, or side rail goes on a resident's bed. R12's assessment form showed none of it had happened. No documentation that staff tried other approaches first. No education given to R12 about the risks versus the benefits. No assessment of whether she could become entrapped between the bar and the mattress. No consent obtained.
Her care plan, dated January 12, 2026, told a different story than R12 did. It described her using the bilateral assist bars to help with turning and repositioning, and noted she could roll side to side with extensive assistance from one staff member using the grab bars while staff guided her lower extremities. A nursing assistant told inspectors on February 12 that R12 used the grab bars to help staff reposition her.
So staff were relying on the bars. R12 said she wasn't using them. And no one had ever formally assessed whether any of this was safe for her specifically.
When inspectors interviewed the nursing staff, the answers were consistent and damning. A licensed practical nurse said nurses were responsible for assessing residents for grab bars and that the assessment should be documented on the physical device assessment form. A registered nurse said the same thing, then confirmed directly that R12's grab bars had never been assessed and should have been.
The director of nursing went further. She told inspectors that nurses were responsible for assessing residents to ensure grab bars meet criteria for safe use, that there needed to be collaboration with the provider, and that consent was required. Documentation of all of it should appear on the physical device assessment. She called it important for resident safety.
The form for R12 was blank where all of that should have been.
Entrapment is the specific danger that grab bar assessments are designed to catch. The space between a grab bar and a mattress, or between a bar and a bed frame, can trap a resident's head, neck, or chest. For a resident with impaired lower extremities who needs substantial help moving in bed, that risk is not abstract.
R12 knew the bars were there. She had her own explanation for them. What she didn't have was anyone sitting down with her, explaining the risks, explaining the benefits, asking whether she agreed, and writing it down.
The inspection covered one resident reviewed for grab bar use. That resident was R12. The facility's own staff, from the nursing assistants to the director of nursing, acknowledged on the day of the survey that the assessment should have been done and wasn't.
R12, meanwhile, had been lying in a bed flanked by equipment installed without her consent, telling an inspector she thought it was 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.
The resident, identified in inspection records as R12, has multiple sclerosis and chronic kidney disease.
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.