Edenbrook Of Edina
EDENBROOK OF EDINA in MINNEAPOLIS, MN — inspection on January 22, 2026.
Found 4 citations. 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
ADON-B stated a resident would need a self-administration assessment, a provider order, and a
an order for nicotine gum. ADON-B stated she was unable to find a self-administration assessment for
important for the assessment and order prior to self-administration to ensure the resident was able to take and store medications safely, and stated it was important for the provider to know all medications including over the counter medications a resident was taking to ensure they would not interfere with other medications ordered.During interview on 1/21/26 at 1:31 p.m., director of nursing (DON) stated an assessment was to be completed and an order obtained prior to a resident storing medication in their room to ensure they were able to take and store it properly. A lock box would have been provided for storage of the medication. DON stated this was also true for over-the-counter medications resident wished to take and keep in their rooms.
The DON stated this was important to make sure there were no contraindications with other medications and to monitor the amount of medication being used.During interview on 1/22/26 at 9:46 a.m., physician assistant (PA)-A stated she was aware R50 was using nicotine gum, but was using it prior to her starting as a PA at the facility, so she was not aware she did not have an order. PA-A confirmed residents should have a provider order for over-the-counter medications.Facility policy for self-administration of medications dated 2/12/24, included a resident would be screened by a licensed nurse for safe administration of medication. A physician order would be needed for those who were self-administering medications.
245275 01/22/2026
Edenbrook of Edina 6200 Xerxes Avenue South Minneapolis, MN 55423
Beneficiary Notice (SNFABN-10055) was provided to 1 or 3 residents (R59) reviewed for Beneficiary
Set (MDS) dated [DATE], indicated R59 was admitted on [DATE] and Medicare Part A discharge date of 8/13/25.R59's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN), informed R59 services would end on 8/14/25.
However, this notice was given outside of the 48 hours prior to services ending requirement and was provided on 9/22/25.On 1/22/26 at 1:14 p.m. the MDS Coordinator (MDSC) stated the facility had struggled to identify the correct payer source for the resident and once they did, they had R59 sign an SNFABN, however they were unable to locate the form and had R59 sign a new SNFABN on 9/22/25.
The MDSC confirmed it was outside the required 48 hours prior to the end of services.On 1/22/25 at 10:18 a.m. the administrator stated their expectation was for the beneficiary notices to be provided to the residents 48 hours prior to the end of their services, and they were important to provide so the residents are aware of their payment changes, and they may be responsible for payment.The facility policy was requested and was provided an undated document titled Beneficiary Notice Guidelines which indicated R59 should have received an SNFABN.
245275 01/22/2026
Edenbrook of Edina 6200 Xerxes Avenue South Minneapolis, MN 55423
resident's ability to function.
record review and interview, the facility failed to ensure ordered as needed (PRN) psychotropic
medications.
Findings include:R34's admission Minimum Data Set (MDS) dated [DATE], indicated R34 was admitted on [DATE], was severely cognitively impaired and had the following diagnoses: hypertension, renal insufficiency, hyperlipidemia, dementia, anxiety, and depression. R34's order summary report dated 1/22/26, indicated R34 was currently prescribed Lorazepam 0.5mg (milligrams) orally every 1-hour PRN with a start date of 12/17/25.
The order lacked an end date. R34's medical record lacked evidence of rationale to continue past the required 14-day timeframe for psychotropic medications.On 1/22/26 at 1:15 p.m. the director of nursing confirmed they were aware of the 14-day time frame for psychotropic medications and stated they missed it with R34 and were currently working on a new process to ensure it does not happen again.
The DON stated the importance of addressing the medications rationale within the 14-day time period to ensure the medications were addressed appropriately and per regulations.The facility Psychotropic Medication Policy last revised 5/1/25, indicated PRN orders for psychotropic drugs are limited to 14 days.
Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN orders to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.
245275 01/22/2026
Edenbrook of Edina 6200 Xerxes Avenue South Minneapolis, MN 55423
reviewed for nutrition.Findings include:R3's admission minimum data set (MDS) dated [DATE],
when excessive water accumulates relative to sodium), and hypertension (high blood pressure).R3's physician order summary report dated 1/22/26, included an order for daily weights due to heart failure with instruction to update the provider with a weight gain of 3 pounds (lbs) or greater in 24 hours or 5 pounds in one week unless otherwise directed by a provider.
Order was started on 10/25/25.R3's weights outside of these parameters were as follows:10/28/25: 218.0 lbs10/29/25: 228.4 lbs11/18/25: 212.2 lbs11/19/25: 221.1 lbs11/28/25: 204.9 lbs11/30/25: 213.8 lbs12/7/25: 201.0 lbs12/8/25: 208.6 lbs12/10/25: 206.0 lbs12/12/25: 214.1 lbs12/24/25: 200.2 lbs12/26/25: 245.6 lbs1/20/26: 187.5 lbs1/21/26: 203.0 lbs Review of R3's medical records failed to include updates to the provider for weight changes as instructed in R3's orders.During interview on 1/21/26 at 11:19 a.m., licensed practical nurse (LPN)-A stated she would typically called a provider if someone had an order to monitor weights and they were outside of the parameters. LPN-A stated she would put a progress note in the resident's chart when she updated the provider.During interview on 1/21/26 at 11:21 a.m., assistant director of nursing (ADON)-A stated floor nurses were supposed to monitor the daily weights when an order is in place and update the provider when a resident is outside of the ordered parameters. ADON-A confirmed he was unable to find progress notes or provider notes when R3 had weight changes outside of the provider parameters. ADON-A stated the resident was at risk for fluid overload which could lead to hospitalization if a provider was not updated when a weight monitoring order was in place.During interview 1/21/26 at 1:37 p.m., director of nursing (DON) stated it was the nurse managers or ADON's responsibility to be monitoring weights and updating a provider as needed.
The DON stated the floor nurse should enter the weight and update the nurse manager or ADON with any concerns they noticed. DON stated the provider could then adjust medication or parameters if the resident's condition indicated the need for changes.During interview on 1/22/26 at 9:46 a.m., physician assistant (PA)-A stated she would have wanted to be updated on any weight changes that were outside of ordered parameters. PA-A stated early adjustment to medications is important because it becomes harder to manage fluid changes with medication the longer it goes untreated. PA-A stated it was the goal to prevent hospitalization with early intervention. PA-A stated she would complete an visit note on all reviews of weight changes she completed.Facility policy for weight monitoring requested and not provided.