Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Linden Llc during CMS and state inspections, most recent first.
Call light left out of resident's reach. A resident with MS, dementia, anxiety, depression, moderate cognitive impairment, and limited lower-extremity ROM was observed multiple times with his call light hanging off the foot of the bed and out of reach while he was in bed or in a reclining chair. The care plan directed staff to keep the call light visible and within reach, and an RN and the DON acknowledged staff were expected to ensure it was accessible.
A resident with multiple sclerosis, dementia, diabetes, impaired mobility, and an unstageable pressure ulcer was ordered to wear Prevalon heel protector boots on both feet at all times, with daily removal for skin checks. Observation showed the boots left on the counter and the resident later without them while out of bed. Staff interviews confirmed the boots were not on, the NA’s shift sheet did not include the boot requirement, and the NP, LPN, RN, and DON all stated the boots were expected to be worn at all times.
The facility failed to ensure EVS staff followed infection control practices when handling soiled linens and cleaning rags for a resident on EBP for a wound, as one EVS staff member cleaned without gown or gloves and carried used cloths against her shirt, and another walked in the hallway with unbagged linens touching her body. The facility also failed to complete infection control surveillance for a resident with respiratory symptoms; the resident had a sore throat, cough, congestion, and low-grade temp, but the symptoms were not reflected in the care plan, Kardex, illness tracker, or change of condition log, and the DON/IP verified the tracking tools were not updated.
A resident with chronic pain syndrome experienced unmanaged pain and withdrawal symptoms due to the facility's failure to administer prescribed medications and notify the physician. The resident missed several doses of Belbuca and Lyrica, leading to increased anxiety and agitation. Staff interviews revealed issues with pharmacy delivery and prescription management, resulting in a lack of timely intervention.
A resident with mild cognitive impairment and multiple sclerosis had their wheelchair locked during mealtime, restricting movement without medical orders. Staff locked the wheelchair to prevent interaction with another resident, despite the resident's independence with wheelchair mobility. The Director of Nursing confirmed this action constituted a restraint.
Call light left out of resident's reach
Penalty
Summary
The facility failed to ensure a resident's call light was accessible. The resident had a modified significant change in status MDS indicating he could make himself understood and understand others, had moderate cognitive impairment, impairment in range of motion to the lower extremities, used a wheelchair, and was dependent on staff for toileting hygiene, showering and bathing, and transfers. His medical history included multiple sclerosis, dementia, anxiety, and depression. His Kardex stated he was alert and oriented times two to three and lacked information about what he required his call light for, and his care plan directed staff to ensure the call light was visible and within reach. During multiple observations, the resident was found in bed or in a reclining chair with his call light hanging off the foot of the bed, between the foot board and the air mattress, and out of his reach. Staff observed him in this condition on more than one occasion, including when he was in his room watching television and when he was in bed. A nursing assistant confirmed the call light was out of reach, and an RN stated the call light intervention was not on the Kardex and that staff were expected to ensure the call light was within reach. The DON stated staff were expected to follow the care plan and that it was important for the resident to have his call light in order to call for assistance.
Failure to Apply Ordered Heel Protector Boots
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not implemented for a resident with multiple sclerosis, dementia, diabetes, anxiety, depression, impaired lower-extremity range of motion, wheelchair use, dependence on staff for most ADLs, an indwelling catheter, occasional bowel incontinence, and an unstageable pressure ulcer. The resident’s MDS indicated moderate cognitive impairment and substantial to maximal assistance was needed for rolling. Orders and the care plan directed that Prevalon heel protector boots be worn on both feet at all times and removed daily to inspect the skin, and the resident also had treatment orders for a wound to the right great toe. The Braden Scale identified the resident as at moderate risk for developing a pressure sore. During observation, the resident was in a reclining chair and the Prevalon boots were on the counter in the room. When the resident was later brought to the dining room, the boots were not on. Staff interviews confirmed the resident was not wearing the boots, and the NA stated the shift sheet did not include the boot requirement. The NP, LPN, RN, and DON each stated the resident was expected to have the Prevalon boots on at all times, and the DON stated the boots should be on when the resident was in bed and up in the chair. Progress notes reviewed did not document that the resident refused to wear the boots.
Infection Control Failures With Linen Handling and Respiratory Surveillance
Penalty
Summary
The facility failed to ensure EVS staff followed infection control measures when handling potentially contaminated laundry and linens for a resident with a right lower leg wound who was on enhanced barrier precautions. During observation, one EVS staff member cleaned a resident bathroom without a gown or gloves, then held cleaning cloths against her shirt while carrying them out of the room before placing them in a plastic bag in the hallway. On another observation, a second EVS staff member exited a resident room and walked down the hallway with unbagged white linens touching her body. The DON/IP stated soiled resident linens and EVS cleaning towels should be bagged before leaving resident rooms and should not touch staff clothing. The facility also failed to complete infection control tracking and surveillance for a resident with respiratory symptoms. The resident had moderate cognitive impairment and required substantial to maximum assistance with toileting hygiene, bathing, and lower body dressing. The resident reported a sore throat and cough, and progress notes documented cold symptoms, sore throat, congestion, and cough with use of Mucinex and Geri-Tussin. The resident’s care plan, Kardex, illness tracker, and change in condition logs did not reflect the respiratory symptoms, and the DON/IP verified the illness tracker and change in condition log were not updated and that the resident was missed on the change of condition review. The DON/IP stated the facility tracked onset of symptoms, temperatures, and medications on a tracker and monitored residents for patterns or trends, but also stated the facility did not have a tracking system for outbreaks. The DON further stated the resident was not on precautions, though if testing was pending the resident would be placed on respiratory precautions. The report also noted the facility’s IPCP policy addressed surveillance, data analysis, outbreak management, and prevention of infection, and the EVS daily cleaning policy required soiled rags to be placed in a plastic bag on the cart, gloves removed, and hand hygiene performed before leaving the room.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to manage pain for a resident, identified as R23, in accordance with the comprehensive assessment, plan of care, and physician's orders. R23, who had a diagnosis of chronic pain syndrome with chronic opioid use due to a motor vehicle accident, experienced unmanaged pain and withdrawal symptoms. The resident's care plan included both pharmacological and non-pharmacological interventions for pain management, but these were not effectively implemented. R23's medication administration record indicated that the resident did not receive the prescribed Belbuca and Lyrica medications for several days, resulting in missed doses. This lapse in medication administration led to R23 experiencing increased anxiety, agitation, and withdrawal symptoms. Despite these symptoms, there was no documentation of physician notification or alternative interventions being provided during this period. Interviews with facility staff revealed that the medications were not available due to issues with pharmacy delivery and prescription management. The facility's registered nurse and nurse manager acknowledged the failure to notify the physician promptly and to provide necessary non-pharmacological interventions. The pain specialty physician confirmed that abrupt discontinuation of opioid medication could lead to severe withdrawal symptoms and increased pain, which was the case for R23.
Resident's Wheelchair Locked Without Medical Justification
Penalty
Summary
The facility failed to ensure that a resident, identified as R15, was free from the use of physical restraints during mealtime in the dining room. R15, who had mild cognitive impairment, multiple sclerosis, dementia with behavioral disturbance, and anxiety, was observed with their wheelchair locked on the left side, restricting their movement. Despite being independent with wheelchair mobility, R15's left wheel was locked by a nursing assistant to prevent interaction with another resident, R13, due to previous altercations. This action was taken without any medical orders or care plan instructions to restrict R15's movement. Throughout the observation period, R15 attempted to move their wheelchair but was only able to pivot in circles due to the locked left wheel. Staff members, including nursing assistants and a registered nurse, were present in the dining room but did not unlock the wheel until much later. Interviews with staff revealed that the wheelchair was locked to prevent R15 from approaching R13, and it was acknowledged that R15 did not know how to unlock the wheelchair. The Director of Nursing confirmed that locking the wheelchair to prevent movement would be considered a restraint, as R15 was unable to unlock it themselves.
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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 Greeley Llc | 0.6 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Stillwater | 0.7 mi | ★★★★★ | 9 | 0 |
| Gables Of Boutwells Landing | 2.2 mi | ★★★★★ | 10 | 0 |
| Christian Community Home | 6.8 mi | ★★★★★ | 0 | 0 |
| Cerenity Care Center White Bear Lake | 10.5 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.