Willows of Episcopal Homes

Survey completed August 10, 2023: 4 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 had the potential to affect all residents of the assisted living facility. [...]”

  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 1620: 144G.70 Subd. 2 (c-e) Initial reviews, assessments, and monitoring Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a comprehensive nursing assessment after initiating hospice services, for two of four residents (R4, R5)

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted a comprehensive nursing assessment after initiating hospice services, for two of four residents (R4, R5) 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, but was not likely to cause serious injury, impairment, or death), and was issued at a widespread scope (when [...]”

  Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

• Tag 1640: 144G.70 Subd. 4 (a-e) Service plan, implementation and revisions to Level 2, pattern scope, scope/level letter E
  Details

  Summary: MDH found the licensee failed to ensure the service plan was updated and included a signature or other authentication by the resident and the facility to document agreement on the services to be provided for three of four residents (R2, R4, R5).

  MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the service plan was updated and included a signature or other authentication by the resident and the facility to document agreement on the services to be provided for three of four residents (R2, R4, R5). [...]”

  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. [...]”

• Tag 2180: 144G.84 SERVICES FOR RESIDENTS WITH DEMENTIA Level 2, widespread scope, scope/level letter F · correction period: Twenty-one (21) days
  Details

  Summary: MDH found the licensee failed to ensure behavioral symptoms were addressed on the service plan for two of two residents (R2, R4).

  MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure behavioral symptoms were addressed on the service plan for two of two residents (R2, R4). [...]”

  Rule cited: “(e) Behavioral symptoms that negatively impact the resident and others in the assisted living facility with dementia care must be evaluated and included on the service or care plan. [...]”

From MDH’s letter: no immediate fines.

Allegation, as written: “Facility staff neglected a resident when they failed to administer a resident's scheduled narcotic pain (morphine) and antianxiety (lorazepam) medications according to the resident's medical provider's orders which caused a delay in the resident getting relief from his anxiety and pain symptoms.”

“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 delayed the processing of the resident's hospice provider's orders for scheduled morphine and lorazepam until 24 hours later, the facility still administered his as needed (prn) doses of lorazepam. It was uncertain if the resident experienced uncontrolled pain during the noted time frame.”

Action taken by facility: “The facility implemented the hospice provider's orders within 24 hours.”

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

Survey completed November 19, 2025: no correction orders issued.

Allegation, as written: “The alleged perpetrator (AP), a facility unlicensed staff member, abused the resident when the AP slapped the resident on her cheek with the back of her hand.”

“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. Due to conflicting information provided, it could not be determined whether the alleged incident did or did not occur. The staff member/alleged perpetrator (AP) denied the allegation, there was a delay in reporting the incident, and there was no camera footage of the alleged incident. In addition, there was no evidence of bruising and/or changes in the resident's mood or behavior following the incident.”

Action taken by facility: “The facility conducted an internal investigation and completed education to all staff after the incident. The AP is no longer employed by the facility.”

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

Survey completed June 25, 2024: no correction orders issued.

Allegation, as written: “The facility neglected the resident when the resident was found lying naked on her bare mattress and she had been incontinent of urine.”

“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. The resident was observed covered by a blanket in bed. The resident's brief was recently changed, and her sheets were removed to wash. Hospice arrived shortly after facility staff cleaned the resident and brought her sheets to launder. Hospice staff bathed and dressed the resident. The resident had no negative outcome from the brief period between undressing, getting clean clothes and bedding applied. At the time of the incident the resident was very agitated and difficult to provide care for. She would remove her brief and clothing. After this incident the facility worked with the resident's primary care provider to adjust her medications to decrease agitation.”

Action taken by facility: “The facility completed an internal investigation and provided education to facility staff. The facility consulted with the residents' primary care provider and medications were adjusted.”

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

Survey completed February 3, 2026: 1 correction order

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

  Summary: MDH found the licensee failed to ensure the resident record included all required content including documentation of complaints for one of one resident (R1) reviewed.

  MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the resident record included all required content including documentation of complaints for one of one resident (R1) reviewed. This deficient practice had the potential to affect all residents. [...]”

  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, [...]”

Allegation, as written: “The facility neglected resident 1 and resident 2 when resident 1 wandered into resident 2's room. Resident 2 sustained a fracture in her right wrist and required hospitalization.”

“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. There was a lack of evidence proving resident 1 physically hurt resident 2. Resident 1 did not have a history of being aggressive toward other residents and did not normally wander into resident rooms. The incident occurred shortly after morning rounds while staff prepared breakfast, started to pass medications, and helped residents get up for the day. Facility staff responded to the incident less than 15 minutes from when resident 1 entered resident 2's room and sent resident 2 to the hospital.”

Action taken by facility: “The facility completed an internal investigation, met with resident 2's family, and re-educated staff on completing safety checks on wandering residents, hourly rounding, and the importance of checking and locking doors. The facility sent resident 2 to the hospital for treatment and increased resident 1's safety checks to every 15 minutes.”

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

Survey completed February 29, 2024: no correction orders issued.