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Edgebrook Care Center: Immediate Jeopardy Choking - MN
The incident happened on August 15, 2025, during dinner....
Latest reports, citations, and penalties from CMS data
The incident happened on August 15, 2025, during dinner....
When a second aide, identified as V6, entered the room and warned against lifting by hand, the first aide, V5, had already started....
Inspectors visited the facility on August 19, 2025....
Six drugs were scheduled to be administered at 8:00 AM....
The inspection was triggered by a complaint....
The August 25 inspection at Providence Living Center, a complaint investigation, centered on a single resident identified only as R1....
Getting those documents wrong, losing them, or failing to transmit them at the moment a resident is rushed to an emergency room is not a paperwork problem....
Federal inspectors documented the gaps during a complaint inspection completed August 22....
Receptionists had been told to ask her to leave and to call police if she refused....
A volunteer identified in the report had already seen it....
"Residents have complained to me about the staffing cuts that were made," the Director of Nursing said during an August 22 interview....
That resident woke up with burns....
The facility suspended at least one nurse while the investigation continued....
Each time, the call light was on the floor....
The incident happened on the night of June 21, 2025....
The answer, according to two staff members interviewed that morning, was a system built on sign-out books and hourly rounds....
The resident, identified in inspection records as Resident #2, has a suprapubic catheter, a tube inserted directly through the abdomen into the bladder....
By the time a federal inspector observed the unit on August 18, water was running along the entire bottom panel, onto the bedside table, and down the wall....
The care plan dated October 20 listed the foley catheter as a focus of care, with instructions to provide skin care and encourage fluids....
Inspectors observed Resident 66 in her wheelchair on the morning of August 24, 2025....