Good Samaritan Stillwater: Dietary Staff Shortages - MN
The woman, identified in inspection records only as R12, told inspectors she didn't use the bars at all. She said she could reposition herself on her own. Then she said something that stopped the interview: she thought the facility used them "to keep us in bed."
Federal inspectors visited Good Samaritan Society - Stillwater on February 12, 2026, and documented that the facility had installed bilateral grab bars on R12's bed without completing the required safety assessment, without trying other options first, and without obtaining her informed consent. The inspection report covered one resident reviewed for grab bar use. That resident was R12.
R12 has multiple sclerosis, a disease that breaks down the protective covering of nerves, along with chronic kidney disease. Her cognition was recorded as intact. She needed substantial help with bed mobility and had significant weakness in both legs, but inspectors noted she was able to assist with her own turning and repositioning.
The facility's own care plan, dated January 12, 2026, described R12's situation in detail. It listed interventions including the use of "assist bars" to help her reposition and noted she "can roll side to side with extensive assist of one staff using grab/assist bars." The care plan treated the bars as an established part of her routine. The physical device assessment, the document where nurses were supposed to record whether alternatives had been tried, whether risks had been explained, and whether the resident had consented, contained none of that. It was blank on every point that mattered.
A nursing assistant told inspectors on February 12 that R12 used the grab bars to help staff reposition her. That may be true. It does not explain why nobody assessed whether the bars posed an entrapment risk, or why R12 was never educated on what the bars were for, or why she was never asked to consent to their use.
Two nurses confirmed to inspectors that assessing residents for grab bars was a nursing responsibility and that the documentation should appear on the physical device assessment. A registered nurse identified as RN-B looked at R12's file and verified the assessment had not been done 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. She called it important for resident safety. She confirmed the documentation belonged on the physical device assessment. The assessment for R12 showed none of it had happened.
The facility's own bed safety policy, updated as recently as September 30, 2025, states that before grab bars are used, a physical device and restraint assessment must be completed. The policy existed. The assessment did not.
Grab bar entrapment is not a theoretical concern. The space between a bar and a mattress, or between bars and a bed frame, can trap a resident's head, neck, or chest, particularly for someone with limited mobility in their lower extremities. R12 had bilateral lower extremity impairment. Nobody at the facility had formally evaluated whether the bars created that risk for her specifically.
R12 told inspectors she didn't use the bars. She said she could manage on her own. She had intact cognition and understood her situation well enough to form a theory about why the bars were there.
She was never given the chance to decide for herself.
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 6, 2026 · Our methodology
Good Samaritan Society - Stillwater in STILLWATER, MN was cited for violations during a health inspection on February 12, 2026.
The woman, identified in inspection records only as R12, told inspectors she didn't use the bars at all.
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.