Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Flagstone during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, anxiety, depression, psychotic disorder, and severely impaired cognitive decision-making skills was prescribed Seroquel for psychosis, but the medical record lacked evidence that informed consent for the current dose and frequency was obtained before administration. An LPN could not find documentation of consent and believed verbal consent may have been obtained, while the resident’s POA said he was not informed of the most recent antipsychotic medication updates. The unit RN stated floor nurses were responsible for contacting family, discussing risks and benefits, and obtaining consent, with the signed form uploaded to the chart.
Missing Instructions for Multiple PRN Psychotropic Medications: A resident with dementia, Alzheimer’s disease, anxiety, depression, and a psychotic disorder had PRN lorazepam and PRN Depakote ordered for agitation, but the care plan and order summary did not include instructions on which medication to give first or how to choose between them. An LPN stated he was unsure which PRN to use first and would just pick one, and an RN confirmed the orders lacked administration guidance.
Incomplete MDS Assessment: A resident’s annual MDS was not completed comprehensively, with multiple required sections for hearing, cognition, mood, and preferences left dashed or blank despite skip patterns indicating further assessment was needed. The MDS coordinator stated parts of the assessment were missed before the ARD and were not found in time to complete, and the DON stated floor nurses completed the MDS while unit managers were responsible for ensuring it was completed accurately.
A resident with severe cognitive impairment and dependence for ADLs was observed with multiple long beard strands on her chin, despite care plan directions for staff to anticipate and meet her needs and provide assistance with grooming and hygiene. RNs confirmed she needed shaving during morning cares or shower day, NA staff said female facial hair should be shaved unless the care plan said otherwise, and the DON stated it was a dignity issue.
A resident with CHF, kidney failure, diabetes, and limited mobility developed recurring redness and scabbing under both eyes where a CPAP mask rested. Staff documentation noted intact skin, but surveyors observed the facial skin alteration, and staff interviews showed the issue had not been consistently reported, assessed, or documented. The mask was found sitting on the affected skin, and staff believed it may have been too tight and improperly adjusted.
A resident using CPAP had nightly use documented and staff applied and removed the device as ordered, but the medical record did not include the CPAP/BiPAP equipment settings. RNs and the DON stated the resident likely came with a preset machine and staff were unsure where the settings were documented, and no order for settings was found in the record.
A facility failed to ensure the CP identified and acted on an irregularity during the monthly med regimen review for a resident receiving Seroquel. The resident had dementia, depression, and behavioral symptoms, and the chart showed Seroquel ordered for sundowning/exit-seeking behavior, but the pharmacist documented no irregularities or recommendations. Staff later said they were unsure of the diagnosis supporting the antipsychotic order, and the CP stated he would have questioned the order if he had noticed it.
A resident with chronic pain and muscle spasms did not receive scheduled baclofen at the ordered 7:30 a.m. time, and morning meds were repeatedly given late, sometimes after 11:00 a.m. The resident and family reported the delays caused pain, and staff confirmed the meds were expected to be given at the ordered time or within the usual medication window.
Failure to Follow EBP and Hand Hygiene Requirements: Staff did not consistently follow EBP for residents with indwelling catheters and did not perform hand hygiene as required. Nursing assistants and an LPN provided direct care, repositioning, catheter-related care, and other high-contact activities without the required gown changes or hand hygiene, despite EBP signs, PPE carts, and facility policy requiring gloves, gowns, and hand hygiene during these resident care tasks.
A resident with recurrent fainting episodes, often while on the toilet, was left without documented care plan interventions or safety precautions. The resident required substantial to maximum assistance with toileting, and staff interviews showed inconsistent awareness about the episodes and whether she could be left alone in the bathroom. The clinical coordinator stated the episodes mostly happened on the toilet and that the resident was not safe to be left alone there.
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 Obtain and Document Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain and document informed consent, including an explanation of risks and benefits, for the use of psychotropic medication for one resident. The resident’s quarterly MDS indicated long-term and short-term memory impairment, severely impaired cognitive decision-making skills, Alzheimer’s disease, anxiety, depression, and a psychotic disorder. The resident’s order summary showed orders for Seroquel 50 mg twice daily and 25 mg daily for psychosis, both with a start date of 3/12/26, but the medical record lacked evidence that consent for the current dose and frequency had been obtained before the medication was administered. During interview, the LPN who cared for the resident stated he reviewed the record and could not find documentation that consent had been obtained, although he believed he had spoken with the resident representative and obtained verbal consent. The resident representative, who was confirmed to be the resident’s POA, stated he had been informed of medication changes in the past but did not believe he had been informed of the most recent March updates to the resident’s antipsychotic medications, including the Seroquel started on 3/12/26. The unit nurse manager stated that floor nurses were responsible for contacting family, discussing the risks and benefits of psychotropic medications, and obtaining consent, and that a form signed by the resident representative would be uploaded to the medical record. The facility’s Psychotropic Medication Use policy dated 3/2025 stated informed consent was to be obtained for psychotropic medications used for behavior management.
Missing Instructions for Multiple PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure instructions for use of multiple as-needed (PRN) psychotropic medications were included for a resident with significant cognitive impairment and psychiatric diagnoses. R43’s quarterly MDS indicated long-term and short-term memory impairment, severely impaired cognitive decision-making skills, Alzheimer’s disease, anxiety, depression, and a psychotic disorder, while also noting no hallucinations, delusions, or rejection of care during the look-back period. R43’s care plan identified altered mood or behavioral expression and dementia with psychotic features, with target behaviors including paranoia, beliefs that were not real, anger at caregivers and family, physical aggression, and wandering/yelling in the hall at others or things that were not there. The care plan also addressed anticonvulsant use, including gabapentin and Depakote, for complaints of pain with ADLs and refusal to complete ADLs, but it did not include instructions for PRN psychotropic use or the order in which medications should be given. R43’s order summary included PRN lorazepam for agitation and psychosis and PRN delayed-release Depakote sprinkles for agitation, but there were no further instructions identifying which medication should be given first or what symptoms each should address. The MAR showed the PRN Depakote was administered eight times and PRN lorazepam was administered four times, with one lorazepam dose documented with a nursing note of agitation. During interview, the LPN stated he used either PRN lorazepam or Depakote when R43 was restless or agitated and was unsure which medication to try first, so he would pick one. An RN confirmed there were no instructions for administration of the PRN psychotropic medications, and the DON stated that when a resident has multiple PRN medications for agitation, the IDT would need to meet and develop a plan with further instructions for when each medication should be administered.
Incomplete MDS Assessment
Penalty
Summary
The facility failed to ensure a complete and comprehensive MDS was completed for one resident, R4, during the annual assessment. The annual MDS dated [DATE] showed multiple sections left incomplete or dashed despite skip patterns indicating further assessment should have been completed. In Section B, B0100 was marked no, but B0200 through B1000 for hearing, speech, understanding, communication, and vision were dashed. In Section C, C0100 was marked yes, but C0200 through C1310 for mental status, memory, cognitive skills, and delirium were dashed. In Section D, D0100 was marked yes, but the mood interview items D0150 A-I were dashed, D0160 was scored 99 indicating the interview could not be completed, and the staff mood assessment items D0500 through D0600 were left blank. In Section F, F0300 was marked yes, but F0400 A-H for daily preferences were dashed and F0800 for the staff assessment of daily and activity preferences was left blank. The MDS coordinator stated she received an email that parts of the assessment, including mood, cognition, and social assessment, had been missed before the ARD, but by the time she looked for the assessments it was past the ARD and she dashed the areas for which she could not find an assessment. The DON stated floor nurses completed the MDS assessments and unit managers were responsible for ensuring they were completed and accurate.
Failure to Provide Routine Facial Hair Grooming
Penalty
Summary
The facility failed to ensure routine personal hygiene care, specifically facial hair removal, was provided for a resident who was dependent on staff for activities of daily living. The resident’s quarterly MDS indicated severe cognitive impairment, no refusal of personal cares, and a need for setup or cleaning assistance with oral hygiene and personal hygiene, as well as moderate assistance with bathing, dressing, and toileting hygiene. The resident’s diagnoses included chronic diastolic heart failure, amnesia, essential hypertension, muscle weakness, and bilateral shoulder pain. The care plan stated the resident was cognitively impaired, had difficulty communicating, and staff were to anticipate and meet her needs; it also identified self-care performance deficits and the need for assistance from one staff member with dressing, grooming, and hygiene. During observation, the resident had about 12 beard strands on her chin, each approximately 4 to 5 centimeters long, and she responded to questions by raising her shoulders. RN-D verified the facial hair and stated nursing assistants needed to help her shave. RN-B stated the resident needed to be shaved on shower day or during morning cares, and noted the resident sometimes became agitated during personal cares, while also confirming there was nothing documented in the care plan about refusing shaving. NA-B stated she shaved female residents’ facial hair unless the care plan indicated otherwise, and the DON stated female facial hair needed to be shaved and that it was a dignity issue. The resident representative later reported seeing a razor in the resident’s room and that staff had shaved her, making her look nicer.
Failure to Assess and Address CPAP-Related Facial Skin Breakdown
Penalty
Summary
The facility failed to comprehensively assess and address a pressure-induced skin alteration for a resident who had intact cognition, no rejection of care behaviors, and diagnoses including heart failure, kidney failure, and diabetes. The resident’s MDS indicated functional limitations in range of motion to both upper extremities, moderate assistance needed for toileting hygiene and bed mobility, dependence for bathing, and risk for pressure ulcers. The care plan identified the resident as at risk for skin impairment and directed staff to inspect the skin during care, notify the nurse of any new breakdown, assist with repositioning and toileting, and help apply the CPAP machine per orders. The resident’s CPAP/BiPAP was documented as being applied nightly and removed each morning, and a progress note stated the skin was clean, dry, and intact. However, during observation and interview, the resident was found with redness and a dark red scab under the right eye in a facial wrinkle where the CPAP mask rested, and later also had new redness in the mirrored wrinkle on the left side of the face. The resident stated the area had drainage, slight pain, and believed it was caused by the CPAP mask. Nursing staff observed the mask sitting on top of the skin alterations, and RN-A stated the mask might be too tight and that the issue had not been reported to him. Interviews with staff showed the skin alteration had not been consistently communicated or documented. A nursing assistant stated the redness and scabbing under the eyes had been recurring and that the scab had been bleeding slightly when the CPAP was removed that morning, and she thought she had told an LPN about it. The LPN did not recall noticing the redness or scabbing and was unsure whether staff had reported it. The unit nurse manager stated she had not been notified before surveyor questioning and observed that staff had been unvelcroing the straps instead of using the clips, which altered the strap length. The facility’s skin integrity policy required inspection of skin under medical devices every shift and weekly body audits, but the resident’s facial skin alteration had not been fully assessed or documented before surveyor observation.
Missing CPAP Settings in Resident Orders
Penalty
Summary
The facility failed to ensure that a resident using a CPAP machine had an appropriate order that included the equipment settings. R19’s annual MDS indicated intact cognition, no rejection of care behaviors, and diagnoses including heart failure, kidney failure, and diabetes. The care plan directed staff to assist R19 in applying his CPAP machine per MD/NP orders, and the order summary included orders for nightly use, overnight checks, morning removal, tubing cleaning, and filling the chamber with water before use, but no CPAP or BiPAP settings were documented in the order summary. R19’s MAR showed the CPAP/BiPAP was applied every night and removed every morning during the review period. During observation, R19 was in his room with a ResMed Airsense 10 CPAP machine on his bedside table and stated he wore it at night and had used it since before admission. RN-A stated he did not know R19’s CPAP settings and believed the machines were preset, while RN-B stated she was unsure whether the facility had any record of the settings and did not think they did. The DON stated that residents usually arrived with preset CPAP machines but expected the orders to be part of the medical record. The facility’s CPAP and BiPAP Management policy directed staff to review the care plan and physician’s orders if required, but did not specify what those orders should include.
Pharmacist Failed to Identify Irregular Antipsychotic Use
Penalty
Summary
The facility failed to ensure the consulting pharmacist identified and acted upon an irregularity during the monthly drug regimen review for a resident receiving psychotropic medication. The resident had severely impaired cognition and diagnoses of dementia and depression, with the medical diagnosis summary also listing dementia with other behavioral disturbance, cognitive communication deficit, and dementia without behavioral/psychotic/mood disturbance or anxiety. The care plan identified use of Seroquel for dementia with behavioral disturbance and noted the dose had been decreased to once daily at bedtime, with target behaviors of crying and talking about needing to get out. The resident’s provider later ordered Seroquel 6.25 mg daily at 2 p.m. for sundowning, and a progress note stated the resident had vascular dementia, sundowning association, and exit-seeking behavior with a desire to call the police in the afternoon. When the pharmacist reviewed the medication regimen, the review documented no irregularities and no recommendations. During interviews, nursing staff stated they were unsure of the diagnosis supporting Seroquel, and the unit nurse manager said the order for sundowning seemed unusual. The consulting pharmacist stated that if he had noticed an antipsychotic ordered for sundowning, he would have sent a letter to the provider to verify an appropriate diagnosis. The facility’s psychotropic medication use policy required the consultant pharmacist to review the medical record for irregularities and report them to the DON and attending physician.
Significant Medication Error: Late Administration of Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that a resident’s medications were administered at the ordered time, resulting in a significant medication error and worsened pain for one resident. The resident was admitted with cognitive intactness and required substantial to maximum assistance with dressing, bathing, and toileting. Her quarterly MDS indicated she received scheduled and as-needed pain medication and had a pain rating of 7/10 in the past five days. Her orders included baclofen 7.5 mg three times daily at 7:30 a.m., 1:00 p.m., and 6:00 p.m. for muscle spasms, along with baclofen 2.5 mg twice daily as needed for muscle spasms, and the order specified to give morning medications around 7:30 a.m. The resident’s MAR showed repeated reports of pain at 5/10 or higher on 30 shifts and as-needed oxycodone given twice for 9/10 pain. During observation, the resident and a family member stated the resident had frequent back pain and that morning medications were often given late, sometimes after 11:00 a.m., despite being scheduled for 7:30 a.m.; they stated the late administration caused pain. At 10:55 a.m., the resident still had not received her morning medications. A TMA stated she had not given the medications because she was waiting for the nurse to obtain AREDS 2. Staff interviews confirmed that medications ordered for a specific time were expected to be given within one hour before or after that time, and the DON stated it was concerning that the resident’s morning medications were being administered past 11:00 a.m. and that the 7:30 a.m. medications were expected to be given at the ordered time to keep the resident comfortable.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed for residents with indwelling urinary catheters and failed to perform hand hygiene for one resident during care. R26 had intact cognition, was dependent on staff for all personal care and transfers, and had an indwelling catheter with physician orders for EBP due to the catheter. Although an EBP sign and PPE cart were present outside the room, a nursing assistant combed R26’s hair, repositioned her in her wheelchair, and attached her urine drainage bag to the wheelchair without wearing a PPE gown. On another occasion, a nursing assistant entered R26’s room with a blood pressure monitor and thermometer, obtained vital signs, and exited without wearing a PPE gown or mask. R51 had intact cognition, was dependent on staff for hygiene and personal care, and had diagnoses including multiple sclerosis, neurogenic bladder, and quadriplegia with a suprapubic catheter. During observation, two nursing assistants transferred R51 with a Hoyer lift while wearing gloves, gowns, and masks, but during care one assistant applied ointment to the buttock and trimmed an abdominal pad around the stoma without changing gloves or performing hand hygiene, and the other emptied the catheter without changing gloves or performing hand hygiene. Later, an unidentified staff member entered R51’s room to answer a call light and provide water without sanitizing or washing hands upon entry. The DON stated staff were expected to wash or sanitize hands before entering any resident room and on exit, and that any staff touching a resident on EBP should wear a gown, mask, and gloves. R4 had an indwelling urinary catheter and was on EBP due to the catheter. During observation, an LPN entered the room wearing gloves but no gown, performed fingerstick blood glucose testing and administered insulin, then removed gloves and performed hand hygiene. When R4 asked to be boosted in bed, the LPN, without gloves or a gown, leaned over the bed and attempted to reposition her by grabbing the sheet under her. The LPN stated a gown and gloves were only needed when changing wounds or working with the catheter. The facility policy stated EBP requires hand hygiene, gloves, and a gown during high-contact resident care activities for residents with wounds or indwelling medical devices.
Failure to Protect a Resident With Recurrent Fainting Episodes
Penalty
Summary
The facility failed to ensure safety measures were in place to prevent accidents for a resident with known fainting episodes, often while on the toilet. The resident’s quarterly MDS indicated she was cognitively intact and required substantial to maximum assistance with dressing, bathing, and toileting. Her family member stated the facility was aware of multiple fainting episodes, including one most recently while she was on the toilet, and expressed concern about her being left alone in the bathroom. The resident’s care plan did not mention her fainting spells or include interventions for her safety or staff actions during or after an episode. Her orders included DNR status and an instruction not to transfer her to the ER for a fainting episode lasting less than 15 minutes, with family to be called immediately. Progress notes documented a fainting episode while she was sitting on the toilet with blood coming from her mouth, and another episode while being transferred from the toilet to her bed via a stand lift. Staff interviews showed inconsistent awareness of the episodes and whether she could be left alone on the toilet, while the clinical coordinator stated the episodes mostly happened on the toilet and that she did not feel the resident was safe to be left alone there.
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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What surveyors actually found near you
We read the 1,032 citations issued within 25 miles in the last 12 months — including the 31 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 13 | 0 |
| Augustana Chapel View Care Center | 5.5 mi | ★★★★★ | 6 | 0 |
| Aurora On France | 5.6 mi | ★★★★★ | 13 | 0 |
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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.