Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society - Stillwater during CMS and state inspections, most recent first.
Employing sufficient staff with the appropriate competencies and skill sets to carry out food and nutrition services was not met. The facility did not have either a full-time RD or a qualified DM in place; the RD worked part time between two facilities, and the DM was not currently qualified and had re-enrolled in classes. Dietary manager qualifications were requested but not provided.
A resident with a stage 4 pressure ulcer to the left elbow, osteomyelitis, and an open wound after an arm fracture did not have required weekly wound assessments and measurements documented in the EMR. Nurses provided wound care and the TAR showed wound measurement entries as completed, but progress notes, wound forms, and the RN assessment lacked wound size and other assessment details. Staff and the DON stated wound documentation was spread across multiple forms and a separate spreadsheet, and the DON said the system was broken.
A resident with dementia, impaired gait and mobility, weakness, and a history of repeated falls was found on the floor in the dining room with head lacerations and was sent to the hospital. Although the resident already had fall-related interventions on the care plan, the fall was not added to the care plan, no new intervention was documented, and the SAFE event report lacked a root cause analysis. Staff interviews confirmed nurses, the MDS nurse, and the DON were responsible for documenting the fall, adding new interventions, and completing the root cause analysis.
Failure to identify PTSD triggers and develop a trauma-informed care plan: A resident with PTSD had a care plan that addressed sleep disturbance but did not include known triggers or individualized trauma-informed interventions. The resident stated staff never discussed past trauma or triggers, identified loud noises and people behind him as triggers, and said he was willing to talk with staff. The trauma assessment incorrectly stated he had no past trauma, while CNA, LPN, and DON interviews confirmed PTSD triggers should be assessed and documented on the care plan and Kardex.
Failure to assess and document safe use of bed grab bars for a resident with MS, CKD, and impaired lower extremity function. The resident had bilateral grab bars on the bed, but the physical device assessment did not show prior alternatives, education on risks vs benefits, entrapment risk assessment, or informed consent. Staff interviews confirmed nurses were responsible for the assessment and documentation, and the DON stated provider collaboration and consent were needed for use.
Failure to use PPE during EBP: Staff did not wear gowns and gloves while providing direct care to two residents on EBP. One resident had an open wound, PICC line, and IV ATB, and an RN performed wound soaking, dressing care, and PICC care without PPE. Another resident had an indwelling urinary catheter, and a CNA completed catheter care without gown or gloves, stating EBP was not indicated because no door sign or supplies were present. Staff interviews showed inconsistent understanding of EBP requirements.
Inaccurate Daily Nurse Staffing Postings: The facility failed to keep the daily staffing post current and accurate. Review of assignment sheets showed multiple mismatches between actual nursing/CNA staffing and the posted counts, and the posted census also differed from the EHR census. The scheduler stated the postings were printed in advance and not updated daily, while the DON and administrator confirmed the posting was expected to reflect the current census and actual direct care staffing numbers and hours.
A resident receiving hospice care was administered ten times the prescribed dose of liquid morphine after a hospice nurse incorrectly transcribed the order, and a facility nurse failed to question or verify the unusually large dose before administration. The error was discovered when a new medication bottle arrived with the correct dosage, and the resident required multiple doses of Narcan to reverse the effects. Staff interviews revealed a lack of double-checking for hospice orders and inconsistencies in documentation of the incident.
A resident with severe cognitive impairment was observed in a state of undress with the door open, compromising privacy and dignity. Despite staff presence, the door was often left open, exposing the resident to others. The care plan lacked specific interventions for maintaining privacy, and the room lacked privacy curtains. Staff interviews confirmed the door should remain open for safety, but observations showed it was not partially shut to provide privacy.
A resident with impaired cognition and blindness did not receive necessary assistance with personal hygiene, including nail trimming and shaving, despite expressing a desire for these services. Observations showed long fingernails and facial hair, and interviews revealed a lack of documentation and adherence to facility protocols by nursing staff.
A facility failed to monitor and document bruising for a resident on anticoagulation therapy, as bruises were observed but not recorded in weekly assessments. Additionally, another resident with edema did not receive prescribed Tubi-grips consistently, as care plans and records lacked documentation of their application and removal. Staff interviews revealed inconsistencies in following care protocols, highlighting deficiencies in monitoring and intervention processes.
The facility failed to implement effective fall prevention measures for two residents, leading to multiple falls. One resident with cognitive impairment and a history of falls was left unattended with call lights out of reach, while another resident on multiple psychoactive medications fell due to inadequate supervision and assistance. Staff interviews revealed inconsistencies in care plan adherence and communication, contributing to the deficiencies.
The facility failed to assess and implement appropriate fall prevention interventions for four residents, leading to multiple falls and injuries. One resident sustained a right ankle fracture, and another fell out of bed while trying to turn off an alarm clock, resulting in a head injury and other injuries. The care plans and kardexes lacked evidence of effective interventions to prevent further falls.
The facility failed to employ a full-time RD or a qualified DM, affecting all 39 residents. The interim DS confirmed the absence of a DM and significant kitchen staff turnover. The RD was only on-site twice weekly, and the administrator mentioned a new DM was hired but awaiting a background check.
The facility failed to ensure sufficient support staff with appropriate competencies in food and nutrition services, affecting all 39 residents. The dietary aide lacked required training, and the dietary supervisor struggled to implement necessary processes due to staff shortages and time constraints.
The facility failed to properly store, label, and date food items, and did not maintain clean air vents and ice machines. Observations revealed improperly stored and expired food, moldy items, and significant dust and calcium build-up. The dietary supervisor acknowledged the issues, and the administrator confirmed that policies were not being followed.
The facility failed to follow standard, contact, and droplet precautions, and perform evidence-based hand hygiene for residents with GI symptoms. Staff did not adhere to proper hand hygiene protocols, did not change gloves between tasks, and mishandled soiled linens, leading to deficiencies in infection control practices.
The facility failed to maintain the walk-in freezer, resulting in a large ice dam that impacted frozen food storage. The dietary supervisor and maintenance personnel were aware of the issue but had not resolved it until help from another facility arrived. The administrator was unaware of the problem, and no policy for maintaining equipment was provided.
The facility failed to ensure adequate monitoring for anticoagulant medications for three residents and did not address duplicative prescriptions for one resident. The care plans and medical records lacked documentation of monitoring for bleeding or bruising, and staff interviews confirmed the absence of necessary monitoring and clarification of medication orders. The facility's policy for high-risk medication side effect monitoring did not address anticoagulant side effects, contributing to the deficiencies observed.
The facility failed to ensure that residents were offered or provided updated pneumococcal vaccines per CDC guidelines. Five residents were not appropriately vaccinated upon admission, and the facility's records lacked documentation of shared clinical decision-making regarding the PCV-20 vaccine. Despite residents being agreeable to receiving the vaccine, the pharmacy was out of stock, leading to the deficiency.
The facility failed to ensure the removal of facial hair for a resident with cognitive impairment and multiple sclerosis, despite her expressing discomfort. Staff were unaware of her preference for chin hair removal, and her care plan lacked specific instructions, leading to a deficiency in maintaining her dignity and comfort.
The facility failed to complete baseline care plans within 48 hours for two residents admitted with significant medical conditions, including fractures and a history of falls. Staff interviews revealed confusion about responsibilities, and the care plans lacked essential details and interventions.
The facility failed to comprehensively assess and include dementia in a resident's care plan and did not assess the safety of another cognitively impaired resident using a Keurig coffee maker. Staff interviews revealed inconsistencies and confusion regarding responsibilities for updating care plans, and the DON acknowledged the need for proper assessments.
The facility failed to ensure nail care was completed for a resident with moderately impaired cognition and a diagnosis of TBI. Despite being dependent on staff for personal hygiene, the resident's nails were observed to be long, chipped, and dirty over several days. Staff interviews revealed confusion about responsibility for nail care, and the medical record lacked documentation of nail care or refusals.
The facility failed to ensure weekly skin assessments for a resident who had a fall and sustained bruising and lacerations. Despite the care plan requiring weekly observations, there was no consistent documentation or follow-up by licensed nurses, leading to a deficiency in the resident's care.
The facility failed to perform weekly skin assessments for a resident at risk for pressure injuries. Despite the care plan indicating a potential for pressure ulcer development, there was no documentation of routine skin checks, and staff interviews revealed inconsistent monitoring and documentation practices.
The facility failed to act on the consulting pharmacist's recommendations for a resident on warfarin therapy. Despite the pharmacist's recommendation for monitoring signs and symptoms of bleeding and bruising, the resident's care plan and orders lacked such monitoring, and there was no follow-up on the initial recommendation.
The facility failed to serve menu items as listed and planned for two residents, leading to dissatisfaction with meal options and inconsistency in receiving chosen meals. The dietary supervisor acknowledged the disorganization and difficulty in following the planned menu, while the dietary aide and nursing assistant confirmed the lack of advance menu provision to residents.
Unqualified food and nutrition leadership
Penalty
Summary
Employing sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, including a qualified dietician, was not met. Based on interview and document review, the facility did not employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to perform the food and nutrition service functions. The registered dietitian worked part time at the facility and also worked between two facilities, according to the administrator. The administrator stated the dietary manager did not have the required qualifications but was signed up for classes. The dietary manager later confirmed she was not currently qualified and had re-enrolled in classes. Dietary manager qualifications were requested but were not received.
Failure to Document Weekly Wound Assessments and Measurements
Penalty
Summary
The facility failed to ensure weekly wound assessments and measurements were completed for a resident with a stage four pressure ulcer on the left elbow. The resident was cognitively intact, required partial to substantial assistance with most ADLs, and had diagnoses including a fracture of the left arm, an open wound on the left elbow, IV medications, and osteomyelitis. The care area assessment identified a pressure injury to the left elbow related to the fracture and noted osteomyelitis/cellulitis, and the care plan directed staff to monitor the location, size, and treatment of the skin injury and to assess and record wound healing daily with daily dressing changes. The physician ordered wound measurements every Monday, but the record lacked evidence that the wound was measured as ordered. Progress notes documented wound care on multiple dates, including descriptions such as deep pressure wound over the left elbow with visible bone and purulent drainage, but several notes contained no wound size, assessment, or measurement. The wound data collection forms also lacked wound characteristics and measurements, despite indicating that measurements were required at least once every 7 days when skin integrity was impaired or an open area was present. The wound RN assessment likewise noted a full thickness wound with interventions in place but did not include further assessment or measurements. The treatment administration record showed wound measurement documentation as completed on multiple Mondays, but the electronic medical record did not contain corresponding wound measurements on those dates. During observation, nurses completed wound care and stated the wound had not changed, but the EMR still lacked wound assessment or measurement documentation for those encounters. Staff interviews confirmed that wound assessments should include description and weekly measurements documented in the EMR, and the DON stated the facility used multiple wound forms and a separate spreadsheet, could not identify where the assessments and measurements were routinely documented, and stated the system was broken.
Failure to complete root cause analysis and update fall interventions after resident fall
Penalty
Summary
The facility failed to ensure a root cause analysis was completed and to implement new interventions after a fall for one resident with severely impaired cognition, dementia, abnormal gait and mobility, difficulty walking, muscle weakness, and a history of repeated falls. The resident’s annual MDS indicated she required partial to moderate assistance with ambulation and had experienced two or more falls since admission, including one with injury. On 10/23/25, she was found on the floor in the middle of the dining room, with her wheelchair about 10 feet away and surrounding chairs about 5 feet away. She had lacerations on her head, was assessed, placed on neurological checks, and sent to the hospital after her daughter requested evaluation and treatment. The resident’s care plan showed prior fall-related interventions, including a gait belt, walker, stand-by assist with one staff contact guard for ambulation to and from meals and activities, a toileting plan, and activities to promote exercise and strength building. However, the care plan did not reflect the 10/23/25 fall or any new fall interventions, and the SAFE resident event report for that fall only listed an intervention to assist the resident to her room after meals, which had already been in place. The SAFE report also lacked documentation of a root cause analysis. Staff interviews confirmed nurses were expected to complete a SAFE event report, add a new intervention with each fall, and that the DON and RN-B were responsible for ensuring interventions were appropriate and for completing a root cause analysis. The facility policy also directed staff to review and update the care plan with any changes or new interventions and to complete the fall investigation in the notes tab of risk management.
Failure to identify PTSD triggers and develop a trauma-informed care plan
Penalty
Summary
The facility failed to identify triggers or attempt to identify triggers to avoid potential re-traumatization and failed to develop a care plan with individualized trauma-informed approaches for one resident with a history of trauma. The resident’s admit MDS indicated intact cognition, no hallucinations, delusions, behaviors, or rejection of care, and independence with ADLs, occasional incontinence, and ambulation with a wheeled walker. The resident’s diagnoses included PTSD and bipolar disorder, and the care plan addressed sleep disturbance related to PTSD with monitoring for tiredness, irritability, dozing during activities, dark circles under the eyes, changes in ADLs, walking/falls, energy level, and medication changes, but it did not identify PTSD triggers or include interventions for them. The trauma assessment indicated the resident did not have past trauma, which conflicted with the resident’s statement that he had PTSD from serving in the Vietnam War and finding his wife deceased. During interview, the resident stated staff had never talked with him about his triggers or past trauma and identified loud noises and being unaware of people behind him as triggers. Staff interviews reflected that CNA, LPN, and DON expected PTSD triggers to be assessed and documented on the care plan and Kardex, and the DON stated trauma assessments were done on admission and as needed, but was unaware the trauma assessment was answered incorrectly and that the care plan lacked triggers or PTSD-related information. The facility policy on Trauma Informed Care directed staff to ensure residents with trauma receive culturally competent, trauma-informed care and to eliminate or mitigate triggers that may cause re-traumatization.
Failure to Assess and Document Safe Use of Bed Grab Bars
Penalty
Summary
The facility failed to identify prior appropriate interventions before using bilateral grab bars for a resident with intact cognition, multiple sclerosis, chronic kidney disease, bilateral lower extremity impairment, and substantial assistance needs for bed mobility. During observation and interview, the resident had bilateral grab bars on the bed and stated she did not use them and was able to reposition herself, adding that she thought the facility used them to keep her in bed. The resident's physical device assessment lacked documentation that alternatives were identified and used before the grab bars, that the resident was educated on the risks versus benefits, that her risk for entrapment was assessed, or that informed consent was obtained. The resident's care plan included interventions for bed mobility using assist bars, including extensive assistance with lower extremities, assistance with turning and repositioning, and use of grab/assist bars, but the physical device assessment did not show the required evaluation for safe use of the grab bars. During interviews, the NA stated the resident used the grab bars to assist staff with repositioning, while the LPN, RN, and DON stated nurses were responsible for assessing residents for grab bars and that this should be documented in the physical device assessment. The DON also stated collaboration with the provider and consent were needed for their use. The facility policy on bed safety stated that prior to use of bed rails, side rails, safety rails, grab bars, and assist bars, a Physical Device and Restraint Assessment or matrix equivalent would be completed.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff used appropriate PPE for residents on enhanced barrier precautions (EBP) during direct care. For one resident with a stage-four pressure ulcer, left arm fracture, open left elbow wound, PICC line, and IV antibiotics for osteomyelitis, an RN entered the room without gloves or a gown, soaked the resident’s elbow in warm soapy water, applied a new dressing, and then flushed the PICC line and attached the IV antibiotic medication ball. When asked, the RN stated she should have been wearing gloves and later confirmed that EBP signs and PPE were present on the door and that she should have donned a gown and gloves for the tasks performed. A second resident had an indwelling urinary catheter, moderate cognitive impairment, limited range of motion, dependence for lower body care, bed mobility, and transfers, and hospice care on admission. The resident’s care plan and updated EBP plan indicated gown and gloves were to be worn for high-contact care activities, including catheter care. During observation, a CNA entered the room without a gown or gloves and completed catheter care without EBP. The CNA stated that if there was no yellow door holder, hallway bin, or sign with EBP supplies, the resident was not on EBP, and verified that none of those indicators were present outside the room. Interviews with facility staff showed inconsistent understanding of EBP expectations. An LPN stated EBP was to be used when physical care was provided to residents on EBP and described door signage and supplies as part of the process. The DON/IP stated EBP should be followed when residents had indwelling devices like IVs or PICCs and open wounds, and that gown and gloves should always be worn during direct patient care. The facility policy stated EBP is used for residents with indwelling medical devices, central lines, and indwelling urinary catheters, and includes gown and glove use during high-contact resident care activities.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure the daily staff posting displayed accurate information about the resident census and the total number and actual hours worked per shift by nursing staff. Review of daily assignment sheets for 2/1/26 through 2/11/26 showed staffing levels that differed from the daily staff postings, including multiple days where the posted CNA count did not match the actual CNA count on the assignment sheets. On 2/11/26 at 8:24 a.m., the staff posting at the reception desk showed a census of 35, while the electronic health record showed a current census of 34. The posting also showed 6 CNAs for the day, while the daily staff schedule for 2/11/26 indicated 8 CNAs. The daily staff postings for 2/12/26 through 2/15/26 were already placed behind the current posting in a plastic display frame and all showed a census of 35 with pre-populated staff numbers and hours. During interview, the scheduler stated the postings were printed about a week in advance and placed in the display stand, and that the daily posting was not updated daily to reflect the actual census or the actual staff working each day. The DON stated the scheduler should be updating the information so the posted sheet displayed accurate data, and the administrator verified the current posting was dated 2/11/26 and stated the expectation was that the posting would be current and accurate and reflect the current resident census and direct care staff numbers and hours. Facility policy required the daily staff posting to include the location, date, resident census, and total number and actual hours worked for licensed and unlicensed nursing staff, and stated the report should be kept updated as changes occur.
Medication Administration Error: Morphine Overdose Due to Transcription Mistake
Penalty
Summary
A medication administration error occurred involving a resident with diagnoses including anemia, heart failure, diabetes mellitus, and seizure disorder, who was receiving hospice care for a terminal prognosis. The resident's physician order specified morphine sulfate concentrate 20 mg/ml, to be given at 0.75 ml every hour as needed for pain or dyspnea. However, a hospice nurse transcribed a new order incorrectly, changing the dose from 0.75 ml to 7.5 ml, which is ten times the intended amount. This transcription error was not identified by the facility nurse, who subsequently administered the excessive dose using multiple syringes. Following the administration of the incorrect morphine dose, the resident exhibited symptoms requiring the use of Narcan (naloxone) to reverse opioid effects. Documentation and interviews revealed inconsistencies in the recording of Narcan administration times and the number of doses given. The error was discovered when a new bottle of morphine arrived from the pharmacy with the correct dosage label, prompting staff to realize the discrepancy and notify appropriate personnel. The facility's medication administration record and staff interviews confirmed that the error was due to the incorrect transcription and lack of verification before administration. Staff interviews indicated that there was no double-checking of hospice orders as is done with new admissions, and the nurse who administered the medication did not question the unusually large volume required for the dose. The director of nursing acknowledged the transcription error but initially did not consider it a facility error, attributing it to the hospice nurse. The facility policy requires medication errors to be reported promptly and defines significant errors as those jeopardizing resident health and safety, which was the case in this incident.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain personal privacy and dignity for a resident, identified as R21, who was observed with bare skin and undergarments visible from the hallway. R21, who had severe cognitive impairment and required maximal assistance for activities of daily living, was found lying in bed with the door wide open, exposing him to other residents, visitors, and staff. The care plan for R21 lacked specific interventions to preserve privacy and dignity, despite acknowledging his incontinence and inappropriate sexual behaviors. During multiple observations, R21 was seen in a state of undress with the door open, and staff members, including a social services designee and a nursing assistant, walked past without addressing the situation. Although a trained medication aide eventually closed the door, it was reopened shortly after, leaving R21 exposed again. The room lacked privacy curtains, and the care plan did not provide guidance on maintaining privacy while ensuring safety, as R21 was at risk for falls. Interviews with staff, including the Director of Nursing, confirmed that the door should remain open for safety reasons, but it could be partially shut to provide some privacy. However, the observations indicated that the door was often left wide open, compromising R21's dignity. The facility's policies on resident dignity and fall prevention were not effectively implemented, leading to the deficiency in maintaining R21's privacy and dignity.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for a resident with moderately impaired cognition and blindness. The resident, who had a history of cerebral vascular accident (CVA), required supervision with personal hygiene and had specific physician's orders for weekly skin assessments, nail trimming, and shaving. However, documentation from a weekly skin observation lacked evidence that the resident's nails were trimmed or that he was offered or refused shaving. Observations revealed that the resident's fingernails were approximately half an inch long, and he had several weeks' worth of facial hair, despite expressing a desire to have his nails trimmed and to be clean-shaven. Interviews with nursing assistants and a licensed practical nurse (LPN) confirmed that nursing assistants were responsible for trimming nails and shaving residents once a week on their bath day. However, there was no specific place to document these tasks, and the staff were expected to re-approach residents who refused care and inform the nurse. The director of nursing (DON) reiterated these responsibilities and the need for documentation. Despite these protocols, the resident did not receive the necessary personal hygiene care, indicating a lapse in the facility's adherence to its policy on providing appropriate treatment and services for ADLs.
Deficiencies in Monitoring and Intervention for Residents on Anticoagulation and Edema Care
Penalty
Summary
The facility failed to adequately monitor and document bruising for a resident on anticoagulation therapy. The resident, who had moderate cognitive impairment and was on daily anticoagulation medication, was observed with multiple bruises on their arms and hands. Despite the presence of these bruises, the facility's weekly skin assessments did not document the bruising, and there was no indication of when the bruising was identified or monitored. Interviews with staff revealed that while bruising was common for residents on blood thinners, there was no specific monitoring in place beyond weekly observations, and the bruising was not consistently documented. Additionally, the facility did not implement prescribed interventions for another resident with edema. This resident, who had congestive heart failure and localized edema, was supposed to have Tubi-grips applied to their lower legs daily. However, the care plan did not reflect this requirement, and the medication and treatment administration records lacked documentation of the Tubi-grips being applied or removed as ordered. Observations confirmed that the resident was not consistently wearing the Tubi-grips, and staff interviews indicated a lack of adherence to the prescribed schedule for applying and removing the compression bandages. The facility's policies on skin assessment and edema monitoring did not adequately address the specific needs of these residents, leading to deficiencies in care. The lack of documentation and adherence to care plans for both residents highlights a failure in the facility's monitoring and intervention processes, which are crucial for residents with conditions requiring specific medical management.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to fully assess and implement fall prevention interventions for two residents, leading to multiple falls. One resident, identified as R21, had a history of falls and was at high risk due to cognitive impairment, impulsivity, and other medical conditions such as dementia and Parkinson's disease. Despite these risks, the facility's care plan and interventions were inconsistently applied. Observations revealed that R21's call light was often out of reach, and the resident was left unattended, leading to several falls. The care plan included interventions like moving the resident closer to the nursing station and using a night light, but these were not effectively implemented, as evidenced by the resident's repeated falls and lack of supervision. Another resident, R187, was admitted with a history of falls and was on multiple psychoactive medications, which increased the risk of falls. The facility's pharmacist recommended reviewing and potentially reducing these medications, but the recommendations were not acted upon. R187 experienced a fall while attempting to ambulate independently, despite being identified as needing assistance. The care plan for R187 included keeping the walker within reach and offering toileting assistance, but these measures were not consistently followed, contributing to the resident's fall. Interviews with staff revealed a lack of adherence to care plans and inadequate communication regarding fall risks and interventions. Nursing assistants and other staff members were not consistently using the Kardex to guide care, and there was confusion about the implementation of fall prevention strategies. The facility's failure to effectively assess and address the fall risks for these residents resulted in repeated falls and injuries, highlighting deficiencies in supervision and care planning.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to assess and implement appropriate interventions to decrease the risk of falls for four residents. Resident 189, who had a history of falls and cognitive impairment, was admitted with a diagnosis of open reduction internal fixation (ORIF) of the left femur. Despite being identified as high risk for falls, the care plan and kardex lacked any evidence of a fall care plan or interventions. This led to Resident 189 falling in the bathroom and sustaining a right ankle fracture, which was not promptly addressed by notifying the physician or implementing immediate interventions to prevent further falls. Resident 7, who had mild cognitive impairment and was at high risk for falls due to impaired mobility and psychoactive medication use, experienced multiple falls. The care plan did not include new interventions after each fall, and the facility's risk management reports lacked evidence of immediate interventions to prevent further falls. Despite repeated falls, the care plan and kardex were not updated with effective interventions to mitigate the risk of future falls. Resident 29, with moderate cognitive impairment and a history of falls, was found on the floor at the foot of his bed. The care plan and fall assessment lacked evidence of new interventions to prevent further falls. Similarly, Resident 24, who was cognitively intact but had a history of falls and was on blood thinners, fell out of bed while trying to turn off an alarm clock. The care plan and kardex were not updated with effective interventions, and the grab bars requested by the resident and family were not properly installed, contributing to the fall and subsequent injuries.
Failure to Employ Qualified Dietary Staff
Penalty
Summary
The facility failed to employ either a full-time registered dietitian (RD) or a qualified dietary manager (DM) to carry out the functions of the food and nutrition service, potentially affecting all 39 residents. The facility's list of hires did not include a DM, and the interim dietary supervisor (DS) confirmed there was no DM currently employed. The DS, who was also working at a sister facility, mentioned significant turnover in the kitchen staff and ongoing hiring efforts. The DS had a food safety manager certificate but could not provide it. The RD was only on-site twice weekly. The administrator confirmed the absence of a dietary director for about a month and mentioned a new DM was hired but awaiting a background check.
Insufficient Support Staff in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure sufficient support staff with the appropriate competencies to carry out the functions of the food and nutrition services, potentially affecting all 39 residents. The facility did not have a dietary manager, and the dietary aide (DA-A) lacked the required training for food safety and safe swallowing. On one occasion, DA-A was left alone to serve breakfast due to an ill call from the cook, resulting in a limited breakfast of cold cereal, yogurt, and toast. DA-A, who initially started as a housekeeper, had not received any formal training related to food service and was unsure of the breakfast menu. The dietary supervisor (DS) had been working at the facility for about a month to help due to the absence of a dietary manager. DS noted the lack of processes for labeling, dating foods, and ordering necessary items. Despite efforts to train staff, DS acknowledged the insufficiency of staff and time to implement needed processes. The administrator expected general education for dietary staff to come from the supervisor, but there was no clear policy on kitchen training and requirements. The facility's documentation did not include a dietary manager, and the training records for DA-A were incomplete.
Improper Food Storage and Unsanitary Conditions in Kitchen
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of frozen and refrigerated food items, as well as the disposal of expired items. During an initial kitchen observation, surveyors found several improperly stored items in the walk-in freezer, including bags of meat with ice crystals and containers of potato and seafood salad that were not meant to be frozen. The walk-in refrigerator contained moldy strawberries, soup bases without use-by dates, and various other items without proper labeling or dating. The dietary supervisor, who was temporarily helping from a sister facility, acknowledged the issues and admitted there was no effective system for dating, labeling, and storing food in place at the facility. Additionally, the facility failed to maintain clean and sanitary conditions in the kitchen, specifically regarding the air vents and ice machine. Observations revealed large grey clumps of dust in the air vents above the kitchen prep area, which were verified by the dietary supervisor. The dietary supervisor also confirmed that there was no cleaning schedule for the kitchen and that the staff was new and struggling to maintain cleanliness. The ice machine used by residents had a significant build-up of crusty white substance, identified as hard water and calcium deposits, which had not been cleaned since the last quarterly maintenance. The facility's policies on food storage, kitchen cleaning, and ice machine maintenance were not being followed. The administrator confirmed that food should be properly dated and stored, and that cleaning schedules should be adhered to. However, the lack of a dietary manager and the presence of new staff contributed to the deficiencies observed. The facility's failure to comply with its own policies and maintain sanitary conditions had the potential to affect all 39 residents receiving food from the kitchen.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to follow standard precautions, contact precautions, droplet precautions, and perform evidence-based hand hygiene for residents with gastrointestinal (GI) symptoms. For instance, a nursing assistant (NA) did not perform hand hygiene before entering a resident's room, donned gloves, and assisted the resident with toileting and other personal care tasks without changing gloves or performing hand hygiene in between tasks. The NA also failed to wipe the resident's perineal area correctly, which could increase the risk of urinary tract infections (UTIs). The infection preventionist (IP) and other staff confirmed the expected procedures for hand hygiene and perineal care, which were not followed in this instance. Another incident involved a nursing assistant (NA) who assisted a resident on GI and contact precautions without washing hands with soap and water after removing gloves and gown. The NA used hand sanitizer instead, despite the sign on the resident's door indicating the need for soap and water handwashing. The NA admitted to not having enough time to wash hands properly between residents. The nurse manager and other staff confirmed the correct procedures for GI/contact precautions, which were not adhered to in this case. Additionally, a housekeeper failed to perform hand hygiene while cleaning a resident's room and handling soiled linens. The housekeeper carried a dirty bedspread with visible bowel movement without wearing gloves or placing it in a bag, and did not wash hands before handling clean linens. The housekeeping supervisor confirmed that housekeepers should wear gloves and perform hand hygiene when handling soiled items and that extra linens should not be returned to storage after being in a resident's room. These actions and inactions led to deficiencies in infection control practices at the facility.
Failure to Maintain Walk-In Freezer
Penalty
Summary
The facility failed to ensure the walk-in freezer was maintained properly, resulting in a large ice dam that impacted frozen food storage. During an initial kitchen observation, it was noted that one of the two fans in the freezer was not functioning due to a large ice dam. The ice dam extended from the fan down to the shelves and floor, freezing onto several unopened boxes. The dietary supervisor confirmed the ice dam had been present since he started a few weeks ago and that maintenance was aware but had not yet fixed the issue. The maintenance personnel admitted to being aware of the problem for about a week and had been attempting to chip away the ice without success until help from another facility arrived to implement a temporary fix. The administrator was unaware of the ice dam and expected all kitchen equipment to be in good working condition. A policy for maintaining equipment was requested but not provided. The deficiency had the potential to impact all 39 residents residing in the facility, as the ice dam could affect the quality and safety of the stored food.
Failure to Monitor Anticoagulant Medications and Address Duplicative Prescriptions
Penalty
Summary
The facility failed to ensure adequate monitoring for unnecessary medications for three residents. Resident 24, who was on warfarin for anticoagulation, did not have monitoring for signs and symptoms of bleeding or bruising documented in their care plan or nursing and provider orders. Similarly, Resident 91, who was on Eliquis for anticoagulation, also lacked monitoring for bleeding or bruising in their care plan and orders. Additionally, Resident 91 had duplicative medications prescribed, including clotrimazole and nystatin creams, which were not clarified by the staff. Resident 31, who was on Apixaban for anticoagulation, also lacked documentation of monitoring for anticoagulant side effects in their care plan and medical record. Interviews with staff confirmed the absence of necessary monitoring and the presence of duplicative medications for Resident 91. The consulting pharmacist and the Director of Nursing (DON) acknowledged the need for monitoring and clarification of medication orders but noted that these actions were not consistently implemented. The facility's policy for high-risk medication side effect monitoring did not address anticoagulant side effects, contributing to the deficiencies observed. The report highlights the facility's failure to ensure proper monitoring and management of anticoagulant medications, leading to potential risks for the residents involved.
Failure to Ensure Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to have a method or system to ensure that residents were offered or provided updated pneumococcal vaccines per CDC recommendations. This deficiency was identified for five residents who were not appropriately vaccinated against pneumonia upon admission. The facility's electronic health records lacked documentation of shared clinical decision-making regarding the administration of the PCV-20 vaccine, which should have been offered at least five years after the last pneumococcal vaccine dose for these residents. The infection preventionist (IP) stated that the facility utilized CDC guidelines and the Pneumorex Advisor application to determine vaccine eligibility. However, despite the residents being agreeable to receiving the additional vaccine dose, the pharmacy was out of stock. The facility's policy indicated that residents should receive pneumococcal vaccinations per CDC guidelines, and the process included obtaining consent, a physician's order, and documenting the administration in Point Click Care (PCC). The sampled residents' records showed that they had received previous doses of PPSV-23 and PCV-13 but had not been offered the PCV-20 vaccine as required. The facility's failure to document shared clinical decision-making and ensure the availability of the vaccine led to the deficiency. The policy also required ongoing review of vaccine eligibility and documentation of declination if residents chose not to be vaccinated, which was not adequately followed in these cases.
Failure to Address Resident's Facial Hair Removal Needs
Penalty
Summary
The facility failed to ensure the removal of facial hair for a resident (R6) who had cognitive impairment and diagnoses of multiple sclerosis and dementia. Despite R6's care plan indicating the need for assistance with personal hygiene, there was no specific mention of chin hair removal. Observations revealed that R6 had several white and gray hairs on her chin, which she expressed were bothersome. Interviews with staff indicated a lack of awareness and communication regarding R6's preference for chin hair removal. The nursing assistant (NA-C) and licensed practical nurse (LPN-C) both confirmed that they were unaware of R6's discomfort and did not know if R6 had an electric razor for use. The Director of Nursing (DON) stated that staff were expected to ask about and offer to shave chin hairs on bath days or anytime to ensure resident comfort, but this was not done in R6's case. The facility's policy on resident dignity, which was revised in November 2023, directed staff to maintain dignity by grooming residents according to their wishes. However, the policy was not followed in R6's case, as her care plan and Kardex lacked specific instructions for chin hair removal, and staff did not take the initiative to address her discomfort. This failure to provide appropriate personal hygiene care resulted in a deficiency in maintaining the resident's dignity and comfort.
Failure to Complete Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to ensure a baseline care plan was completed for two residents within 48 hours of their admission. Resident R89, who was admitted with diagnoses including a fracture of the lower end of the right humerus, pain in the right arm, and congestive heart failure, did not have a baseline care plan in her medical record. Interviews with various staff members, including licensed practical nurses and the nurse manager, revealed confusion and inconsistency regarding who was responsible for completing and updating the baseline care plan. The MDS nurse confirmed that R89 did not have a baseline care plan and was unsure why it was missed. Similarly, Resident R189, who was admitted with a history of falls and an open reduction internal fixation of the left femur, also lacked a baseline care plan. The resident's care plan did not include any evidence of a fall care plan, fall history, or interventions to decrease the risk for falls. Additionally, the care plan lacked details on the resident's ADL self-care performance deficit and necessary interventions. The DON confirmed that the facility had 48 hours to complete a baseline care plan and that it was crucial for staff to know how to care for the residents properly.
Failure to Comprehensively Assess and Update Care Plans
Penalty
Summary
The facility failed to comprehensively assess and include dementia in the care plan for a resident with severely impaired cognition and a diagnosis of dementia. Despite the resident's quarterly Minimum Data Set (MDS) indicating severe cognitive impairment and dependence on staff for activities of daily living (ADL) and mobility, the care plan dated 3/28/24 lacked any mention of dementia. Interviews with various staff members, including licensed practical nurses (LPNs), the nurse manager, the MDS nurse, and the director of nursing (DON), revealed inconsistencies and confusion regarding the responsibility for completing and updating the comprehensive care plan. The MDS nurse confirmed that the resident's care plan did not address dementia, which should have been included for the safety and proper care of the resident. Additionally, the facility failed to assess the safety of a cognitively impaired resident using a Keurig coffee maker in their room. The resident's quarterly MDS indicated cognitive impairment and diagnoses of chronic lung disease, kidney disease, and weakness. The medical record lacked evidence of an assessment to ensure the safe use of the coffee maker, and the care plan did not address it. Staff interviews revealed that while some staff were aware of the coffee maker, they were unsure of any safety concerns or assessments conducted. The DON acknowledged that an assessment should have been completed and included in the care plan to ensure safe use of the appliance.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure nail care was completed for a resident (R19) who was dependent on staff for personal hygiene. R19 had moderately impaired cognition, a diagnosis of traumatic brain injury (TBI), and was known to reject care 1-3 times per week. Despite these conditions, R19's medical record lacked documentation that nail care had been performed. Observations over several days revealed that R19's nails were approximately 1/2 inch long, chipped, jagged, and had brown matter, which R19 expressed dissatisfaction with and a desire to have them cut. Interviews with staff revealed confusion about who was responsible for nail care, with some stating it was the nurses' responsibility and others stating it was the nursing assistants' responsibility. The nurse manager confirmed that R19's nails were very long and had only been trimmed after the surveyor's inquiry. The director of nursing (DON) stated that both nurses and nursing assistants were responsible for cutting residents' nails, with a preference for nurses to cut the nails of diabetic residents. The DON also mentioned that nail care should be performed once a week on bath day and refusals should be documented in the medical record. However, there was no documentation of nail care or refusals in R19's medical record. The facility's policy on activities of daily living (ADLs) indicated that appropriate treatment and services should be provided to maintain or improve residents' abilities, but this was not adhered to in R19's case.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure weekly skin assessments were completed for a resident (R24) who had a fall and sustained bruising and lacerations. R24's care plan required weekly skin observations by a licensed nurse, but the medical record lacked indication that these assessments were completed since January 2024. Additionally, the care plan did not include continued monitoring of R24's bruising and facial lacerations after the initial 72-hour period post-fall. Observations and interviews revealed that while nursing assistants were aware of the need to monitor skin during baths, there was no consistent documentation or follow-up by licensed nurses as required by the facility's policy. R24, who was cognitively intact and had diagnoses including congestive heart failure and vascular disease, experienced a fall resulting in a grape-sized bump on the forehead, facial bleeding, and a large skin tear on the right deltoid. Despite these injuries and the resident's use of warfarin, which could complicate healing, the facility did not document ongoing assessments or monitoring of the injuries. Interviews with staff, including LPNs and the Director of Nursing, confirmed that the expected weekly monitoring and documentation were not consistently performed, leading to a deficiency in the resident's care.
Failure to Perform Weekly Skin Assessments for At-Risk Resident
Penalty
Summary
The facility failed to ensure weekly skin assessments were completed for a resident (R8) who was at risk for pressure injuries. Despite R8's care plan indicating a potential for pressure ulcer development due to decreased mobility and other risk factors, there was no indication that weekly skin assessments were required or performed. The resident's medical record lacked documentation of routine skin checks, and the active nursing and provider orders did not include a requirement for routine skin assessments. Observations and interviews revealed that while nursing assistants monitored skin during baths and reported issues to nurses, there was no consistent documentation or follow-up by the nursing staff. On one occasion, R8 reported pain and irritation below the nose from oxygen tubing, which was observed as a small reddened area. Although the resident mentioned that staff were aware of the issue, there was uncertainty about any preventive measures being taken. Interviews with nursing staff and the Director of Nursing confirmed that skin monitoring was expected to be done daily by nursing assistants and documented on bath days, but this was not consistently practiced or recorded. The facility's policy on skin assessment and pressure ulcer prevention required accurate documentation and systematic skin inspections, which were not adhered to in R8's case.
Failure to Act on Pharmacist's Recommendations for Anticoagulation Monitoring
Penalty
Summary
The facility failed to ensure that the consulting pharmacist's recommendations were acted upon for a resident (R24) who was taking anticoagulation medication. R24, who was cognitively intact and had diagnoses of congestive heart failure and atrial fibrillation, was on warfarin therapy. The resident's nursing and provider orders did not include monitoring for bleeding, bruising, or other side effects of the anticoagulation medication. Additionally, R24's care plan lacked any indication of monitoring for these side effects. Despite the consulting pharmacist's recommendation in December for monitoring signs and symptoms of bleeding and bruising, there was no follow-up or implementation of this recommendation in the resident's care plan or orders. Interviews with staff revealed that the pharmacy sends recommendations to the nurse practitioner, who then decides on the necessary actions. The Director of Nursing (DON) stated that pharmacy recommendations are received monthly and are either acted upon or delegated. However, the consulting pharmacist acknowledged that there had been no further direction or follow-up on the initial recommendation for anticoagulation monitoring since December. The facility's policy directs the pharmacist to report any irregularities to the attending physician or the DON, and these reports must be acted upon with follow-up documentation maintained. This process was not followed in the case of R24, leading to a deficiency in care.
Failure to Serve Menu Items as Planned
Penalty
Summary
The facility failed to serve menu items as listed and planned for two residents reviewed for nutrition services. Resident 25, who has diagnoses of chronic obstructive pulmonary disease (COPD) and dysphagia, reported not receiving the Salisbury steak and potatoes he selected for dinner, instead receiving a bowl of soup and half a grilled cheese sandwich. Similarly, Resident 8, who has heart disease, kidney disease, and high blood pressure, stated that the food was not always great, there were limited choices, and often received whatever was left rather than the selected option. Both residents expressed dissatisfaction with the meal options and the inconsistency in receiving their chosen meals. The dietary supervisor, who had been at the facility for about a month, acknowledged the difficulty in following the previous dietary manager's menu and the lack of alignment between available food and the planned menu. The dietary supervisor admitted that the facility was supposed to be on a different menu week and that the current situation was disorganized. The dietary aide and nursing assistant confirmed that residents were asked about their meal preferences before each meal, but there was no menu provided to residents ahead of time. The administrator expected the kitchen staff to follow the scheduled menu and consider residents' preferences, but this was not being effectively implemented. Facility policies directed staff to prepare menus in advance and ensure resident preferences were considered, but these policies were not being followed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 620 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Stillwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Estates At Linden Llc | 0.7 mi | ★★★★★ | 4 | 0 |
| The Estates At Greeley Llc | 0.8 mi | ★★★★★ | 0 | 0 |
| Gables Of Boutwells Landing | 2.4 mi | ★★★★★ | 10 | 0 |
| Christian Community Home | 7.5 mi | ★★★★★ | 0 | 0 |
| Cerenity Care Center White Bear Lake | 9.9 mi | ★★★★★ | 8 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.