Episcopal Church Home: Dignity Violations Found - MN
When inspectors sat down with him on August 18, 2025, he told them he did not like urinating in his pad. He said he had no choice. Then he stopped talking.
The inspection at Episcopal Church Home The Gardens, a nursing facility at 1860 University Avenue West in Saint Paul, was triggered by a complaint. What inspectors found when they arrived documented something that had apparently been happening for months, had been reported to nursing leadership, and had not stopped.
R2's family member, identified in records as FM-C, told inspectors she had overheard a nursing assistant tell R2 to urinate in his pad. She could not recall the exact date. She reported it to the director of nursing. The nursing assistant was spoken to. FM-C said she then began watching the video camera installed in R2's room. What she saw over time did not reassure her.
"She does not see him being offered toileting or his urinal," the inspection report states, summarizing what FM-C told investigators. "She witnessed staff changing his pad and at times does not witness staff in his room at all overnight."
FM-C told inspectors directly: "They don't honor our request to have him taken to the bathroom."
R2's care plan, written in March 2025, instructed staff to encourage him to use his urinal or the bathroom and to provide reassurance and redirection when he experienced confusion. The plan existed on paper. The family watched the camera feed and saw something different.
Down the hall, a woman identified as R3 was sitting in a recliner in her room when inspectors arrived on the morning of August 18. R3 is cognitively intact, scoring a 15 out of 15 on the same cognitive assessment. She had a stroke and lives with weakness on one side of her body, chronic pain, and degenerative nerve disease. She needs one to two staff members and a gait belt to transfer to a toilet. Her care plan documented all of this.
R3 told inspectors she had waited for staff often. She said she had developed skin breakdown from sitting in a wet brief while she waited, though she was not currently experiencing that. Then she said something that stopped the interview: she was not aware she had the right to ask to use a toilet instead of urinating in her brief.
During the interview, she asked multiple times whether she could use the bathroom.
Her family member, FM-D, was in the room. He told inspectors he was not certain R3 could even transfer to a toilet anymore. He had not seen it happen or heard of it happening in months. He said he would speak to management about having her taken to the bathroom when she asked.
R3's care plan said she would state when she needed to use the toilet. It said staff should transfer her. It said to apply moisture barrier with each brief change. The plan described a woman who communicated her needs and could be helped to a toilet with assistance. The woman inspectors met did not know she was allowed to ask.
The director of nursing, interviewed the afternoon of August 18, told inspectors it was not acceptable to tell a resident to urinate in their brief. She said that when nursing assistants were too busy to respond, they were supposed to find a nurse to help. The regional operations manager, who was filling in for the administrator, said the same thing: telling residents to urinate in their briefs was not the standard of care the facility endorsed.
Inspectors requested a copy of the facility's written policy on dignity. None was provided.
The deficiency was cited under F0550, which covers resident rights to dignity and respect. CMS rated the level of harm as minimal harm or potential for actual harm, affecting a few residents. That rating reflects the regulatory framework's language, not the experience of a man who cannot move himself, cannot always find words for what he needs, and told a federal inspector he had no choice but to urinate where he lay.
R3's skin had already broken down once from waiting in a wet brief. She had been in that facility long enough that her family member had forgotten what it looked like when she used a toilet. She sat in her recliner on the morning of August 18 and asked, more than once, if she was allowed to go to the bathroom.
The answer was in her care plan. Nobody had told her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Episcopal Church Home the Gardens from 2025-08-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
EPISCOPAL CHURCH HOME THE GARDENS in SAINT PAUL, MN was cited for violations during a health inspection on August 18, 2025.
When inspectors sat down with him on August 18, 2025, he told them he did not like urinating in his pad.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.