Edgewood Hermantown I Sr Lvg.

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 medication was not administered as ordered. The resident developed sepsis and died in the hospital four days later. Investigative Findings and Conclusion: The Minnesota Department of Health determined neglect was not substantiated. Although, the resident did not receive the medication for the urinary tract infection (UTI), the facility staff made numerous phone calls and fax communications to the medical provider and pharmacy in an attempt to coordinate and expedite delivery and administration of the medication. During the investigation it was discovered the medication ordered after the initial urinalysis (UA) was found to not be the best antibiotic to treat the UTI after the final results from the urine culture and sensitivity were received by the facility the same day the resident was transferred to the hospital. The investigator conducted interviews with facility staff members, including administrative staff, nursing staff, and unlicensed staff. The investigation included review of the resident record, death record, facility internal investigation, facility incident reports, staff schedules, and related facility policy and procedures. Hospital records were requested but not received. Also, the investigator toured the facility and observed interactions between facility staff members and residents during the onsite visit. The resident resided in a secured assisted living memory care unit. The resident’s diagnoses included a recent cognitive decline, chronic pain, and chronic kidney disease. The resident’s service plan included assistance with medication management and administration, dressing and toileting. The resident’s assessment indicated a recent decline in cognition, needed frequent reminders and used a walker for ambulation. The resident readmitted to the facility on the 19th day of the month after receiving short term therapy in a transitional care facility for a previous hospitalization for a sudden onset of lethargy (marked drowsiness and an unusual lack of energy and mental alertness). On the 27th day of the month, four days before the hospitalization, the resident had an appointment with a physician regarding chronic hip pain where her gabapentin dose (a medication used to treat nerve pain and seizures) was increased. The next day, on the 28th day of the month, a progress note in the resident’s medical record indicated the resident’s gabapentin dose was increased and later in the afternoon, a urinalysis (UA) was obtained after reports of foul-smelling urine. The same note indicated the resident was not experiencing urinary pain or other symptoms at that time. Later that evening, preliminary lab results were received by fax at the facility. On Saturday, the 29th day of the month the facility on-call nurse contacted the medical provider as the facility, nor the pharmacy had received orders regarding the UA results the previous day. The facility nurse faxed the UA results to the medical provider for review and to order medications, if warranted. A progress note indicated the facility requested new medication orders be sent to a local pharmacy for faster delivery and administration. The on-call medical provider ordered an antibiotic for the resident and sent an electronic prescription to the pharmacy. The pharmacy faxed a copy of the prescription received to the facility. (It was unclear if the prescription was sent to a local pharmacy by the medical provider as requested.) On Sunday, the 30th day of the month, the on-call nurse was updated by the facility staff the medication had not yet arrived at the facility and the resident was now having trouble walking. A progress note indicated the difficulty walking was contributed to the recent increased gabapentin dose. The note went on to indicate the on-call nurse contacted the pharmacy to inquire when the antibiotic would arrive and was told it had been shipped and would arrive that day. The on-call nurse instructed the facility staff to hold the afternoon dose of gabapentin, if the resident did not want to take it and follow up with the provider of the resident’s concerns on the next day (Monday). Later that morning on Sunday, the completed urinalysis with culture and sensitivity results were received by fax at the facility and forwarded to the medical provider. The results indicated the medication ordered initially was not the best choice to treat the organism causing the UTI. The resident’s medical record indicated on Sunday later in the afternoon, the resident began not feeling well and began shaking. Per resident and family member request, emergency medical services (EMS) were called, and the resident was transferred to the hospital for evaluation. The note indicated the facility staff notified EMS of the resident’s current urinary tract infection and medications had not yet arrived to start administration. Medical records received indicated the resident admitted to the hospital with urosepsis (a system wide infection in the body that originates as a urinary tract infection). The records received indicated the resident did not receive antibiotics at the hospital because the resident was placed on comfort care. The resident died four days later. During an interview, the nurse stated the facility staff and on call nurse acted within their ability. The facility on-call nurse made requests to the provider and pharmacy staff to send the new medication order to a local pharmacy for faster delivery, however the medication order was sent through the mail delivery system. The nurse stated when the family reported the resident was experiencing a change in condition to unlicensed caregivers, EMS was notified, and the resident was transferred to the hospital for evaluation. During an interview, the family member reported she had taken the resident to see a medical provider about chronic hip pain, after that visit she became concerned the resident was experiencing an infection and updated a facility unlicensed caregiver. The following day she inquired if a urinalysis was completed before taking the resident out to lunch, and a UA was obtained by facility staff and sent to the laboratory. The family member asked on Saturday if family could pick up the medication, and the facility staff said the medication was sent to the mail order pharmacy. On Sunday, the family member reported the resident did not complain of urinary pain or difficulty urinating but was having difficulty walking and declined to go to church that morning. By the afternoon, the resident did not feel well and began shaking. An unlicensed caregiver notified EMS, after family members request. The resident’s condition continued to progressively decline and ultimately was unable to recognize her family. Upon admission to the hospital, the resident was put on comfort care and died four days later. 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.

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 Hermantown I Senior Living, LLC June 5, 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: St - 0 - 0775 - 144g.45 Subd. 2. (a) - Fire Protection And Physical Environment - $500.00 St - 0 - 0800 - 144g.45 Subd. 2 (a) (4) - Fire Protection And Physical Environment 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 Hermantown I Senior Living, LLC June 5, 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 HHH PRINTED: 06/05/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 30824 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4195 WESTBERG ROAD EDGEWOOD HERMANTOWN I SR LVG HERMANTOWN, MN 55811 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 FOLLOW UP using federal software. Tag numbers have SURVEY WITH RE-ISSUE OF ORDERS been assigned to Minnesota State Statutes for Assisted Living Facilities. The INITIAL COMMENTS assigned tag number appears in the SL#30824016-1 far-left column entitled "ID Prefix Tag." The state Statute number and the On April 23, 2025,through April 24, 2025, the corresponding text of the state Statute out follow-up survey at the above provider to Statement of Deficiencies" column. This follow-up on orders issued pursuant to a survey column also includes the findings which completed on January 29, 2025. At the time of are in violation of the state requirement the survey, there were 168 residents receiving after the statement, "This Minnesota services under the Assisted Living License. As a requirement is not met as evidenced by." result of the follow-up survey, the following orders Following the evaluators ' findings is the were reissued and/ or issued. Time Period for Correction. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVIDER'S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS 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. {0 100} 144G.10 Subdivision 1 License required {0 100} SS=F (a)(1)Beginning August 1, 2021, no assisted living LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM 6899 1BB312 If continuation sheet 1 of 18 PRINTED: 06/05/2025 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING: ______________________ R B. WING _____________________________ 30824 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4195 WESTBERG ROAD EDGEWOOD HERMANTOWN I SR LVG HERMANTOWN, MN 55811 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) {0 100} Continued From page 1 {0 100} facility may operate in Minnesota unless it is licensed under this chapter. (2) No facility or building on a campus may provide assisted living services until obtaining the required license under paragraphs (c) to (e). (b)The licensee is legally responsible for the management, control, and operation of the facility, regardless of the existence of a management agreement or subcontract. Nothing in this chapter shall in any way affect the rights and remedies available under other law.