Edgebrook Care Center
Inspection Findings
F-Tag F0803
F 0803 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
blue. LPN-A preformed the Heimlich maneuver and back thrusts and nothing came out of Resident R1's mouth.
LPN-A did a mouth sweep with her finger and there was nothing in Resident R1's mouth. Trained Medication assistant (TMA)-A and the activity director (AD)- A started taking turns doing the Heimlich maneuver on Resident R1 until she was breathing better. Resident R1's oxygen saturation was in the 70s, (normal mid to upper 90's) LPN-A placed oxygen on Resident R1 and her oxygen saturation when up to the 90s and Resident R1's lips were no longer blue.
LPN-A called hospice and Resident R1's family. During an interview on 8/21/25 at 1:10 p.m., speech therapist (ST)-A stated the last time he worked with Resident R1 was 5/27/25, at that time ST-A recommended a minced and moist diet and moderate to extremely thick fluids. Cheese cubes were not a safe food for Resident R1 to have due to it not being minced and moist. During an interview on 8/21/25 at 1:15 p.m., activity director (AD)-A stated on 8/15/25, during dinner, AD-A heard Resident R1 gasping and called out that Resident R1 was choking. Resident R1 was brought the nurses station and LPN-A started the Heimlich maneuver on Resident R1. R1s lips were blue but once oxygen was placed on Resident R1, she started breathing better and her lips returned to a normal color. AD-A looked at Resident R1's tray and saw cheese cubes, regular crackers, soup, and a pureed sandwich on her plate. AD-A stated Resident R1 should not have had crackers or cheese cubes due to her diet. During an interview on 8/21/25 at 1:58 p.m., hospice registered nurse (HRN)-A stated on 8/15/25 at 5:30 p.m., the facility called and stated Resident R1 was choking. HRN-A told LPN-A to give Resident R1 morphine and oxygen and HRN-A was on her way. HRN-A arrived at 5:45 p.m., Resident R1 was coughing and gasping however, Resident R1 was not blue. HRN-A preformed the Heimlich maneuver on Resident R1 but nothing came out. At 6:15 p.m. Resident R1 was able to talk with HRN-A and was breathing normally again. During an interview on 8/21/25 at 2:21 p.m., dietary manager (DM)-A stated staff who plated and passed residents food were expected to look at the name and diet on each meal card to ensure
the meal was correct and given to the right resident. DM-A stated the incident on 8/15/25, with Resident R1 occurred due to human error and staff not paying attention. During an interview on 8/22/24 at 8:46 a.m., Resident R1's medical doctor (MD)-A stated cheese cubes were not safe for Resident R1 to eat because they were too big and not soft enough. MD-A stated she expected staff to assist Resident R1 with meals and follow Resident R1's diet. MD-A stated Resident R1 receiving cheese cubes caused harm to Resident R1 and could have caused her death. During an interview on 8/22/25 at 9:57 a.m., the director of nursing (DON) stated it was expected that staff read the meal card for each resident to ensure the resident received the right diet and textured meal. During an interview on 8/22/25 at 10:00 a.m., the administrator stated the staff were expected to ensure each resident received the right diets when preparing and passing meals. The facility policy Proper Reading of Diet Cards and Meal Delivery undated, indicated staff would accurately read diet cards, verifying patient identification, and ensuring the correct dietary items were provided to each patient. The past noncompliance immediate jeopardy began on 8/15/25. The immediate jeopardy was removed, and the deficient practice was corrected by 8/19/25, after the facility implemented a systemic plan that included the following actions: The facility re-educated all staff who prepare and pass meals on the policy and procedure of meal service. The facility completed audits twice a week by observing staff preparing and passing meals to the correct residents with
the right diet and the results were to then be brought to QAPI committee. Verification of corrective action was confirmed by observation, interview, and document review on 8/21/25 and 8/22/25.
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If continuation sheet
Edgebrook Care Center in EDGERTON, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EDGERTON, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Edgebrook Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.