Episcopal Church Home of Minnesota

Inspectors wroteBased on observation, interview, and document review the facility failed to provide supervision to necessary prevent elopement for 1 of 1 resident (R1) who required continuous care and supervision, resided on a semi-locked unit and left the facility without their knowledge. This resulted in an Immediate Jeopardy (IJ) for R1. The Immediate Jeopardy (IJ) began on 7/9/26, when R1 was visiting another resident outside the semi-locked unit on the first floor between 8:30 a.m. and 9:30 a.m. At approximately 9:30 a.m., assisted living campus administrator (ACA) noticed R1 was walking alone outside the facility in the parking lot heading towards a busy avenue. The Administrator and Director of Nursing (DON) were notified of the IJ on 7/21/26 at 5:15 p.m. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to report an injury of unknown origin to the State Agency (SA) immediately, but not later than two hours, for 1 of 1 (R1) residents reviewed for resident safety.

Inspectors wroteBased on observation, interview and document review the facility failed to comprehensively assess bruising for 1 of 1 resident (R1), and the facility was unable to ensure neurological checks (a critical assessment to identify any potential damage to the brain and nervous system) had been completed according per protocol.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medications were stored appropriately, securely, and not expired for 3 of 5 medication carts reviewed for medication storage. This had the potential to affect all the residents who received medications from those carts or resided in or visited the area of the facility in which those medication carts were located. In addition, the facility failed to ensure a medication for one resident (R8) was not left at the bedside of a different resident (R87), contributing to inappropriate medication storage practices for the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure appropriate hand hygiene for 1 of 1 resident (R21) during incontinence cares and for 1of 1 resident (R29) during meal service which had the potential to affect all 14 residents in that household. The facility further failed to ensure appropriate personal protective equipment (PPE) was being worn for 1 of 2 residents (R115) on enhanced barrier precautions (EBP).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medication was administered safely for 2 of 2 (R68, R117) who had been assessed as unable to safely self-administer medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the primary care provider (PCP) was notified of a change in condition for 1 of 2 residents (R21) reviewed for a change of condition.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a new skin alteration was comprehensively assessed and monitored consistently in accordance with nursing standards of practice, and that orders for monitoring and referral were entered into the electronic medical record (EMR) for 1 of 2 residents (R21) reviewed for new skin alterations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident was safe to have a lift reclining chair for 1 of 1 resident (R92) reviewed for falls.

Inspectors wroteBased on interview and document review the facility failed to immediately respond, investigate timely, and implement resident protections for 2 of 4 residents (R1, R2) following an allegation of verbal, mental and physical abuse of R1 and an allegation of mental abuse and neglect of care of R2, that were both reported to the facility. The immediate jeopardy began on 10/6/25 at 10:30 a.m. when R1's family member (FM)-A reported to social worker (SW)-A an allegation of staff to resident mental and physical abuse. Additionally, on 11/3/25, R2's FM-B reported an allegation of staff to resident mental abuse and neglect of care. The facility failed to report timely the incidents to the State Agency (SA), conduct a thorough investigation, and to implement resident protections to ensure other vulnerable residents at risk of abuse were safe during the investigation. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure annual performance reviews were completed for 4 of 5 nursing assistants (NA-A, NA-B, NA-C, and NA-D) whose personnel files were reviewed. This deficient practice had potential to affect all residents who currently resided in the nursing home and who could receive care from this staff.

Inspectors wroteBased on interview and document review, the facility failed to promote dignity while providing care for 3 of 4 residents (R1, R2, R3) reviewed who required assistance with activities of daily living.

Inspectors wroteBased on interview and document review, the facility failed to report allegations of physical and verbal abuse immediately (within two hours) to the State Agency (SA) for 3 of 4 residents (R1, R2, R3) after family members and/or residents reported the alleged abuse.

Inspectors wroteBased on interview and document review, the facility failed to ensure completion of 12 hours of annual in-service training for 3 of 5 nursing assistants (NA-A, NA-C, NA-D) reviewed for annual training.

Inspectors wroteBased on interview and document review the facility failed to monitor and assess for presence of signs/symptoms of urinary tract infections and for antibiotic effectiveness and/or adverse reactions for 2 of 3 residents (R1, R2) reviewed for change of condition.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure frozen food items were stored in a manner to prevent cross contamination in 2 of 3 unit kitchenettes reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure provider notification occurred when a skin altercation was identified for 1 of 1 residents (R24) reviewed for surgical incision care.

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess a new skin alteration and changes in a surgical incision for 1 of 1 residents (R24) who developed gangrenous toe that required surgical treatment. Furthermore, the facility failed ensure coordination of care for a hospice patient with a change in condition for 1 of 1 residents (R25) reviewed for hospice.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a safe smoking environment was provided for 2 of 2 residents (R50 and R55) reviewed for smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dialysis fistula site was maintained according to professional standards of care for 1 of 2 residents (R24) reviewed for dialysis.

Inspectors wroteBased on interview and document review the facility failed to ensure antifungal medications without an end date were monitored and evaluated for the appropriateness of continued use for 2 of 2 residents (R17, R27) reviewed who were prescribed antifungal medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure hand hygiene was performed for 2 of 3 residents (R24, R84) observed during personal cares and 1 of 1 residents observed during wound cares. Furthermore, the facility failed to ensure transmission-based precautions (TBP) were followed for 1 of 3 (R24) residents observed for TBP.

Inspectors wroteBased on interview and document review the facility failed to ensure 2 of 5 residents (R59, R211) were offered and/or provided updated vaccinations for pneumococcal disease and 1 of 4 residents (R59) were offered and/or provided updated vaccinations for influenza in accordance with the Centers for Disease Control (CDC) vaccinations.

Inspectors wroteBased on interview and document review the facility failed to provide a COVID-19 vaccination timely to 1 of 1 resident (R211) who requested to be vaccinated.

Inspectors wroteBased on interview and record review the facility failed to ensure treatment, monitoring, and care in accordance with professional standards of practice were provided for 1 of 3 residents (R1) reviewed when skin ulcerations developed. R1's primary physician was not immediately notified when the first wound was discovered or when the wound had a significant change. R1 was admitted to the hospital with wounds on both legs requiring surgical interventions. The facility was only aware of the wound on R1's right leg.

Inspectors wroteBased on interview and record review the facility failed to prevent three pressure ulcers for 1 of 3 residents (R1) reviewed for skin integrity. R1 was harmed when he developed three pressure ulcers that went without treatment, staff were aware but did not implement a treatment plan. The hospital identified the pressure ulcers when R1 was admitted for wound care and subsequent surgical debridement.

Inspectors wroteBased on interview and record review the facility failed to notify the resident's representative with a change to a resident's health when a new medication and treatment were ordered for 1 of 3 resident reviewed. R1 was identified as having a wound on his right leg and the facility notified the provider, obtained an order for an antibiotic, and a dressing change. The change and treatment were initiated without informing the resident representative.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of neglect immediately, but not later than two hours, to the State Agency (SA) for 1 of 1 resident (R1) reviewed for skin integrity when the hospital contacted the facility when R1 was admitted for wound care that required surgical intervention and three pressure ulcers were found.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan to address a significant change to skin integrity with wound treatment interventions for 1 of 3 residents (R1) reviewed. In addition, R1 was using a mechanical lift for transfers and a wheelchair for ambulation and the care plan indicated R1 transferred with the assistance of one staff member.

Inspectors wroteDuring observation and interview, the facility failed to ensure the use of hair restraints during food preparation. This had potential to affect all 116 residents. During observation on 1/23/24 at 1:45 p.m., cook (C)-A prepared chicken on pans before placing into oven. C-A had facial hair and wore a face mask. During observation on 1/23/24 at 2:33 p.m., C-B had a beard which was uncovered. C-B covered and dated multiple pans of Swedish meatballs. C-B stirred taco meat which was cooling. During observation and interview on 1/25/24 at 9:19 a.m., C-A had facial hair and wore a mask while preparing turkey and bread. C-A stated they wore a mask to cover their facial hair. C-B had a beard which was uncovered and poured liquid into a mixture and prepared other ingredients for a dessert. C-B stated they prepared food for Episcopal Church Home and the Transitional Care Unit. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a dignified morning and rising routine was implemented for 1 of 2 residents (R21, R51) reviewed for dignity.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self administration of medication assessment (SAM) was completed to allow residents to safely administer their own medications for 2 of 2 residents (R42, R97) observed with medications at the bedside.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure personal privacy was maintained for 1 of 1 residents (R51) reviewed who required staff assistance with personal care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide follow up vision services for 1 of 1 resident (R21) reviewed for vision treatment.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure the environment was free of accident hazards for 1 of 1 residents (R39) found to have a space heater operating in their room.

Inspectors wroteBased on interview and document review, the consultant pharmacist (CP) failed to report irregularities to the provider for 1 of 1 residents (R27) reviewed who was due for a gradual dosage reduction (GDR) of an antipsychotic.

Inspectors wroteBased on interview and document review, the facility failed to ensure a gradual dose reduction (GDR) was attempted, or obtain adequate medical justification for the continued use of an antipsychotic medications for 1 of 1 residents (R27) reviewed who was due for a GDR.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 5 resident (R102) were offered or received the pneumococcal vaccine in accordance with the Center for Disease Control (CDC) recommendations.