Episcopal Church Home: Hospice Coordination Failures - MN
The hospice registered nurse who visited the facility, identified in inspection records as RN-A, told inspectors she had not known that a resident's pain patches had been doubled on August 1, 2025. She learned about a second incident six days later only because a family member called her directly. She said she didn't know the facility had a hospice coordinator at all. She had just been calling whichever nurse happened to be on each floor.
When inspectors sat down with the administrator in training on August 14, she said she wasn't certain whether the facility had a hospice coordinator either. She suggested they ask the director of nursing, who had been there longer.
The director of nursing had an answer, but it wasn't a name. She told inspectors that there was no single person designated as coordinator. It was, she said, a team effort. The social worker handled referrals and admissions. The nurse manager worked with hospice companies once they were already involved. That was the system.
The facility's own contract with its hospice provider told a different story. Signed in March 2022, the agreement required the facility to designate a specific member of its interdisciplinary team to serve as hospice coordinator — one person responsible for collaborating with hospice staff on care planning, communicating with the hospice medical director and attending physicians, and ensuring that everyone involved in a dying resident's care was actually talking to each other. The contract listed those responsibilities in detail across three separate clauses.
Three years after signing that agreement, the facility had not named anyone to the role.
Inspectors also asked for a copy of the facility's hospice policy. None was provided.
The inspection, completed August 18, 2025, was a complaint survey. Inspectors cited the deficiency under F0849, which covers the requirement that nursing facilities have systems in place to ensure hospice care is properly coordinated. The level of harm was listed as minimal harm or potential for actual harm, affecting a small number of residents.
What that language doesn't capture is the specific situation that appears to have triggered the complaint: a resident whose pain patches were doubled without the hospice nurse's knowledge, and a second medication incident a week later that the nurse only learned about because a family member made a phone call. The inspection record doesn't describe the resident's condition in detail or say what the consequences of either incident were. It records, plainly, that the hospice nurse was not in the loop.
Hospice care exists for people who have decided to stop pursuing curative treatment. The coordination requirements in contracts like the one Episcopal Church Home signed exist because the margin for error is different when a patient is actively dying. A missed medication change, an unreturned call, a physician who doesn't know what another physician has ordered — these are not administrative inconveniences. They are the difference between a peaceful death and one marked by preventable pain or confusion.
The facility's answer to how it managed all of that was that it was a team effort. The hospice nurse didn't know there was a team. The administrator in training didn't know who was on it. And when the family of at least one resident needed someone to call, they called the hospice nurse themselves.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
EPISCOPAL CHURCH HOME THE GARDENS in SAINT PAUL, MN was cited for violations during a health inspection on August 18, 2025.
She learned about a second incident six days later only because a family member called her directly.
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.