Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Flagstone during CMS and state inspections, most recent first.
Staff failed to perform hand hygiene before and after administering medications to multiple residents. Observations showed that medication assistants and an RN did not sanitize their hands as required, even after touching residents and objects in resident rooms. Interviews with staff and a resident confirmed that hand hygiene was not consistently practiced during medication passes, contrary to facility policy.
The facility failed to provide a private meeting space for resident council meetings, holding them in the dining room during lunch without informing residents. This affected all residents who regularly attended, as they were not aware these were council meetings. The activity director and administrator did not ensure proper communication or privacy, contrary to facility policy.
The facility failed to assist residents with personal hygiene, as observed in three residents who required varying levels of assistance with ADLs. One resident with severe cognitive impairment was not shaved despite a care plan indicating a preference for it. Another resident, who needed moderate assistance, had significant facial hair and reported issues with obtaining a working shaver. A third resident, requiring maximal assistance, was not shaved regularly despite expressing a preference for frequent shaving. Staff interviews confirmed inconsistencies in providing shaving assistance.
The facility failed to assess the ability of three residents to self-administer medications before leaving medications with them. One resident had Nystatin powder on the bedside table without an order or assessment. Another resident had multiple medications, including eye drops and Tums, without orders for them to be left at the bedside. The third resident had Aspercream with lidocaine on the bedside table, despite the care plan indicating no self-administration except for Aspercream, but lacked an assessment. The director of nursing confirmed the absence of self-administration assessments for all three residents.
A resident with depression and malnutrition was not assisted into a wheelchair for meals as required by their care plan. Staff acknowledged the expectation but did not comply, assuming the resident would refuse. Interviews confirmed the care plan's importance for repositioning and quality of life, but no refusal was documented, and a care plan policy was not provided.
A resident receiving hospice services, who required assistance with daily activities, was not provided with meaningful and engaging activities as per her care plan. She reported not receiving an activities calendar or being invited to activities, which was confirmed by staff interviews. The life enrichment director and DON acknowledged the lack of documentation and engagement, leaving the resident feeling sad and isolated.
A resident with severe cognitive impairment and a recent fall resulting in a fracture was not provided with adequate fall prevention interventions. Despite being at high risk for falls, the resident's wheelchair was not placed next to the bed as required by the care plan, leading to a deficiency in the facility's fall prevention measures.
A newly admitted resident with chronic kidney disease and other conditions did not receive the required 30-day physician visits for the first 90 days. Despite being seen by a nurse practitioner, the resident's medical record lacked evidence of physician visits, contrary to the facility's policy. The administrator and DON confirmed the deficiency.
The facility failed to ensure medications were available and administered as ordered for two residents. One resident did not receive Creon for several days due to unavailability, and the provider was not notified. Another resident missed doses of Zoloft, with the medication initially not found in the cart. The facility's medication administration policy was not adequately followed, contributing to the deficiency.
A LTC facility experienced a 7% medication error rate due to two incidents involving incorrect medication administration. One resident with Crohn's disease did not receive their prescribed Creon due to unavailability, while another resident received a 4% Lidocaine patch instead of the ordered 5% due to pharmacy supply issues. The facility's medication administration policy, which includes the eight rights of drug administration, was not adhered to, resulting in these errors.
The facility failed to maintain a resident's room in good repair, with visible scuff marks, plaster coming off the walls, and dents present for over a month. Despite the facility's system for reporting maintenance issues, no work order was submitted to address the damage, compromising the resident's homelike environment.
The facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment and psychotropic medication use. The care plan lacked resident-specific goals and interventions, despite the resident's history of hallucinations and agitation. Interviews confirmed the care plan was general and did not meet the facility's policy requirements.
The facility failed to provide adequate grooming and shaving for a resident with moderate cognitive impairment and multiple health conditions. Despite the care plan and facility policy requiring daily grooming, observations over several days showed that the resident's facial hair was not addressed. Staff acknowledged the need for shaving and the availability of necessary supplies, but the task was not completed, leading to a deficiency in providing proper grooming care.
A resident with severe cognitive impairment, diabetes, and multiple pressure ulcers did not receive consistent care as outlined in the care plan. Despite the requirement to use blue heel boots and elevate legs with pillows at all times, staff failed to implement these interventions, leading to inadequate pressure ulcer management.
The facility failed to adequately monitor orthostatic blood pressures and weight changes for a resident using antipsychotic drugs and a diuretic. The resident experienced significant weight fluctuations and symptoms like dizziness and wheezing, which were not properly documented or reported to the provider. The facility did not follow the care plan and physician's orders for monitoring side effects and fluid status.
The facility failed to ensure appropriate follow-up on wound culture results for a resident with a stage 4 pressure ulcer, leading to potential inappropriate use of antibiotics and lack of special precautions. The resident's care plan and medical records lacked documentation of the wound infection, and staff interviews revealed inconsistencies in tracking and following up on culture results.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed during medication administration for five residents. Observations revealed that trained medication assistants and a registered nurse did not sanitize their hands before or after administering medications, despite handling residents, touching personal items in resident rooms, and preparing medications. For example, one medication assistant assisted a resident to stand, touched the resident's fridge, and administered medications without hand sanitization before or after the process. Another medication assistant and a registered nurse also failed to perform hand hygiene before entering resident rooms or after administering medications. Interviews with residents and staff confirmed that hand hygiene was not consistently practiced during medication passes. One resident reported rarely seeing staff sanitize their hands before or after giving medications. Both a registered nurse and a medication assistant acknowledged that hand sanitizer should be used before and after medication administration. The interim director of nursing also stated that hands should be sanitized between medication passes. Facility policy directs staff to perform hand hygiene before and after contact with residents and after contact with objects in resident rooms.
Lack of Private Meeting Space for Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were provided a private meeting place without staff present for resident council meetings, affecting all five residents who regularly attended these meetings. Interviews with residents revealed that they were not aware of the resident council meetings, as they were not invited or informed about them. The activity director conducted the meetings during lunch in the dining room, which was not communicated as a resident council meeting to the residents. This practice did not allow for a private setting where residents could freely express their concerns. The review of the resident activity calendar showed that the location of the meetings was not specified, and the activity director was unable to explain how residents who did not eat in the dining room were invited to the meetings. The administrator believed that residents could discuss concerns privately with the activity director or fill out a grievance form, but did not see an issue with the meetings being held in the dining room with staff present. The facility's policy stated that residents should have the opportunity to meet in a private space, which was not adhered to in this case.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for four residents, all of whom required varying levels of assistance with activities of daily living (ADLs). Resident R7, who had severe cognitive impairment and required staff assistance for personal hygiene, was observed with long facial hair despite the care plan indicating a preference for being shaved when facial hair was visible. Staff interviews revealed that R7 had not been shaved recently, and there was uncertainty about the last time shaving assistance was provided. Resident R33, who had no cognitive impairment but required moderate assistance with personal hygiene, was observed with significant facial hair over multiple days. R33 reported that his shaver was not working and was under the impression that residents needed to purchase their own shavers. Staff confirmed that shaving tasks were not completed daily, and there was a lack of readily available shavers for residents. Resident R267, who required maximal assistance with personal hygiene, was also observed with long facial hair over several days. Despite expressing a preference for being shaved often, R267 was not shaved regularly, and staff were unclear about the frequency of shaving required. The facility's policy indicated that ADL care should be provided based on resident preferences, but observations and interviews demonstrated a failure to adhere to this policy.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that residents' ability to self-administer medications was assessed before leaving medications with them. Three residents were involved in this deficiency. The first resident, identified as R33, had no cognitive impairment but required moderate assistance with personal hygiene. Despite this, Nystatin powder was found on the resident's bedside table without an order to leave it there or an assessment for self-administration. The care plan for R33 lacked information regarding self-administration of medication, and the registered nurse confirmed the medication should not have been left at the bedside. The second resident, R267, also had no cognitive impairment and required maximal assistance with personal hygiene. This resident had several medications, including eye drops and Tums, on the bedside table without orders for them to be left there. The care plan indicated that R267 chose not to self-administer medications, and there was no assessment for self-administration. A licensed practical nurse confirmed the presence of these medications and the lack of orders for them to be left at the bedside. The third resident, R9, had no cognitive impairment and needed moderate assistance with activities of daily living. Aspercream with lidocaine was found on the bedside table, although the care plan indicated that R9 chose not to self-administer medications except for Aspercream. However, there was no assessment for self-administration, and the registered nurse confirmed the lack of an order for self-administration. The director of nursing verified that none of the three residents had self-administration assessments completed, which was against the facility's medication administration policy.
Failure to Follow Care Plan for Resident's Meal Positioning
Penalty
Summary
The facility failed to adhere to the comprehensive care plan for a resident identified as R62, who was diagnosed with depression and malnutrition and required extensive assistance with activities of daily living. The care plan, revised on 12/30/24, specified that R62 should be up in her wheelchair for all meals due to limited physical mobility and self-care deficits. However, during an observation on 1/28/25, a nursing assistant (NA-F) delivered R62's meal tray to her bedside and did not assist R62 into her wheelchair, contrary to the care plan instructions. NA-F acknowledged the expectation to get R62 up for meals but did not do so, assuming R62 would refuse. Interviews with staff, including a registered nurse (RN-C), a household coordinator (HC), and the director of nursing (DON), confirmed that R62 was supposed to be in her wheelchair for meals to aid in repositioning and quality of life. The DON emphasized the expectation for staff to follow care plans and report any refusals. Despite these expectations, the care plan was not followed, and no documentation of refusal was noted. Additionally, the facility was unable to provide a care plan policy when requested.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful and engaging activities for a resident, identified as R62, who was reviewed for activities. R62, who had no cognitive impairment and was receiving hospice services, required extensive assistance with activities of daily living. Her care plan indicated a preference for visits from her daughter, talking with staff, watching television, one-to-one visits, and group activities. However, R62 reported not being offered any activities or visitors since her admission and did not have an activities calendar in her room, which was confirmed by observations and interviews. The life enrichment director confirmed that activity calendars were supposed to be distributed to each resident at the beginning of the month and that staff were expected to invite residents to group activities. However, there was no documentation to confirm that R62 had been invited to or participated in any activities. The director of nursing corroborated these findings, acknowledging the lack of documentation and stating that staff were expected to engage all residents in daily activities. Despite the facility's procedures, R62 was left without engagement, leading to feelings of sadness and isolation.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions for a resident who had a recent fall resulting in a significant injury and remained at high risk for falls. The resident, identified as having severe cognitive impairment and diagnoses including anxiety disorder, dementia, and a left humerus fracture, required extensive assistance with activities of daily living. Despite being identified as high risk for falls, the resident's care plan was not adequately followed, as evidenced by the improper placement of the resident's wheelchair, which was supposed to be next to the bed as a fall prevention measure. Observations and interviews revealed that the resident's wheelchair was found five feet away from the bed and in the bathroom, contrary to the care plan's instructions. Nursing staff, including a nursing assistant, nurse manager, and the director of nursing, confirmed the resident's recent fall and the expectation that the wheelchair should have been placed next to the bed. The facility's Fall Prevention and Management Program Policy required that all residents be assessed for fall risk and that interventions be implemented according to specific risk factors, which was not adhered to in this case.
Failure to Provide Required Physician Visits for New Resident
Penalty
Summary
The facility failed to ensure that a newly admitted resident received the required 30-day physician visits for the first 90 days after admission. The resident, identified as R30, was admitted with no cognitive impairment and had diagnoses including chronic kidney disease, an indwelling catheter, and a history of urinary tract infections. R30 required moderate assistance with activities of daily living such as bathing, transfers, and toileting. Despite these needs, R30's medical record showed no evidence of being seen by a physician since admission. During interviews, R30 confirmed not having seen a physician and expressed that staff avoided him when he requested a visit. Although R30 had been seen by a nurse practitioner three times, the facility's policy required physician visits every 30 days for the first 90 days, which was not met. The administrator and director of nursing confirmed these findings and acknowledged the failure to adhere to the facility's policy.
Medication Availability and Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for two residents, R61 and R57. R61, who had moderate cognitive impairment and diagnoses including Crohn's disease, heart failure, and chronic kidney disease, did not receive Creon, a medication necessary for pancreatic insufficiency, from January 22 to January 28. The medication was not available, and the facility's process to reorder it was not effectively implemented. The pharmacy was contacted, but the provider was not notified of the unavailability of the medication, which was a critical step missed in the process. R57, who had moderate cognitive impairment and diagnoses including hypertension, depression, Alzheimer's, aphasia, and seizure disorder, did not receive Zoloft, a medication for depression, on January 26 and 27. The medication was not found in the medication cart initially, but was later located in the medication room. The facility's process for reordering medications was not followed, and the physician was not informed of the missed doses, which was a necessary action to ensure continuity of care. The facility's medication administration policy, revised in May 2021, was not adequately followed. The policy required the eight rights of drug administration to be adhered to and included instructions to contact the pharmacy if medications were unavailable. However, it lacked specific guidance on notifying the resident's provider if a medication was not available, which contributed to the deficiency in ensuring medications were administered as ordered.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility had a medication error rate of 7%, exceeding the acceptable threshold of 5%, due to errors in medication administration for two residents. One resident, identified as R61, who had moderate cognitive impairment and diagnoses including Crohn's disease, heart failure, and chronic kidney disease, did not receive their prescribed Creon medication from 1/22/25 because it was unavailable. The trained medication aide (TMA) responsible for administering the medication indicated that the Creon was not available and planned to reorder it from the pharmacy. The clinical coordinator confirmed the medication had not been administered since 1/22/25, and the director of nursing (DON) later discovered the issue was due to an insurance problem. Another resident, R44, who was cognitively intact and had diagnoses including arthritis and sciatica, received an incorrect dosage of Lidocaine patch. The order was for a 5% Lidocaine patch, but a 4% patch was administered instead because the pharmacy did not have the 5% version. The TMA acknowledged the discrepancy, and the clinical coordinator confirmed the error. The facility's usual process for handling unavailable medications was not followed, as the physician was not contacted to determine if an alternative medication should be administered. The facility's policy requires adherence to the eight rights of drug administration, which was not followed in these instances, leading to the medication errors.
Failure to Maintain Resident Room in Good Repair
Penalty
Summary
The facility failed to ensure that a resident's room walls were in good repair, compromising the homelike environment for a resident with severe cognitive impairment who required extensive assistance with mobility and daily living activities. The resident's room had visible scuff marks, plaster coming off the walls, and dents, which had been present for more than a month. Family members and nursing assistants confirmed that the damage was likely caused by the resident's wheelchair and mechanical lift used by staff. Despite the facility's system for reporting maintenance issues, no work order had been submitted to address the wall damage in the resident's room. Interviews with staff, including the environmental services director, nursing assistants, and the director of nursing, revealed that maintenance issues should be reported immediately and addressed within 24 hours. However, the system failed in this instance, as no work order was found for the resident's room repairs. The facility's administrator confirmed that there was no specific policy on maintaining a homelike environment, although residents were provided with a rights booklet upon admission, which included the right to a safe, clean, and comfortable environment.
Failure to Develop Comprehensive Care Plan for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident (R54) who was taking psychotropic medications, including an antipsychotic. The resident had severe cognitive impairment, Alzheimer's disease, psychotic disorder, and legal blindness. The care plan lacked resident-specific goals and interventions for psychotropic medication use, including person-centered goals and resident-specific interventions to address target behaviors. The care plan identified the use of antidepressant, antianxiety, and antipsychotic medications but did not provide details about the medications and resident-specific behaviors and interventions. The resident's Care Area Assessments (CAAs) indicated restlessness, agitation, and a history of hallucinations treated with psychotropic drugs. Despite this, the care plan did not include non-pharmacologic interventions or specific details about the resident's previous favorite activities. Interviews with the hospice case manager, a registered nurse, and the director of nursing confirmed that the care plan was general and lacked the necessary specifics. The facility's policies on psychotropic and unnecessary medication use and care planning required individual interventions, which were not reflected in the resident's care plan.
Failure to Provide Adequate Grooming and Shaving for Resident
Penalty
Summary
The facility failed to provide adequate grooming and shaving for a resident (R22) who was dependent on staff for activities of daily living (ADLs). R22 had moderate cognitive impairment and required assistance with personal hygiene due to conditions such as depression, anxiety, dementia, and psychosis. Despite the care plan indicating that R22 should be clean and well-dressed daily with staff assistance for personal hygiene, observations over several days showed that R22 had significant facial hair that was not addressed. Nursing assistants and other staff members were observed interacting with R22 multiple times without addressing the facial hair, and it was noted that the electric razor might need new batteries, which were readily available in the supply room. The director of nursing confirmed that shaving should occur every bath day, and there were no special preferences for R22 regarding facial hair. However, the facial hair remained unchanged throughout the observations, indicating a failure to follow the care plan and facility policy for daily grooming and shaving. The observations and interviews revealed that the nursing assistants and other staff members did not adequately perform grooming tasks, specifically shaving, for R22. Despite the care plan and facility policy requiring daily morning and bedtime care, including shaving, R22's facial hair was not addressed over several days. The nursing assistant acknowledged the need for shaving and the availability of batteries for the electric razor, but the task was not completed. The registered nurse and director of nursing both confirmed the expectation for staff to assist with shaving, highlighting a lapse in the execution of these duties, leading to the deficiency in providing proper grooming care for R22.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure proper interventions were in place for a resident with pressure ulcers. The resident, who had severe cognitive impairment, diabetes, peripheral vascular disease, and dementia, was frequently incontinent and required extensive assistance with mobility and toileting. The resident had multiple pressure ulcers, including a stage three pressure ulcer on the left heel, an unstageable pressure ulcer, a diabetic foot ulcer, and moisture-associated skin damage. The care plan indicated the use of blue heel boots and pillows to elevate the legs at all times, both in bed and in the wheelchair, to reduce pressure and promote healing. However, observations revealed that the resident did not have a pillow under her legs while in the wheelchair on multiple occasions. Despite the care plan and task forms indicating the need for leg elevation, staff failed to consistently implement this intervention. Interviews with staff, including a licensed practical nurse (LPN) and a nursing assistant (NA), confirmed that the resident was supposed to have pillows under her legs at all times. The LPN and NA acknowledged the oversight and verified that the care sheet required leg elevation, but the intervention was not consistently followed. The facility's Skin Integrity Management Policy emphasized the importance of implementing preventative measures and appropriate treatment modalities for pressure ulcers. Despite this policy, the staff did not adhere to the care plan's interventions, resulting in the resident not receiving the necessary care to prevent further skin breakdown. The director of nursing (DON) and other staff members acknowledged the deficiency and the expectation that the care plan should be followed to ensure the resident's well-being.
Failure to Monitor Orthostatic Blood Pressures and Weight Changes
Penalty
Summary
The facility failed to ensure adequate monitoring of orthostatic blood pressures for a resident using antipsychotic drugs and did not adequately monitor weights and fluid status for the same resident. The resident, who had moderate cognitive impairment, received a diuretic, an antidepressant, and an antipsychotic on a routine basis. The resident's diagnoses included high blood pressure, high cholesterol, peripheral vascular disease, edema, depression, anxiety, insomnia, dementia, and psychosis. Despite the care plan indicating the need for monitoring side effects and targeted behaviors, the facility did not document orthostatic blood pressures as required by the physician's orders and the facility's policy on psychotropic and unnecessary medication use. The resident's electronic health record (EHR) lacked documentation of orthostatic blood pressures, and the treatment administration record (TAR) only showed completion for side effect monitoring on two specific dates. Additionally, the resident's EHR revealed significant weight fluctuations that were not reported to the provider as required. The resident's weights showed differences of more than 5 pounds on multiple occasions, but there was no documentation that the provider was updated regarding these changes. The resident's care plan identified the need to monitor weights and fluid status due to the use of a diuretic and the risk of dehydration or fluid deficit. During observations and interviews, it was noted that the resident experienced dizziness, leg tenderness, and audible wheezing, which were not adequately addressed by the staff. The nursing assistant and registered nurse acknowledged the resident's symptoms but did not follow through with proper documentation or notification to the provider. The director of nursing confirmed that the facility did not follow up on the provider's plan to monitor weight and fluid status and acknowledged the lack of documentation and provider notification for the resident's weight changes and orthostatic blood pressures.
Failure to Follow Up on Wound Culture Results
Penalty
Summary
The facility failed to implement a system to ensure appropriate follow-up on wound culture results for a resident with a stage 4 pressure ulcer, leading to potential inappropriate use of antibiotics and lack of special precautions. The resident had multiple diagnoses, including multiple sclerosis, paraplegia, and a history of urinary tract infections. Despite having a wound culture obtained at a wound clinic, the facility did not follow up on the culture and sensitivity report in a timely manner, resulting in a delay in appropriate treatment and precautions for the resident's wound infection, which included MRSA and mixed flora bacteria. The resident's care plan and medical records lacked documentation of the wound infection and the necessary follow-up on the wound culture report. The facility's antibiotic tracking log indicated the presence of a wound infection but did not document the follow-up of the culture results. Interviews with staff revealed inconsistencies in the process of tracking and following up on culture results, with the infection preventionist and registered nurse acknowledging the lack of documentation and follow-up on the wound culture report. The facility's policy on infection prevention and control, including antibiotic stewardship, emphasized the importance of tracking and reporting antibiotic use and outcomes. However, the facility failed to adhere to these guidelines, resulting in a deficiency in ensuring appropriate follow-up on wound culture results and the implementation of necessary precautions for the resident's wound infection.
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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 Eden Prairie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Village Of Bloomington | 2.1 mi | — | 13 | 0 |
| Hopkins Restorative Care Center | 4.4 mi | — | 23 | 0 |
| Hope Springs At Minnetonka | 5.4 mi | — | 0 | 0 |
| Augustana Chapel View Care Center | 5.5 mi | — | 6 | 0 |
| Aurora On France | 5.6 mi | — | 0 | 0 |
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