Good Samaritan Society - Stillwater
Good Samaritan Society - Stillwater in STILLWATER, MN — inspection on February 12, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During interview on 2/12/26 at 9:51 a.m., LPN-A stated wounds should be assessed with
stated the assessments should include a description and weekly wound measurements and findings
should be obtained and documented in order to base any changes observed on the weekly assessments.
During interview on 2/12/26 at 10:49 a.m., director of nursing (DON) stated expectations for wound assessments with wound description and measurements should be completed every seven days and findings documented, and an initial assessment of those findings should be completed within 24 hours of admission. DON stated she and the nurse practitioner round weekly and measure and take pictures of the wounds. DON was not sure where the pictures, assessments or measurements were routinely being documented, nor who was completing the documentation. DON stated there were currently three different forms for skin/wound assessment and realized the system was broken.
During follow up interview on 2/12/26 at 12:48 p.m., DON stated weekly wound measurements were being collected from several sources throughout the EMR and transferred to a separate spreadsheet and sent to corporate every month. DON could not explain why there was not a more streamlined process for documenting the wound assessments and why they could not all be located in the EMR. DON stated again the system was broken.
Facility policy Wound and Pressure Ulcer Management dated 7/7/25, indicated accurate assessment and documentation of wounds were used to promote healing, pain and prevention of complications of wounds and contribute to appropriate wound management.
245207 02/12/2026
Good Samaritan Society - Stillwater 1119 Owens Street North Stillwater, MN 55082
update the care plan with any changes/new interventions.
Furthermore, the policy directed staff to
245207 02/12/2026
Good Samaritan Society - Stillwater 1119 Owens Street North Stillwater, MN 55082
During an interview on [DATE] at 3:50 p.m., R1 stated he had PTSD and had known triggers. R1 stated staff at the facility had never talked to him about his triggers or past trauma. R1 stated triggers, included loud noises or being unaware of people behind him. R1 stated he was willing to talk to staff about triggers.
R1 discussed his PTSD, started from being in Vietnam war and then found his wife deceased .
During an interview on [DATE] at 12:17 p.m., certified nursing assistant (CNA)-A stated if a resident had a history of PTSD and had triggers it would be important to know what their triggers were to better care for them. CNA-A stated their triggers would be on the care plan and Kardex if a resident had PTSD.
During an interview on [DATE] at 2:15p.m., licensed practical nurse (LPN)-A stated they identify individual resident's needs would be on the care plan and the Kardex.
The nurses and MDS put the information from the chart into the care plan.
During an interview on [DATE] at 2:47 p.m., director of nursing (DON) stated if a resident had PTSD they needed to be assessed for triggers, and those triggers would be documented on the care plan to help better care for the residents. DON stated assessments for triggers were done upon admission, and as needed, and stated these assessments would help identify any triggers, and behaviors would also be monitored. DON stated that she was unaware the Trauma Assessment was answered incorrectly and that the R1 care plan did not have triggers or any information regarding the diagnosis of PTSD.A facility policy titled Trauma Informed Care dated [DATE], directed staff to ensure that residents who experienced trauma receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization.
Each employee will have training in caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or posttraumatic stress disorder.
245207 02/12/2026
Good Samaritan Society - Stillwater 1119 Owens Street North Stillwater, MN 55082
During interview on 2/12/26 at 9:54 a.m., licensed practical nurse (LPN)-B stated nurses were responsible for assessing residents for grab bars and it should be documented on the physical device assessment.
During interview on 2/12/26 at 10:37 a.m., registered nurse (RN)-B stated nurses were responsible for assessing residents for grab bars and it should be documented in the physical device assessment. RN-B also verified R12's grab bars had not been assessed and should have been.During interview on 2/12/26 11:54 a.m., the director of nursing (DON) stated nurses were responsible for assessing the residents for grab bars to ensure they meet criteria for safe use.
There also needs to be collaboration with the provider and consent for their use.
Documentation of this would be on the physical device assessment. DON stated this was important to ensure resident safety.
The facility's policy on bed safety dated 9/30/25, indicated prior to use of bed rails, side rails, safety rails, grab bars and assist bars a PhysicalDevice and Restraint Assessment or Matrix equivalent will be completed.
245207 02/12/2026
Good Samaritan Society - Stillwater 1119 Owens Street North Stillwater, MN 55082
During interview on 2/11/26 at 10:50 a.m., scheduler stated the process was to print the daily postings about a week in advance and place them in the display stand at the front desk.
Then someone from the night staff would remove the top sheet every day and place it in the mailbox for retention.
Scheduler stated the daily posting was not updated daily to reflect the actual census or the actual staff working each day.
During interview on 2/12/26 at 10:44 a.m., director of nursing (DON) stated the scheduler printed the staff posting the day prior and then it was posted in the morning. DON stated the scheduler should be updating the information to reflect the actual census and daily staff numbers and hours so that the posted sheet displayed accurate data.
During observation on 2/12/26 at 12:08 p.m., the daily staff posting was dated 2/11/26.
During interview on 2/12/26 at 12:11 p.m., administrator verified current staff posting displayed was dated 2/11/26.
Administrator further stated expectation that the daily staff posting would be current and accurate and reflect the current resident census and direct care staff numbers and hours.
Facility policy Nursing Staff Daily Posting Requirements dated 12/1/25, indicated a daily staff posting would include the location, date, resident census, and total number and actual hours worked for licensed and unlicensed nursing staff.
The policy further indicated, It is important to keep the report updated by making changes as thy occur to the electronic schedule.and a new report will need to be printed and posted.
the food and nutrition service, including a qualified dietician.
dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition
include:Dietary manager qualifications were requested however were not received.
The registered dietitian worked part time at facility.
When interviewed on 2/11/26 at 2:00 p.m., the administrator stated the facility had a part time dietitian who worked between two facilities.
The administrator stated dietary manager did not have required qualifications however was signed up for classes.
When interviewed on 2/12/26 at 1:08 p.m. stated DM had accepted the role in November as DM. DM verified she was not currently qualified however had re-enrolled in classes.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245207 02/12/2026
Good Samaritan Society - Stillwater 1119 Owens Street North Stillwater, MN 55082
directed staff to use EBP in situations in which exposure to blood and body fluids is anticipated and
used for residents with indwelling medical devices, central lines, hemodialysis catheters, and
assisting during bathing, providing hygiene, changing briefs or assisting with toileting, changing linens, indwelling urinary catheter, and wound care.
Enhanced barrier precautions are intended to be used for the duration of a resident's stay.
245207 02/12/2026
Good Samaritan Society - Stillwater 1119 Owens Street North Stillwater, MN 55082