Good Samaritan Society - Stillwater

In the surveyor’s words

From the most serious findings on record at Good Samaritan Society - Stillwater, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 23, 2024

  Based on observation, interview and document review, the facility failed to assess for and implement appropriate interventions to decrease the risk for falls for 4 of 4 residents (R189, R7, R29, R24) reviewed for falls. This failure led to actual harm for R189 when R189 obtained a right ankle fracture after a fall. Findings include: R189 R189's admission MDS dated [DATE], indicated R189 was admitted to the facility on [DATE], at risk for falls and had a fall with injury prior to admission. Further indicated, diagnosis of open reduction internal fixation (ORIF) of the left femur. R189's cognitive loss/dementia CAA dated 9/2/23, indicated R189 had confusion, disorientation, and forgetfulness and requires frequent reorientation, reassurance, and reminders to help make sense of things. […]

• No harm, potential for more than minimal, widespreadF801Feb 12, 2026

  Based on interview and document review, 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. This had the potential to affect all 34 residents who resided in the facility.Findings include:Dietary manager qualifications were requested however were not received. The registered dietitian worked part time at facility. When interviewed on 2/11/26 at 2:00 p.m., the administrator stated the facility had a part time dietitian who worked between two facilities. The administrator stated dietary manager did not have required qualifications however was signed up for classes. When interviewed on 2/12/26 at 1:08 p.m. stated DM had accepted the role in November as DM. […]

• No harm, potential for more than minimal, widespreadF801Apr 23, 2024

  Based on interview and record review, 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. This had the potential to affect all 39 residents who resided in the facility. Findings include: The facility's undated list of hires did not include a DM. The interim dietary supervisor (DS)'s qualifications for a dietary manager was requested however was not received. When interviewed on 4/15/24 at 1:08 p.m., the DS stated there was not a DM currently employed at the facility. DS was a DS at a sister facility and was currently working both facilities. DS further stated there had been a lot of turnover in the kitchen staff and the facility was working on hiring. […]

• No harm, potential for more than minimal, widespreadF802Apr 23, 2024

  Based on observation, interview, and record review the facility failed to ensure sufficient support staff with the appropriate competencies to carry out the functions of the food and nutrition services. This had the potential to affect all 39 residents who reside in the facility. Findings include: The facility's undated list of hires did not include a dietary manager (DM). An undated facility document titled Annual and New Hire Education Dietary indicated all dietary staff had required training titled Basics of Food Safety in Long Term Care Facilities and IDDSI training for safe swallowing. […]

• No harm, potential for more than minimal, widespreadF812Apr 23, 2024

  Based on observation, interview, and document review, the facility failed to ensure frozen and refrigerated food items were properly stored, labeled, and dated and disposed of after expiration date. Furthermore, the facility failed to ensure the ice machine and air vents were clean and sanitary. This deficient practice had the potential to affect all 39 residents who receive food from the kitchen. Findings include: Food Storage During the initial kitchen observation on 4/15/24, at 12:46 p.m., the walk-in freezer contained the following: -a Ziplock bag labeled corn beef hash dated 2/11/24. The contents of the bag were brown meat with crystals of ice that had formed on the meat and the inside of the bag. -a Ziplock bag labeled turkey dated 4/12/24. […]