Episcopal Church Home of Minnesota

In the surveyor’s words

From the most serious findings on record at Episcopal Church Home of Minnesota, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 22, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF610Dec 18, 2025

  Based 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. […]

• Actual harm, isolatedF684May 29, 2024

  Based 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. Findings include: R1's care plan dated 10/28/23 - 5/28/24 did not indicate any focus, goals or interventions for potential skin integrity concerns or actual focus, goals, or interventions when a wound was discovered on 5/1/24. […]

• Actual harm, isolatedF686May 29, 2024

  Based 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. Findings include: R1's care plan dated 10/28/23 - 5/28/24 did not indicate any focus, goals, or interventions for potential or actual skin integrity concerns when three pressure ulcers were discovered on 5/16/24 during a hospital admission. […]

• No harm, potential for more than minimal, widespreadF812Jan 25, 2024

  During 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. […]