Edgebrook Care Center
Edgebrook Care Center in EDGERTON, MN — inspection on August 22, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 8/21/25 at 1:10 p.m., speech therapist (ST)-A stated the last time he worked with 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 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 R1 gasping and called out that R1 was choking. R1 was brought the nurses station and LPN-A started the Heimlich maneuver on R1. R1s lips were blue but once oxygen was placed on R1, she started breathing better and her lips returned to a normal color. AD-A looked at R1's tray and saw cheese cubes, regular crackers, soup, and a pureed sandwich on her plate. AD-A stated 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 R1 was choking. HRN-A told LPN-A to give R1 morphine and oxygen and HRN-A was on her way. HRN-A arrived at 5:45 p.m., R1 was coughing and gasping however, R1 was not blue. HRN-A preformed the Heimlich maneuver on R1 but nothing came out. At 6:15 p.m. 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 R1 occurred due to human error and staff not paying attention.
During an interview on 8/22/24 at 8:46 a.m., R1's medical doctor (MD)-A stated cheese cubes were not safe for R1 to eat because they were too big and not soft enough. MD-A stated she expected staff to assist R1 with meals and follow R1's diet. MD-A stated R1 receiving cheese cubes caused harm to 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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