Episcopal Church Home: Medication Safety Failures - MN
Episcopal Church Home The Gardens failed to address consultant pharmacy warnings about duplicate medications for a resident taking both MiraLAX and docusate sodium for constipation. The facility's consultant pharmacist issued the same recommendation three separate times between October 2025 and February 2026, each time noting the duplication and requesting either usage parameters or discontinuation of one medication.
The resident, identified as R10 in inspection documents, had adjustment disorder with mixed anxiety and depressed mood, chronic pain syndrome, and constipation. Care plans noted the resident was frequently incontinent and taking opioid medications, which can worsen constipation issues.
The consultant pharmacist first flagged the problem in an October 2025 review, writing: "The resident has orders for MiraLAX PRN [as needed] for constipation as well as docusate PRN for constipation. To ensure consistent administration and for state survey purposes, please set parameters for use [e.g. which to use first] or, if a duplication, consider discontinuing one of the above."
Someone added an undated handwritten note to that review saying "use MiraLAX first" and signed it, but the medication administration records were never updated.
The pharmacist repeated the identical recommendation in subsequent monthly reviews. One review included a handwritten note indicating it was "faxed to provider per licensed practical nurse (LPN)-A." Another showed LPN-A claimed to have updated the resident's medication record, but monthly administration records from October 2025 through February 2026 showed no evidence of usage instructions.
Both medications remained listed with identical dosing: "Give by mouth every 24 hours as needed for Constipation." Staff had no written guidance about which medication to administer first when the resident experienced constipation.
The resident's care plan specifically warned staff to monitor for medication side effects including "constipation fecal impaction," which occurs when stool becomes hardened and stuck in the rectum due to long-term constipation. Despite this documented risk and the resident's cognitive impairment, the medication duplication persisted.
During the April inspection, the director of nursing acknowledged the consultant pharmacy recommendations should have been addressed more quickly. The director explained that clinical pharmacists email recommendations to both the director of nursing and clinical nurse managers, with the responsible nurse manager forwarding recommendations to providers when appropriate.
"Urgent recommendations should be addressed promptly, and less urgent ones should be addressed in one to two months at the most," the director told inspectors.
The consultant pharmacist expressed frustration during the inspection, telling investigators facilities should address recommendations within 30 days. The pharmacist said they should not have to issue the same recommendation multiple times without it being addressed, and expected the duplicate medication issue to have been resolved much sooner than five months.
The facility's policy for reviewing pharmacy recommendations was requested during the inspection but never provided to investigators.
Federal inspectors found the facility failed to follow its own irregularity reporting guidelines and procedures. The violation affected few residents but created potential for actual harm, according to the inspection report.
The case highlights a common problem in nursing home medication management, where consultant pharmacists identify potentially dangerous drug duplications or interactions, but facilities fail to implement recommended changes in a timely manner. For residents with cognitive impairment like R10, unclear medication protocols can lead to over-medication, under-medication, or dangerous drug interactions.
The resident continued receiving both constipation medications without clear usage parameters through at least February 2026, five months after the first pharmacy recommendation to address the duplication.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Episcopal Church Home the Gardens from 2026-04-09 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: June 20, 2026 · Our methodology
EPISCOPAL CHURCH HOME THE GARDENS in SAINT PAUL, MN was cited for violations during a health inspection on April 9, 2026.
Care plans noted the resident was frequently incontinent and taking opioid medications, which can worsen constipation issues.
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.