Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Estates At Greeley Llc during CMS and state inspections, most recent first.
Two residents at high risk for falls did not receive care planned interventions to prevent accidents. One resident, dependent on a full body lift for transfers, was instead transferred with a standing lift, resulting in a fall. Another resident, with severe cognitive impairment and a history of falls, was observed without non-slip footwear and was not offered toileting as care planned. Staff interviews and documentation confirmed that required fall prevention measures were not consistently implemented.
A facility failed to report allegations of sexual abuse within the required two-hour timeframe to the State Agency for a resident with cognitive impairments. The incident involved a sexual interaction between two residents, initially reported as consensual but later escalated to nonconsensual. Facility staff, including the administrator and social worker, did not report the incident promptly, citing reasons such as the resident's initial claim of consent and the belief that the hospital social worker was handling the report. The facility's policy mandates reporting all allegations of abuse within two hours, which was not followed.
A facility failed to thoroughly investigate a sexual abuse allegation involving a resident with cognitive impairments and another cognitively intact resident. The initial investigation was not revisited after receiving additional information from a hospital social worker, which detailed further abuse. This inaction was against the facility's policy to investigate all abuse allegations.
A facility failed to update a resident's care plan to include interventions for monitoring behaviors and interactions with female residents. The resident, who was cognitively intact and had a history of a fractured rib and weakness, was identified as a vulnerable adult. Despite discussions among staff about the resident's behaviors, the care plan lacked documentation of these interventions. Interviews with the social worker, nurse practitioner, and DON confirmed the oversight, and the facility could not provide a care planning policy.
A facility failed to implement proper infection control measures for two residents requiring precautions. One resident with C. diff was not managed with appropriate contact precautions, as staff did not wear PPE or perform hand hygiene. Another resident requiring enhanced barrier precautions was not properly managed, with staff failing to wear gowns and perform hand hygiene during care. Interviews revealed misunderstandings and policy gaps regarding infection control procedures.
A resident with severe cognitive impairment was found to have her wheelchair locked by a housekeeper, which was considered a restraint as the resident could not unlock it herself. The facility lacked a policy on restraints, and the care plan did not include specific interventions for wheelchair locking, leading to a deficiency in ensuring the resident's freedom from restraints.
Two residents at risk for pressure injuries did not receive proper skin assessments and interventions. One resident's cam boot was not removed for skin checks, leading to significant skin issues, while another resident did not have documented interventions for pressure injury prevention. The facility failed to follow its policy on skin assessment and wound management, resulting in deficiencies.
A resident with a history of ankle fracture and other conditions required podiatry services for overgrown and thick toenails, as noted in weekly skin inspections. Despite the need, the resident was not placed on the list for in-house podiatry services, and no urgent referral was made. Observations showed the resident's foot was extremely dry with peeling skin and thick, curled toenails. Interviews revealed a lack of clarity in the process for obtaining podiatry services, leading to the deficiency.
A resident with severe cognitive impairment and a history of falls experienced repeated falls due to inadequate supervision and inconsistent implementation of fall prevention measures. Despite having a care plan, staff failed to follow it consistently, leading to the use of restraints and improper use of fall mats. The facility lacked a policy on restraints, and staff were unclear about fall prevention interventions.
The facility failed to attempt or justify gradual dose reductions (GDR) for psychotropic medications for two residents. One resident with moderate cognitive impairment and insomnia was on trazodone without a GDR attempt or clinical contraindication documentation. Another resident with major depressive disorder was on escitalopram, and the nurse practitioner noted 'patient POA refused' without providing a clinical rationale. Interviews revealed inadequate documentation and communication regarding GDRs, leading to the deficiency.
The facility failed to provide menus and alternate food choices to two residents, leading to their unawareness of meal options. Despite having care plans that included offering substitutes, the residents reported not receiving menus or being asked about meal preferences. Staff interviews revealed inconsistencies in menu distribution and communication, with some staff unaware of the facility's policy requiring menus to be developed and posted for resident choice.
The facility did not post complete and timely nurse staffing information, affecting all 48 residents, staff, and visitors. A form titled 'Estates at [NAME]' lacked the census number, complete staff titles, and total hours worked by RNs, LPNs, and NAs. The administrator confirmed the omissions, and the DON verified that forms from late July to early August lacked tallied hours.
A resident with epilepsy was admitted to a facility with a prescription for 1250 mg of Depakote twice daily. Due to a transcription error, the medication was administered only once daily, leading to subtherapeutic levels and subsequent seizures. The error was not caught by the health information manager or the LPN responsible for confirming the order, resulting in the resident being hospitalized.
Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement care planned interventions to reduce fall risk for two residents identified as being at risk for falls. One resident, with a history of vascular dementia, stroke, and right-sided weakness, was care planned to require two staff and a full body lift (MAXI lift) for all transfers. Despite this, a nursing assistant attempted to transfer the resident using a standing lift at the resident's request, resulting in the resident's right leg buckling and a fall to the floor. Multiple staff interviews confirmed that the transfer was not performed according to the care plan, and the resident's medical condition necessitated the use of the full body lift for safety. Another resident, with severely impaired cognition, heart failure, repeated falls, and on hospice care, was care planned to always have non-slip footwear and to be offered toileting at specific times, including before and after meals. Observations revealed the resident was found wearing slippery socks without grips and was not offered toileting as specified in the care plan. Staff interviews confirmed awareness of the care plan requirements, but these interventions were not consistently implemented during the survey period. Facility policies required that care plans be updated to reflect fall interventions and that staff use the care plan to guide daily care routines. Documentation and staff statements indicated that the care planned interventions for both residents were not followed, resulting in increased risk for falls and actual incidents of falls.
Failure to Timely Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse within the required two-hour timeframe to the State Agency (SA) for a resident who was moderately cognitively impaired with diagnoses including dementia, anxiety, depression, psychotic disorder, and post-traumatic stress disorder. The incident involved a sexual interaction between this resident and another resident, which was initially reported as consensual but later escalated to nonconsensual. The facility staff, including the administrator, social worker, and nurse practitioner, did not report the incident promptly, citing various reasons such as the resident's initial claim of consent and the belief that the hospital social worker was handling the report. Interviews with facility staff revealed a lack of immediate action in reporting the incident. The administrator acknowledged receiving a report from the hospital social worker indicating nonconsensual penetration but did not report it to the SA immediately. The social worker at the facility assumed the hospital social worker's report sufficed, while the nurse practitioner did not report the incident, believing it was not her responsibility since the resident was not in the facility at the time. The facility's policy mandates reporting all allegations of abuse within two hours, which was not adhered to in this case.
Failure to Reinvestigate Sexual Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of sexual abuse involving a resident, identified as R1, who was moderately cognitively impaired with diagnoses including dementia, anxiety, depression, psychotic disorder, and post-traumatic stress disorder. The incident involved another resident, R2, who was cognitively intact. R1 reported a sexual interaction with R2 that began consensually but escalated to nonconsensual, with R2 allegedly pinning or grabbing R1's hands. The initial investigation included interviews with R1 by a social worker, staff, and other residents, as well as a review of R1's care plan and directives. However, the investigation lacked follow-up after additional information was provided by a hospital social worker. The facility's social worker and administrator acknowledged that the additional information from the hospital, which included details of R1 being held down and penetrated by R2, was not further investigated. The director of nursing confirmed that the facility did not reinvestigate the incident after receiving this new information. This inaction was contrary to the facility's policy, which mandates the investigation of all alleged or suspected abuse incidents. The failure to reinvestigate after receiving new information represents a deficiency in the facility's handling of the abuse allegation.
Failure to Update Care Plan for Resident's Behavioral Monitoring
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident, identified as R2, to include necessary interventions for monitoring relationships and behaviors. R2 was cognitively intact and had diagnoses including a fractured rib and weakness. Despite being identified as a vulnerable adult, R2's care plan did not address the relationship with another resident, R1, nor did it provide instructions for staff to monitor R2's behavior and interactions with female residents. Interviews with the social worker, nurse practitioner, and director of nursing revealed that although R2's behaviors were discussed and staff were informed to monitor interactions, these interventions were not documented in the care plan. The facility was unable to provide a policy for care planning upon request.
Failure to Implement Proper Infection Control Measures
Penalty
Summary
The facility failed to implement proper transmission-based precautions for a resident diagnosed with Clostridium difficile (C. diff), a highly contagious infection. The resident's admission records and care plan did not indicate the need for contact precautions, despite the presence of a sign on the resident's door. During an observation, a certified occupational therapy assistant (COTA) was seen assisting the resident without wearing the required personal protective equipment (PPE) such as gloves and a gown, and did not perform hand hygiene upon entering or exiting the room. Interviews with staff revealed a misunderstanding of the requirements for PPE usage, with some staff believing that gowns and gloves were only necessary when performing direct care. Another deficiency was noted with a second resident who required enhanced barrier precautions (EBP) due to their medical conditions, including Parkinson's disease and diabetes. The resident's care plan and orders did not indicate the need for EBP, although signage was present on the resident's door. During an observation, a nursing assistant (NA) failed to wear a gown and did not perform hand hygiene after glove removal while assisting the resident with personal care tasks. The NA admitted to not following proper procedures, citing the lack of hand sanitizer in their pocket as a reason for not performing hand hygiene. Interviews with the Director of Nursing (DON) and the infection preventionist (IP) confirmed that staff were expected to follow posted precautions, including wearing gowns and gloves and performing hand hygiene when moving from unclean to clean tasks. The facility's policies on transmission-based precautions and handwashing were found to lack specific guidance on enteric precautions and the necessity of handwashing with soap and water for infections like C. diff. This oversight contributed to the improper implementation of infection control measures for the residents involved.
Failure to Ensure Resident Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, was free from physical restraints. R37, who had severe cognitive impairment and was on hospice care, was observed to have her wheelchair locked by a housekeeper while she was at the dining room table. The housekeeper stated that she locked the wheelchair brakes to prevent R37 from trying to get up. However, this action was not in line with the facility's practices, as locking the wheelchair was considered a restraint, especially since R37 was unable to unlock it herself. Interviews with various staff members, including a licensed practical nurse and a registered nurse, confirmed that locking the wheelchair was considered a restraint and could pose a safety issue. R37's care plan and physician's orders did not include the use of restraints, and the facility did not have a policy on restraints because they did not use them. The care plan indicated that R37 was at risk for falls and had a history of impulsive behavior and forgetfulness. Despite this, the care plan lacked specific interventions regarding the locking of the wheelchair. The director of nursing acknowledged that housekeeping staff needed education on this matter, as they did not have access to the care plan. The nursing assistant also confirmed that R37 could not think to unlock the wheelchair, indicating a lack of understanding and communication among staff regarding the resident's care needs.
Failure to Conduct Proper Skin Assessments and Implement Interventions
Penalty
Summary
The facility failed to ensure proper skin assessments and interventions for two residents at risk for pressure injuries. Resident 16, who had a cam boot for a left ankle fracture, did not have the boot removed for skin assessments as required. Despite being cognitively intact and aware of the boot's removal instructions, the resident reported that the boot was never removed for skin checks. Nursing staff were unaware of the need to remove the boot, and conflicting orders were not clarified until after the survey entrance. Upon removal of the boot, significant skin issues were observed, including dry, cracked skin and a strong odor, indicating a lack of proper skin care. Resident 20, who was at risk for pressure injuries due to conditions such as Parkinson's disease and diabetes, did not receive appropriate interventions to prevent skin breakdown. The care plan required daily monitoring of skin integrity and the use of pressure-reducing devices, but these interventions were not documented or communicated effectively to the staff. The nursing assistant was unaware of the resident's risk for pressure injuries and did not encourage leg elevation in the recliner, as required. Additionally, there was no evidence of a skin and wound evaluation for the resident's deep tissue injury, and hospice care was managing the condition without proper documentation or follow-up by the facility's nursing staff. The facility's policy on skin assessment and wound management was not followed, as weekly skin assessments and appropriate interventions were not consistently implemented. The lack of communication and documentation regarding residents' care needs and the failure to update care plans and orders contributed to the deficiencies observed. The Director of Nursing acknowledged the expectation for staff to follow up on skin concerns and ensure that orders were updated upon residents' return from appointments, but these practices were not adhered to in the cases of Residents 16 and 20.
Failure to Obtain Podiatry Services for Resident
Penalty
Summary
The facility failed to ensure podiatry services were obtained for a resident who required assistance with foot care. The resident, who was cognitively intact, had a history of a left ankle fracture, lung disease, and schizoaffective disorder, and was dependent on staff for personal care, including bathing and dressing the lower body and feet. Weekly skin inspections from mid-June to mid-July indicated the resident had overgrown and thick toenails that required podiatry services. However, the resident's medical record did not show any indication that they had been seen or referred for podiatry services. On August 7th, a registered nurse observed the resident's foot to be extremely dry with peeling skin and yellowed, thick toenails that were slightly curled over the toes. Interviews with nursing staff and the admission coordinator revealed a lack of clarity and communication regarding the process for obtaining podiatry services. The resident was not placed on the list for in-house podiatry services, which were offered every 2-3 months, and no urgent referral was made despite the evident need. The Director of Nursing expected residents requiring podiatry services to be on the list and seen when podiatry was in-house, but this did not occur for the resident in question.
Failure to Prevent Falls and Use of Restraints
Penalty
Summary
The facility failed to ensure that a resident, identified as R37, was free from accident hazards and provided with adequate supervision to prevent falls. R37, who had severe cognitive impairment and a history of falls, was observed to have multiple falls over several months. Despite having a care plan in place with various interventions, such as ensuring the TV remote was within reach, encouraging the resident to be in common areas, and implementing a toileting schedule, these measures were insufficient in preventing repeated falls. The care plan also lacked specific interventions, such as ensuring the resident's wheelchair was locked when at the dining room table. Observations and interviews revealed that staff did not consistently follow the care plan. For instance, a housekeeper locked R37's wheelchair, which was considered a restraint, and left the resident unattended. Additionally, the floor mat intended to prevent falls was not always used correctly, as it was found on the floor even when R37 was not in bed. Staff interviews indicated a lack of clarity and consistency in implementing fall prevention measures, with some staff believing that locking the wheelchair was a restraint and others stating that the mat should always be on the floor. The facility's documentation, including incident reviews and analysis forms, highlighted multiple instances where R37 fell, often due to self-transferring or tripping over the floor mat. Despite these incidents, the facility did not have a policy on restraints, and there was a lack of specific fall prevention interventions documented in the CNA report sheet. The director of nursing acknowledged the need for staff education and the importance of following the care plan, but the report indicates that these measures were not effectively implemented, leading to the deficiency.
Failure to Attempt or Justify Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure gradual dose reductions (GDR) were attempted or adequately justified for the use of psychotropic medications for two residents. Resident 19, who had moderate cognitive impairment and a history of Parkinson's disease, dementia, and insomnia, was on trazodone for insomnia. Despite the requirement for a GDR within the first year of medication use, no attempt was made, nor was there documentation of clinical contraindication. The consultant pharmacist recommended a dose reduction assessment, but the response from the provider was merely 'patient refuses,' lacking any clinical rationale. Similarly, Resident 14, diagnosed with major depressive disorder, was on escitalopram. The resident's care plan indicated a potential for adverse reactions, and the consultant pharmacist recommended a GDR assessment. However, the nurse practitioner noted 'patient POA refused' without providing a clinical rationale or noting any contraindications. The facility's policy required documentation of clinical rationale if a GDR was not attempted, which was not adhered to in these cases. Interviews with the Director of Nursing and the consultant pharmacist revealed a lack of proper documentation and communication regarding the necessity of GDRs. The DON acknowledged that 'patient refused' was not an adequate rationale, and the consultant pharmacist admitted to accepting refusals without verifying the resident's decision-making capacity. This lack of adherence to policy and proper documentation led to the deficiency in managing psychotropic medication use.
Failure to Provide Menus and Meal Choices
Penalty
Summary
The facility failed to provide menus and alternate food choices to two residents, R14 and R98, as required. R14, who has intact cognition and medical conditions including congestive heart disease, type II diabetes, and hypertension, reported not receiving a menu or being asked about meal preferences. Despite having a care plan that included offering substitutes for dislikes, R14 stated that he was unaware of the available menu options and had to eat whatever was provided. Similarly, R98, who also has intact cognition and medical conditions such as enterocolitis due to C-diff and hypertension, expressed that she did not know what meals she would receive and was not informed about alternative menu items. Interviews with staff revealed inconsistencies in the distribution and communication of menu options. The cook mentioned that menus were posted in dining halls and that residents received a menu upon admission, but acknowledged that staff did not ask residents about their meal preferences. The dietary manager stated that the facility had a fixed menu with limited options and a Bistro menu with alternatives, but the Bistro menu was not distributed to residents or prominently displayed. Nursing assistants and other staff members provided conflicting accounts regarding the distribution of menus, with some stating that residents received weekly menus and others indicating that it was the residents' responsibility to request them. The facility's policy on menus, dated October 2017, required that menus be developed to meet resident choices and posted in accessible areas. However, the survey revealed that this policy was not consistently followed, leading to residents being unaware of their meal options and not receiving the necessary information to make informed dietary choices. This deficiency highlights a lack of communication and adherence to established procedures regarding menu distribution and resident choice in meal planning.
Incomplete Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that complete and timely nurse staffing information was posted daily, which had the potential to affect all 48 residents, staff, and visitors who might wish to review this information. On August 6, 2024, a form titled 'Estates at [NAME]' was found next to the administrator's office. This form was missing the census number and did not include all staff and their titles, nor did it provide information on the total number and actual hours worked by registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs). During an interview, the administrator confirmed that the form was intended for staff posting and acknowledged the missing census number, which was then added. The administrator also mentioned that the total hours worked were usually recorded after the shift was completed. The director of nursing (DON) confirmed that staff posting forms from July 26, 2024, through August 6, 2024, lacked tallied hours, and a policy was requested but not received.
Medication Transcription Error Leads to Resident Seizures
Penalty
Summary
The facility failed to accurately transcribe a physician's order for an anti-convulsant medication, Depakote, for a resident upon admission. The resident, who had a history of epilepsy, was supposed to receive 1250 mg of Depakote twice daily. However, due to a transcription error, the medication was ordered to be administered only once daily at bedtime. This error went unnoticed by both the health information manager and the licensed practical nurse responsible for confirming the order. As a result of the transcription error, the resident did not receive the correct dosage of the anti-seizure medication, leading to subtherapeutic levels of valproic acid in their system. Consequently, the resident experienced a petit mal seizure followed by a grand mal seizure and required hospitalization. The hospital records indicated that the resident's valproic acid levels were significantly lower than the normal range, which was attributed to the incorrect administration frequency of the medication. Interviews with facility staff revealed that the error was a result of human oversight during the transcription process. The licensed practical nurse and the health information manager both failed to catch the discrepancy between the hospital discharge orders and the electronic health record. The facility's director of nursing later discovered the error while reviewing the resident's orders after the incident, confirming that the resident did not receive the medication as prescribed from the time of admission until the seizures occurred.
Removal Plan
- House audits were performed to ensure all orders entered on admission in EHRs corresponded with original hospital admission orders for all residents on the TCU, all new admissions, and all residents taking medications for seizures.
- Audits were performed of other resident charts to ensure current orders were all correct.
- Hospital admission orders had a new third check by nursing management to ensure orders were entered correctly.
- Nursing management was performing ongoing audits of orders to ensure they were accurate.
- Staff responsible for error received education and corrective action.
- House-wide audit for new admissions.
- Therapeutic dosing medications will pull labs to get baseline levels and put orders to repeat those labs every three months.
- Nursing leadership will conduct audits to ensure resident's orders are being inputted accurately.
- Education on Medication Transcription Errors must be reviewed and understood prior to next shift.
- Audits done by Nurse Leadership team to ensure orders are accurate.
- Education provided: education on Medication Transcription Errors.
- Policy titled Admission Order Transcription was reviewed with staff in this education.
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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.
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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 | 0.6 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society - Stillwater | 0.8 mi | ★★★★★ | 9 | 0 |
| Gables Of Boutwells Landing | 1.6 mi | ★★★★★ | 10 | 0 |
| Christian Community Home | 6.7 mi | ★★★★★ | 0 | 0 |
| Cerenity Care Center White Bear Lake | 10.1 mi | ★★★★★ | 8 | 1 |
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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.