Edgewood Sartell

Survey completed May 22, 2023: 16 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

• Tag 485: 144G.41 Subd 1. (13) (i) (A) and (C) Minimum Requirements Level 1, widespread scope, scope/level letter C · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure the Assisted Living With Dementia Care contract did not require any resident to include and pay for meals as a part of their assisted living package fee.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the Assisted Living With Dementia Care contract did not require any resident to include and pay for meals as a part of their assisted living package fee. In addition, the licensee failed to ensure menus were available to the residents at least one week in advance. This had the potential to affect all residents of the facility. [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (i) at least three nutritious meals daily with snacks available seven days per week, according to the recommended dietary allowances in the United States Department of [...]”

• Tag 510: 144G.41 Subd. 3 Infection control program Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days · fine: $500.00 assessed
  Details

  Summary: MDH found the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical, and nursing standards for infection control for two of three employees (unlicensed personnel (ULP)-Q and ULP-F) observed while providing cares.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to establish and maintain an infection control program to comply with accepted health care, medical, and nursing standards for infection control for two of three employees (unlicensed personnel (ULP)-Q and ULP-F) observed while providing cares. [...]”

  Rule cited: “(a) All assisted living facilities must establish and maintain an infection control program that complies with accepted health care, medical, and nursing standards for infection control. [...]”

• Tag 680: 144G.42 Subd. 10 Disaster planning and emergency preparedness Level 2, widespread scope, scope/level letter F · correction period: Twenty-One (21) days
  Details

  MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to post an emergency preparedness plan prominently and failed to provide building emergency exit diagrams to all residents. This had the potential to affect all residents receiving services under the assisted living with dementia care license, staff and visitors. [...]”

  Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

• Tag 810: 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  MDH’s finding, as written: “Based on a record review and interview, the licensee failed to provide the required documentation of employee and resident training on fire safety and evacuation drills. This had the potential to affect all staff, residents, and visitors. [...]”

  Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

From MDH’s letter: the letter says the facility is in substantial compliance.

Fines assessed by MDH

• Tag 510 (144g.41 Subd. 3 - Infection Control Program): $500.00
• Tag 1290 (144g.60 Subdivision 1 - Background Studies Required): $3,000.00

Total fines assessed, as printed in the letter: $3,500.00.

Allegation, as written: “The resident was abused when Alleged Perpetrator 1, (AP1), AP2, and AP3 forcibly restrained the resident while assisting the resident with cares causing bruising on the resident's forearms, wrists, and hands.”

“The Minnesota Department of Health determined abuse was inconclusive.”

Summary: MDH looked into an allegation and found: abuse inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined abuse was inconclusive. AP1, AP2, and AP3 attempted to assist the resident with toileting and the resident was resistive and became combative. Instead of reapproaching the resident, the AP's continued to attempt to provide cares. After the incident occurred, bruising was noted on the residents' hands, wrists, and forearms. However, AP1 and AP2 denied holding/restraining the resident, or seeing anyone do so. There were no other witnesses to the incident. It could not be determined if abuse occurred.”

Action taken by facility: “The facility held a care conference with the resident's family following the incident. Reviewed the video provided, suspended the staff involved, reported the concern to the Minnesota Adult Abuse Reporting Center (MAARC), and re-educated staff involved on dementia challenging behaviors. AP3 is no longer employed by the facility.”

Action taken by MDH: “The facility was found to be in noncompliance.”

Survey completed February 14, 2025: 2 correction orders

• Tag 730: 144G.43 Subd. 3 Contents of resident record Level 2, isolated scope, scope/level letter D · correction period: Twenty-One (21) days
  Details

  Summary: MDH found the licensee failed to ensure resident records had the required content including documentation of incidents involving the resident, and accurate documentation of assessment of bruising injuries following an allegation of abuse for one of one resident (R1) reviewed for maltreatment.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure resident records had the required content including documentation of incidents involving the resident, and accurate documentation of assessment of bruising injuries following an allegation of abuse for one of one resident (R1) reviewed for maltreatment. [...]”

  Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

• Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 3, isolated scope, scope/level letter G · correction period: Fourteen (14) days
  Details

  Summary: MDH found the licensee failed to ensure the plan of care was implemented for one of one resident's (R1) reviewed with dementia behaviors.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the plan of care was implemented for one of one resident's (R1) reviewed with dementia behaviors. Harm occurred for R1 after he was incontinent of stool, and resisted/refused cares, 3 staff failed to follow R1 plan of care and forced cares on R1 for approximately 12 minutes. The incident caused R1 distress, agitation, and likely provoked R1 to respond to staff in an aggressive manner. [...]”

  Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

Allegation, as written: “The facility neglected the resident when staff failed to ensure food was prepared and served per Minnesota Food Code. The resident was served undercooked pork and became sick with a foodborne illness. In addition, the facility failed to ensure services were provided according to the resident's care plan and failed to check on the resident for six hours. The resident was found on the floor, covered in secretions and vomit, and cold to the touch. The resident was admitted to the hospital where he later died.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. The resident's death certificate listed his cause of death as acute infectious gastroenteritis (inflammation of the stomach and intestines causing diarrhea, vomiting, and nausea) due to yersinia enterocolitica (a bacteria most often acquired by handling or eating raw or undercooked pork). However, it is unable to be determined where or how the resident acquired the bacteria. Menus reviewed indicated that pork was served by the facility days prior to the resident's hospitalization, but there was no evidence that other residents experienced similar symptoms. The facility was found to have deficient practices related to food handling and food preparation. [...]”

Action taken by facility: “The facility was found to be in noncompliance. To view a copy of the Statement of Deficiencies and/or correction orders, please visit: https://www.health.state.mn.us/facilities/regulation/directory/provcompselect.html If you are viewing this report on the MDH website, please see the attached Statement of Deficiencies. You may also call 651-201-4200 to receive a copy via mail or email”

Action taken by MDH: “Insert appropriate action from standard language document”

Survey completed April 29, 2024: 3 correction orders

• Tag 480: 144G.41 Subd 1 (13) (i) (B) Minimum requirements Level 2, widespread scope, scope/level letter F · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to ensure food was prepared and served according to the Minnesota Food Code.

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure food was prepared and served according to the Minnesota Food Code. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all the [...]”

  Rule cited: “(13) offer to provide or make available at least the following services to residents: (B) food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626; and”

• Tag 620: 144G.42 Subd. 6 (a) / 626.557, Subd. 3 Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to submit a report to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) who was hospitalized with a foodborne illness.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to submit a report to the Minnesota Adult Abuse Reporting Center (MAARC) for one of one resident (R1) who was hospitalized with a foodborne illness. [...]”

  Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

• Tag 2320: 144G.91 Subd. 4 (b) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards when staff failed to investigate a suspected reported foodborne illness for one of

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide care and services according to acceptable health care, medical, or nursing standards when staff failed to investigate a suspected reported foodborne illness for one of one resident (R1) reviewed. The licensee was aware R1 was admitted to the hospital and diagnosed with Yersinia enterocolitica (an infection that can be caused by raw or undercooked pork). [...]”

  Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

Allegation, as written: “The facility neglected the resident when the resident fell and sustained facial trauma, a nasal bone fracture, and a C5 spinous process fracture (neck spinal injury).”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although the facility failed to have a system in place where staff documented every 30 minutes safety checks, it could not be determined whether staff provided every 30-minute safety checks and if the safety checks would have prevented the resident's fall.”

Action taken by facility: “After staff found the resident on the floor, staff called the on-call nurse, 911, and transferred the resident to the emergency room for evaluation.”

Action taken by MDH: “No further action taken at this time.”

Survey completed November 28, 2023: 1 correction order

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure one of two residents reviewed (R1) was free from maltreatment.

  MDH’s finding, as written: “The facility failed to ensure one of two residents reviewed (R1) was free from maltreatment. Findings include: The Minnesota Department of Health (MDH) issued a determination maltreatment occurred, and an individual person was responsible for the maltreatment, in connection with incidents which occurred at the facility. Please refer to the public maltreatment report for details.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”

Allegation, as written: “The facility neglected the resident when staff did not follow the resident's plan of care for lymphedema, including the application of compression stockings and lymphedema pumps, and the resident was hospitalized.”

“The Minnesota Department of Health determined neglect was inconclusive.”

Summary: MDH looked into an allegation and found: neglect inconclusive.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was inconclusive. Although the resident was hospitalized for right lower leg cellulitis (skin infection), conflicting information was provided on if the plan of care was consistently followed by facility staff. The facility was aware the resident was at risk for skin breakdown; however, the resident's skin integrity status prior to hospitalization is unknown.”

Action taken by facility: “When the facility noticed a change in condition, the resident was sent to the hospital for further evaluation.”

Action taken by MDH: “No further action taken at this time.”

Survey completed April 26, 2023: 4 correction orders

• Tag 620: 144G.42 Subd. 6 (a) Compliance with requirements for reporting ma Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for one of one resident (R1) with records reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment and complete a thorough investigation for one of one resident (R1) with records reviewed. [...]”

  Rule cited: “(a) The assisted living facility must comply with the requirements for the reporting of maltreatment of vulnerable adults in section 626.557. [...]”

• Tag 2320: 144G.91 Subd. 4 (b) Appropriate care and services Level 3, isolated scope, scope/level letter G · correction period: Seven (7) days
  Details

  Summary: MDH found the licensee failed to provide care and services in accordance with the service plan, when staff failed to administer medications as ordered, resulting in medication error for one of one resident (R1) reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide care and services in accordance with the service plan, when staff failed to administer medications as ordered, resulting in medication error for one of one resident (R1) reviewed. R1 received another resident's medication and was hospitalized for an unintentional drug overdose. [...]”

  Rule cited: “(b) Residents have the right to receive health care and other assisted living services with continuity from people who are properly trained and competent to perform their duties and in sufficient numbers to adequately provide the services agreed to in the [...]”

• Tag 2360: 144G.91 Subd. 8 Freedom from maltreatment
  Details

  Summary: MDH found the facility failed to ensure one of one residents (R1) reviewed.

  MDH’s finding, as written: “Based on observations, interviews, and document review, the facility failed to ensure one of one residents (R1) reviewed. R1 was neglected. Findings include: On May 4, 2023, the Minnesota Department of Health (MDH) issued a determination that neglect occurred, and that the facility was responsible for the maltreatment, in connection with incidents which occurred at the facility. The MDH concluded there was a preponderance of evidence that maltreatment occurred.”

  Rule cited: “Residents have the right to be free from physical, sexual, and emotional abuse; neglect; financial exploitation; and all forms of maltreatment covered under the Vulnerable Adults Act.”

• Tag 3000: 626.557 Subd. 3 Timing of report Level 2, isolated scope, scope/level letter D · correction period: Seven (7) days
  Details

  MDH’s finding, as written: “Based on interview and record review the licensee failed to immediately report to the Minnesota Adult Abuse Reporting Center (MAARC) suspected maltreatment for one of one resident (R5) with records reviewed. [...]”

  Rule cited: “(a) A mandated reporter who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained shall immediately report the information [...]”

Allegation, as written: “The facility neglected the resident when the resident was found on the floor with bleeding from his nose and mouth. The resident was transferred to the hospital and passed away three days later.”

“The Minnesota Department of Health determined neglect was not substantiated.”

Summary: MDH looked into an allegation and found: neglect not substantiated.

MDH’s conclusion, as written: “The Minnesota Department of Health determined neglect was not substantiated. Although the resident did fall multiple times during the five-day period, the facility provided appropriate care each time.”

Action taken by facility: “No action required.”

Action taken by MDH: “No further action taken at this time.”

Survey completed November 7, 2024: no correction orders issued.