Edgewood Baxter Llc.
Edgewood Baxter Llc is Grade C, ranked in the top 48% of Minnesota memory care with 1 MDH citation on record; last inspected Mar 2025.
A large home, reviewed on public record.
Ranked against 142 Minnesota facilities.
ALF memory care · 36-month window. Higher percentile = better. Source: Minnesota Dept. of Health · Health Regulation Division.
FACILITY WATCH · BETA
Edgewood Baxter Llc has 1 citation on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
1 deficiencie on record. Each bar is a month with a citation.
Finding distribution
1 total · 36 monthsScope × Severity (CMS A–L)
Questions to ask before you visit.
A short pre-tour checklist tailored to Edgewood Baxter Llc's record and state requirements.
The March 27, 2025 inspection by the Minnesota Department of Health resulted in zero deficiencies across all regulatory areas — can you walk us through the written policies and staff training materials that support your dementia care program under Minnesota Statute chapter 144G?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Three complaints were filed with MDH during the inspection period on file — were any of those complaints substantiated, and what documentation can you provide families about the facility's response and any corrective measures taken?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Your license designates this as an Assisted Living Facility with Dementia Care under chapter 144G — what specific dementia care services, environmental modifications, and staff competencies distinguish your dementia care programming from your general assisted living services?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
Every MDH visit, verbatim.
4 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-04-20Complaint InvestigationNo findings
Plain-language summary
A complaint investigation found that a resident received an incorrect dose of Mounjaro on two occasions when a manager mistakenly believed the resident had completed the 5 milligram phase and gave the 7.5 milligram dose instead; the resident was hospitalized for nausea, vomiting, and weakness but returned to the facility in baseline health two days later. The Minnesota Department of Health concluded the allegation of neglect was not substantiated because the error was isolated, the resident received timely medical care and recovered, and the facility took corrective action by requiring the pharmacy to dispense medications according to the prescribed schedule. The family member reported no concerns about the overall care provided.
Full inspector notes
Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when the resident was prescribed a titrating dose of Mounjaro but received a higher dose than ordered during the 5 mg phase, resulting in medication errors on two occasions. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the medical error happened, the error was an isolated incident. The resident was sent to the hospital due to nausea, vomiting, and weakness, and returned to the facility two days later at their baseline health condition. The investigator conducted interviews with facility administrative staff and family member. The investigation included review of the resident’s records, internal investigation documentation, incident reports, staff schedules, policies, and procedures. The resident resided in an assisted living facility. The resident’s diagnoses type two diabetes. The resident’s service plan included assistance with medication administration. According to the medication administration record, the resident was prescribed a titrating dose of Mounjaro: 2.5 milligrams subcutaneously weekly for four doses, then 5 milligrams subcutaneously weekly for four doses, followed by 7.5 milligrams weekly for four doses. A concern arose when the resident was sent to the hospital due to nausea, vomiting, and weakness. During her hospitalization, the hospital discovered the medication error. During an interview, a family member said the resident received an incorrect dose of Mounjaro. Instead of gradually increasing the dose as prescribed, it was increased from 2.5 milligrams to 7.5 milligrams. The family member stated the resident was hospitalized for two days and went back to her baseline. She said she had no concerns regarding the overall care provided to the resident. During an interview, a manager stated the resident was scheduled to receive 2.5 milligrams weekly for four doses, followed by 5 milligrams weekly for four doses, and then 7.5 milligrams weekly. The manager said a staff member notified her one day that the 5 milligram dose was unavailable. While attempting to manage the situation using two applications on her phone, she mistakenly believed the resident had completed the 5 milligram phase and initiated the 7.5 milligram dose prematurely. As a result, the resident received incorrect doses on two separate occasions. The manager further stated a few days later, the resident was admitted to the hospital due to nausea, vomiting, weakness, and cardiac concerns. The family contacted the facility regarding suspected incorrect dosing. Upon confirmation, the manager contacted the primary care provider and the pharmacy. It was then discovered that the pharmacy had not shipped the 5 milligram dosage and could not provide an explanation. Upon the resident’s return to the facility, the provider reassessed the resident and adjusted the medication regimen. The facility also implemented a corrective measure requiring the pharmacy to dispense medications in accordance with the prescribed schedule, rather than supplying all doses at once. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. (4) an individual makes an error in the provision of therapeutic conduct to a vulnerable adult which does not result in injury or harm which reasonably requires medical or mental health care; or (5) an individual makes an error in the provision of therapeutic conduct to a vulnerable adult that results in injury or harm, which reasonably requires the care of a physician, and: (i) the necessary care is provided in a timely fashion as dictated by the condition of the vulnerable adult; (ii) if after receiving care, the health status of the vulnerable adult can be reasonably expected, as determined by the attending physician, to be restored to the vulnerable adult's preexisting condition; (iii) the error is not part of a pattern of errors by the individual; (iv) if in a facility, the error is immediately reported as required under section 626.557, and recorded internally in the facility; (v) if in a facility, the facility identifies and takes corrective action and implements measures designed to reduce the risk of further occurrence of this error and similar errors; and (vi) if in a facility, the actions required under items (iv) and (v) are sufficiently documented for review and evaluation by the facility and any applicable licensing, certification, and ombudsman agency. Vulnerable Adult interviewed: No. Family/Responsible Party interviewed: Yes Alleged Perpetrator interviewed: Not Applicable. Action taken by facility: Upon the resident’s return to the facility, the provider reassessed the resident and adjusted the medication regimen. The facility also implemented a corrective measure requiring the pharmacy to dispense medications in accordance with the prescribed schedule, rather than supplying all doses at once. The facility retrained all caregivers on this topic. Action taken by the Minnesota Department of Health: No further action taken at this time. cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 04/ 23/ 2026 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/ SUPPLIER/ CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30293 03/ 03/ 2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14211 FIREWOOD DRIVE EDGEWOOD BAXTER LLC BAXTER, MN 56425 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER' S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS- REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 On March 3, 2026, the Minnesota Department of Health initiated an investigation of complaints #HL302939822M/ HL302934322C. No correction orders are issued. LABORATORY DIRECTOR' S OR PROVIDER/ SUPPLIER REPRESENTATIVE' S SIGNATURE TITLE (X6) DATE STATE FORM 6899 9IDS11 If continuation sheet 1 of 1
2025-06-27Complaint Investigation1 · Substantiated Finding
Plain-language summary
A complaint investigation found that the facility neglected a resident with dementia by failing to identify, assess, and implement safety interventions despite knowing the resident had aggressive behaviors, wandering, and multiple altercations with other residents over a five-month period, including six police contacts. Staff documented ongoing incidents of resident-to-resident conflict and the resident's family raised concerns about bullying, but the facility did not update the resident's care plan, investigate the allegations, or develop new behavioral interventions. The Minnesota Department of Health substantiated neglect and held the facility responsible.
“MDH substantiated maltreatment or licensing violation finding”
Full inspector notes
Finding: Substantiated, facility responsibility Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The facility neglected the resident when it failed to implement interventions to ensure the resident’s safety. The resident had known behaviors towards other residents and staff failed to put interventions in place to ensure the resident’s safety. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. Facility staff failed to identify, assess, and implement interventions to address the resident’s behavior despite knowledge of multiple incidents and altercations involving other residents and contact with police. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigator contacted law enforcement. The investigation included review of the resident records, facility incident reports, personnel files, staff schedules, law enforcement reports, body camera footage, and related facility policy and procedures. Also, the investigator observed the resident’s interactions with other residents at the facility. The resident resided in an assisted living facility. The resident’s diagnoses included dementia, anxiety, and hearing loss. The resident’s service plan included assistance with behavior management for wandering and physical aggression. The resident’s assessment indicated the resident had behaviors, including a history of wandering into other resident's apartments, touching other residents, and kicking and poking at other residents. The assessment indicated the resident was able to communicate but may not be consistent due to dementia. Staff were to anticipate needs and advocate for the resident. The resident was noted to have moderately impaired cognition with memory problems. Facility documentation indicated the resident’s family requested bullying by other residents to be added to his assessment; however, the resident’s assessment lacked any documentation on bullying or concerns with the resident being bullied or him bullying other residents. Police reports reviewed identified police were contacted six times over a three-month period for the following incidents: - the facility called police to report the resident (R1) was being disruptive, harassing staff, and attempting to enter other resident's rooms. Police advised R1 return to his room. Facility documentation lacked any documentation of a police response or that family had been notified. - the facility called police for R1 playing loud music. Facility documentation indicated the executive director requested staff call police for assistance with the R1's behaviors. Facility documentation lacked evidence family was notified. - staff called police to report R1 was sexually harassing residents and refusing to go to his room. Police escorted R1 back to his room. Facility documentation lacked any documentation of a police response or that family had been notified. - staff called police to report R1 was making inappropriate sexual comments and grabbed the director by the arm. Facility documentation lacked any documentation of a police response or that family had been notified. -a visitor called police around 5:30 p.m. to report R1 was harassing other residents. Facility documentation indicated the resident's power of attorney was called at 6:00p.m. -the facility called police after R1 had a physical altercation with another resident. Facility documentation indicated the power of attorney was notified at 6:29 p.m., and police were called at 6:33 p.m Despite ongoing behaviors and police contact there was no additional assessment or interventions implemented to address the resident’s behavior. Five months of facility documentation was reviewed, and records indicated there were frequent and ongoing interactions and altercations between the resident and other residents at the facility. There were several documented incidents of resident to resident altercations including when another resident threatened to hit the resident with a shoe, the resident was grabbed by another resident, the resident was threatened with a knife by another resident, the resident had water dumped on him by another resident, and other residents made comments to him including to go away, “I’m going to slap you so hard you won’t wake up,” that he belongs in a looney bin, and that no one likes him. Facility documentation indicated the resident’s family filed a grievance regarding the resident being bullied, however the grievance was not responded to as the facility requested the family provide specifics on bullying allegations. There was no documentation of investigation of many of the documented allegations and staff were not interviewed to determine if the resident was being bullied by other residents as alleged by the resident’s family. The resident’s family brought up in a care conference that they felt the resident was being bulled and wanted a police report made. The facility filed a vulnerable adult report but failed to take further action. The resident’s assessment was not updated to include the family’s concerns on the resident being bullied. The resident’s individual abuse prevention plan lacked any documentation on the resident being bullied or the ongoing resident to resident altercations or continued contact with police. Facility records indicated nursing would often document the resident’s behaviors and note that interventions were not successful, however they failed to identify new interventions or determine why interventions were not successful. The resident had many behaviors that the facility failed to assess including playing loud music, following staff into resident rooms, interrupting activities, or eating food off other resident’s plates.Documentation indicated the resident’s family requested adding certain interventions they felt might be successful, however the family’s suggestions were never added to the assessment or care plan. During staff interviews, multiple staff members stated they had observed the resident get bullied and that he sometimes initiated the bullying. Multiple staff members stated they had observed a group of residents start saying rude things to the resident without the resident doing anything to provoke them first. Multiple staff members stated they had limited interventions for the resident’s behaviors and many times, interventions were not successful, which nursing was aware of. Facility management stated it was an unfortunate situation between the resident and some other residents and that there was some bullying in the building. Management stated they didn’t think anyone understood how much work the facility had put in to help the situation for the resident and all the other residents to make everyone feel safe and were trying to intervene as much as they could. Facility management felt they had implemented many interventions to manage the resident’s behaviors. A nurse manager stated she was not aware of any bullying of the resident. The visitor who contacted police over the resident’s behavior was interviewed and stated that she only called the police because the resident kept bothering another resident and staff were not able to assist her with removing him. The visitor stated that she asked staff what she was supposed to do about R1's behaviors and staff said she needed to call the police so she did. The visitor stated that she didn't know R1 well at that point or else she would have tried redirecting him and after observing how police interacted with him, she regretted that she called police for help. During an interview, the resident’s power of attorney (POA) stated the facility failed to consider and implement intervention options suggested and provided to them by the resident’s family members. The POA also indicated they had not been told of many of the police calls made and only found out after they spoke with a responding officer after the last phone call when the officer made a comment that they had been there a few times before due to the resident’s behaviors. The POA stated when they requested police records from the police department they were "floored" when they saw how many times officers had been called to intervene and they were never notified and would have expected to be called before police were called as it was in his plan of care. The POA stated they had suggested many interventions to help with the resident’s behaviors but the facility was resistant to implementing them or found reasons why they couldn't try the interventions. During an interview, law enforcement stated they didn’t believe the facility had disclosed to them that the resident had any cognitive impairments at the time law enforcement was initially called.
2025-03-27Annual Compliance VisitNo findings
Plain-language summary
A standard inspection of Edgewood Baxter LLC on March 27, 2025 found a violation of the facility's infection control program requirements under Minnesota law. The facility was assessed a $500 fine for this Level 2 violation and must document the actions it takes to correct the deficiency.
Full inspector notes
correction orders and document the actions taken to comply in the facility's records. The Department reserves the right to return to the facility at any time should the Department receive a complaint or deem it necessary to ensure the health, safety, and welfare of residents in your care. STATE CORRECTION ORDERS The enclosed State Form documents the state correction orders. MDH documents state licensing correction orders using federal software. Tag numbers are assigned to Minnesota state statutes for Assisted Living Facilities. The assigned tag number appears in the far left column entitled "ID Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance are listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by . . ." IMPOSITION OF FINES In accordance with Minn. Stat. § 144G.31, Subd. 4, fines and enforcement actions may be imposed based on the level and scope of the violations and may be imposed immediately with no opportunity to correct the violation first as follows: Level 1: no fines or enforcement. Level 2: a fine of $500 per violation, in addition to any enforcement mechanism authorized in § 144G.20 for widespread violations; Level 3: a fine of $3,000 per violation per incident, in addition to any enforcement mechanism authorized in § 144G.20. Level 4: a fine of $5,000 per incident, in addition to any enforcement mechanism authorized in An equal opportunity employer. Letter ID: IS7N REVISED 09/13/2021 Edgewood Baxter LLC April 22, 2025 Page 2 § 144G.20. Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, the following fines are assessed pursuant to this survey: 0510 - 144g.41 Subd. 3 - Infection Control Program - $500.00 Therefore, in accordance with Minn. Stat. §§ 144G.01 to 144G.9999, t he total amount you are assessed is $500.00. You will be invoiced approximately 30 days after receipt of this notice, subject to appeal. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minn. Stat. § 144G.30, Subd. 5(c), the licensee must document actions taken to comply with the correction orders within the time period outlined on the state form; however, plans of correction are not required to be submitted for approval. The correction order documentation should include the following: Identify how the area(s) of noncompliance was corrected related to the resident(s)/employee(s) identified in the correction order. Identify how the area(s) of noncompliance was corrected for all of the provider’s resident(s)/employees that may be affected by the noncompliance. Identify what changes to your systems and practices were made to ensure compliance with the specific statute(s). CORRECTION ORDER RECONSIDERATION PROCESS In accordance with Minn. Stat. § 144G.32, Subd. 2, you may challenge the correction order(s) issued, including the level and scope, and any fine assessed through the correction order reconsideration process. The request for reconsideration must be in writing and received by MDH within 15 calendar days of the correction order receipt date. To submit a reconsideration request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm REQUESTING A HEARING Alternatively, in accordance with Minn. Stat. § 144G.31, Subd. 5(d), an assisted living provider that has been assessed a fine under this subdivision has a right to a reconsideration or a hearing under this section and chapter 14. Pursuant to Minn. Stat. § 144G.20, Subd. 14 and Subd. 18, a request for a hearing must be in writing and received by the Department of Health within 15 business days of the correction order receipt date. The request must contain a brief and plain statement describing each matter or issue contested and any new information you believe constitutes a defense or mitigating factor. Edgewood Baxter LLC April 22, 2025 Page 3 To submit a hearing request, please visit: https://forms.web.health.state.mn.us/form/HRDAppealsForm To appeal fines via reconsideration, please follow the procedure outlined above. P lease note that you may request a reconsideration o r a hearing, but not both. If you wish to contest tags without fines in a reconsideration and tags with the fines at a hearing, please submit two separate appeals forms at the website listed above. The MDH Health Regulation Division (HRD) values your feedback about your experience during the survey and/or investigation process. Please fill out this anonymous provider feedback questionnaire at your convenience at this link: h ttps://forms.office.com/g/Bm5uQEpHVa. Your input is important to us and will enable MDH to improve its processes and communication with providers. If you have any questions regarding the questionnaire, please contact Susan Winkelmann at susan.winkelmann@state.mn.us or call 651-201-5952. You are encouraged to retain this document for your records. It is your responsibility to share the information contained in the letter and state form with your organization’s Governing Body. If you have any questions, please contact me. Sincerely, Jessie Chenze, Supervisor State Evaluation Team Email: jessie.chenze@state.mn.us Telephone: 218-332-5175 Fax: 1 -866-890-9290 JMD PRINTED: 04/22/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30293 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14211 FIREWOOD DRIVE EDGEWOOD BAXTER LLC BAXTER, MN 56425 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ASSISTED LIVING PROVIDER LICENSING Minnesota Department of Health is CORRECTION ORDER(S) documenting the State Correction Orders using federal software. Tag numbers have In accordance with Minnesota Statutes, section been assigned to Minnesota State 144G.08 to 144G.95, these correction orders are Statutes for Assisted Living Facilities. The issued pursuant to a survey. assigned tag number appears in the far-left column entitled "ID Prefix Tag." The Determination of whether violations are corrected state Statute number and the requires compliance with all requirements corresponding text of the state Statute out provided at the Statute number indicated below. of compliance is listed in the "Summary When Minnesota Statute contains several items, Statement of Deficiencies" column. This failure to comply with any of the items will be column also includes the findings which considered lack of compliance. are in violation of the state requirement after the statement, "This Minnesota INITIAL COMMENTS: requirement is not met as evidenced by." Following the evaluators ' findings is the SL30293016 Time Period for Correction. On March 24, 2025, through March 27, 2025, the PLEASE DISREGARD THE HEADING OF survey at the above provider. At the time of the STATES,"PROVIDER'S PLAN OF survey, there were 66 residents; 66 receiving CORRECTION." THIS APPLIES TO services under the Assisted Living Facility with FEDERAL DEFICIENCIES ONLY. THIS Dementia Care license. WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 0 480 144G.41 Subdivision 1 Subd. 1a (a-b) Minimum 0 480 SS=F requirements; required food services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 N5RB11 If continuation sheet 1 of 32 PRINTED: 04/22/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ B. WING _____________________________ 30293 03/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14211 FIREWOOD DRIVE EDGEWOOD BAXTER LLC BAXTER, MN 56425 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 480 Continued From page 1 0 480 (a) Except as provided in paragraph (b), food must be prepared and served according to the Minnesota Food Code, Minnesota Rules, chapter 4626. (b) For an assisted living facility with a licensed capacity of ten or fewer residents: (1) notwithstanding Minnesota Rules, part 4626.0033, item A, the facility may share a certified food protection manager (CFPM) with one other facility located within a 60-mile radius and under common management provided the CFPM is present at each facility frequently enough to effectively administer, manage, and supervise each facility's food service operation; (2) notwithstanding Minnesota Rules, part 4626.
2025-02-24Complaint InvestigationNo findings
Plain-language summary
A complaint investigation found that a resident did not receive their prescribed antidepressant medication for 11 days due to a transcription error in the electronic medication record system, which led to two hospitalizations, but the Minnesota Department of Health determined the facility was not neglectful because the error was isolated and staff took immediate corrective action once discovered. The facility completed staff education and the resident's health improved after the medication was restarted. The facility was found in noncompliance and issued a correction order.
Full inspector notes
Finding: Not Substantiated Nature of Investigation: The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type. Initial Investigation Allegation(s): The resident was neglected when facility staff did not receive scheduled Cymbalta (antidepressant) medication, and the medication was not administered for several days. The resident was hospitalized due to the medication error. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although the medication error occurred, the error was an isolated incident. Upon discovery of the error, facility staff contacted the resident’s provider. The resident later returned to their baseline health condition. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident medical record, hospital records, facility internal investigation documentation, facility staff schedules, and related facility policy and procedures. At the time of the onsite visit, the investigator observed medication administration and interactions between staff and residents. The resident resided in an assisted living facility. The resident’s diagnoses included congestive heart failure, major depressive disorder, and seasonal affective disorder. The resident’s service plan included assistance with medication administration. The resident’s assessment indicated was alert, and oriented. The resident utilized medication to manage depression per physician orders. The resident’s physician’s orders included an order for Cymbalta (antidepressant) 120 milligrams daily. Facility documentation indicated facility staff were questioned on when the resident last received prescribed Cymbalta as the resident was weepy and did not feel well. The investigation indicated a transcription error was discovered. The transcription error occurred within the electronic record system when the resident’s Cymbalta order was merged with Doxycycline (antibiotic) which discontinued the Cymbalta order. As a result, the Cymbalta order did not appear on the medication record for staff to administer the medication and the resident did not receive Cymbalta for 11 days. Review of the resident’s medical record and hospital records indicated that in the eleven days the resident did not receive his prescribed Cymbalta medication, the resident was hospitalized twice, and hospital records did not identify the Cymbalta order was missing or discontinued. Two days after the transcription error occurred the resident was hospitalized for low blood pressure, severe anemia, and respiratory symptoms. The hospital discharge orders did not include Cymbalta. Five days later, the resident was seen in the emergency room for weakness, anxiety attack, and upper respiratory infection. The emergency room discharge orders did not include Cymbalta. During an interview, the registered nurse (RN) indicated after the medication error was discovered, she immediately assessed the resident and contacted the resident’s medical provider to obtain a new order for Cymbalta. The medication was re-started that day. The RN stated the facility completed re-education for staff. During an interview, the resident stated she had been on Cymbalta for years for depression. The resident stated she “felt horrible,” and did not know what was wrong with her. The resident stated she felt much better since Cymbalta was re-started. During an interview, the resident’s family member stated the resident’s mood had improved since the Cymbalta was re-started; however, she was concerned the same issue could happen to another resident. In conclusion, the Minnesota Department of Health determined neglect was not substantiated. “Not Substantiated” means: An investigatory conclusion indicating the preponderance of evidence shows that an act meeting the definition of maltreatment did not occur. Neglect: Minnesota Statutes, section 626.5572, subdivision 17 “Neglect” means neglect by a caregiver or self-neglect. (a) "Caregiver neglect" means the failure or omission by a caregiver to supply a vulnerable adult with care or services, including but not limited to, food, clothing, shelter, health care, or supervision which is: (1) reasonable and necessary to obtain or maintain the vulnerable adult's physical or mental health or safety, considering the physical and mental capacity or dysfunction of the vulnerable adult; and (2) which is not the result of an accident or therapeutic conduct. Vulnerable Adult interviewed: Yes. Family/Responsible Party interviewed: Yes. Alleged Perpetrator interviewed: Not Applicable Action taken by facility: An internal investigation was initiated, and education was provided. Action taken by the Minnesota Department of Health: 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 cc: The Office of Ombudsman for Long Term Care The Office of Ombudsman for Mental Health and Developmental Disabilities PRINTED: 02/25/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30293 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14211 FIREWOOD DRIVE EDGEWOOD BAXTER LLC BAXTER, MN 56425 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Initial Comments 0 000 ******ATTENTION****** Minnesota Department of Health is documenting the State Correction Orders ASSISTED LIVING PROVIDER CORRECTION using federal software. Tag numbers have ORDER been assigned to Minnesota State Statutes for Assisted Living Facilities. The In accordance with Minnesota Statutes, section assigned tag number appears in the 144G.08 to 144G.95, these correction orders are far-left column entitled "ID Prefix Tag." The issued pursuant to a complaint investigation. state Statute number and the corresponding text of the state Statute out Determination of whether a violation is corrected of compliance is listed in the "Summary requires compliance with all requirements Statement of Deficiencies" column. This provided at the statute number indicated below. column also includes the findings which When a Minnesota Statute contains several are in violation of the state requirement items, failure to comply with any of the items will after the statement, "This Minnesota be considered lack of compliance. requirement is not met as evidenced by." Following the evaluators ' findings is the INITIAL COMMENTS: Time Period for Correction. #HL302933721C/#HL302937882M On January 9, 2025, the Minnesota Department PLEASE DISREGARD THE HEADING OF of Health conducted a complaint investigation at THE FOURTH COLUMN WHICH the above provider, and the following correction STATES,"PROVIDER'S PLAN OF orders are issued. At the time of the complaint CORRECTION." THIS APPLIES TO investigation, there were 66 residents receiving FEDERAL DEFICIENCIES ONLY. THIS services under the provider's Assisted Living with WILL APPEAR ON EACH PAGE. Dementia Care license. The following correction order is issued/orders are issued for THERE IS NO REQUIREMENT TO #HL302933721C/#HL302937882M, tag SUBMIT A PLAN OF CORRECTION FOR identification 1760, 2480. VIOLATIONS OF MINNESOTA STATE STATUTES. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 O3W411 If continuation sheet 1 of 10 PRINTED: 02/25/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ C B. WING _____________________________ 30293 01/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 14211 FIREWOOD DRIVE EDGEWOOD BAXTER LLC BAXTER, MN 56425 SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X4) ID ID (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE TAG TAG DEFICIENCY) 0 000 Continued From page 1 0 000 ISSUED PURSUANT TO 144G.31 SUBDIVISION 1-3. 01760 144G.71 Subd. 8 Documentation of 01760 SS=F administration of medication Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. The documentation must include the medication name, dosage, date and time administered, and method and route of administration. The staff must document the reason why medication administration was not completed as prescribed and document any follow-up procedures that were provided to meet the resident's needs when medication was not administered as prescribed and in compliance with the resident's medication management plan.
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