Episcopal Church Home The Gardens: Bed Rail Failures - MN
The inspection, completed August 18, 2025, found that the facility had been installing half-length bilateral bed rails on residents without completing the assessments its own policy required, without documenting whether residents or their families had ever been told about the risks, and without trying any other approach first.
The director of nursing, when asked why the facility hadn't attempted alternative methods before putting up the rails, responded with a question of her own: "What else are you going to use?"
That answer captures the problem inspectors documented. The facility's bed safety policy, dated 2018, states that half-side rails will be used only after an assessment shows a benefit to the resident's functional status, and that continued use must be periodically reassessed. Neither step was happening in any documented, consistent way.
One resident, identified in the report as R3, is 83 years old and lives with the effects of a stroke, weakness on one side of her body, and dementia. When inspectors observed her on August 14, she was seated in a reclining chair while permanently affixed half-length rails sat on both sides of her bed. She told inspectors she needed the rails for all movement in bed. A physical device review from July 21, 2025, described the rails as a mobility enabler and repositioning tool, and noted that R3 was able to use them appropriately. But that same review was missing critical information: her medical diagnosis, her size and weight, her cognition and communication, and whether she could remove the rails herself had not been assessed. Whether she or her representative had ever been educated about the risks wasn't documented either.
A licensed practical nurse told inspectors that the facility assessed bed rails on all residents during quarterly reviews and that residents and families were educated on risks and benefits. Then came the admission: the facility had no place to document that education had ever taken place.
On August 15, one day into the inspection, the facility removed most of the bed rails. A regional operations manager, who was filling in for the administrator, told inspectors that the facility sent an email to residents and their representatives. Some rails stayed up. Those were the residents whose family members were present at the facility and refused to allow removal.
The director of nursing maintained that none of the rails counted as restraints because residents were able to get in and out of bed on their own. The regional operations manager said the facility planned to start the assessment process from scratch.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, affecting a small number of residents. But the scope of the problem was larger than one resident. The director of nursing acknowledged the facility had not tried alternative methods before installing the rails on anyone. The licensed practical nurse confirmed the documentation gap applied broadly. The assessments that did exist, like the one for R3, were incomplete in ways the facility's own policy was designed to prevent.
Bed rails have been associated with entrapment, strangulation, and falls when residents attempt to climb over them. The risks are specific enough that federal guidance requires facilities to weigh them carefully, document the reasoning, and show that other options were considered first. Episcopal Church Home The Gardens had a policy that described that process. Inspectors found the process wasn't being followed.
R3 is still there. She told inspectors she needs the rails to move in bed at all.
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.
Neither step was happening in any documented, consistent way.
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.