Episcopal Church Home: Oxygen Safety Failures - MN
The resident, identified as R15 in inspection documents, requires continuous oxygen at 4 liters per minute for chronic obstructive pulmonary disease and severe shortness of breath. Her care plan specifically warned that her oxygen levels "would drop into the 80s when oxygen was removed."
When inspectors found her without oxygen on April 6, the resident told them she was supposed to have her oxygen on at 5 liters per minute. She said she wasn't currently in respiratory distress but couldn't remember how long she had been without oxygen.
The next morning brought more problems.
Inspectors observed R15 sleeping with her nasal cannula positioned on her chin rather than in her nose. The oxygen concentrator was running at 3 liters per minute instead of the ordered 4. When nursing assistants entered to deliver breakfast and later to help position her in bed, none addressed the misplaced tubing or incorrect flow rate.
"She took the oxygen off for breakfast and would replace it once she was done eating," R15 told inspectors after the nursing assistants left her room.
The resident's oxygen tubing carried no labels indicating when it had last been changed, despite facility policy requiring weekly changes with proper dating.
Later that morning, nursing assistant NA-B entered R15's room and confirmed the resident was supposed to receive continuous oxygen at 4 liters per minute. When asked about the current setting, NA-B acknowledged it was set at 3 liters but "should be on 4" and changed it to 4 liters per minute.
That adjustment violated facility protocols.
Registered nurse RN-A told inspectors that nursing assistants should not adjust oxygen flow rates and that NA-B should have notified a nurse about the incorrect setting instead of changing it herself.
"Staff should encourage her to keep it on at all times," RN-A said about R15's continuous oxygen requirement. The nurse initially thought the flow rate could be adjusted during the day but found no such instructions in the resident's electronic health record.
R15's medical history painted a picture of significant respiratory compromise. Her quarterly assessment indicated she was cognitively intact but dependent on staff for most daily activities including bed mobility and transfers. Her diagnoses included chronic respiratory failure with low oxygen levels, COPD, anxiety, and shortness of breath.
Provider orders from July 29, 2025, were explicit: oxygen via nasal cannula at 4 liters per minute continuously for shortness of breath, with tubing and cannula changes every Tuesday evening.
A shortness of breath evaluation confirmed R15 was oxygen dependent.
Licensed practical nurse LPN-A reinforced the protocols during her interview with inspectors, stating that oxygen flow rates should match provider orders and that nursing assistants should notify nurses rather than make adjustments themselves.
The facility's director of nursing expected R15's oxygen to be administered exactly as ordered, with tubing properly labeled and dated. She confirmed that nursing assistants were not supposed to adjust oxygen flow rates.
The Episcopal Church Home's own policy on safe oxygen use, dated August 28, 2020, required staff to ensure residents were educated about safe oxygen use and to report any concerns to registered nurses.
The inspection revealed a cascade of protocol failures surrounding life-supporting respiratory therapy. Staff repeatedly failed to ensure proper oxygen delivery for a resident whose care plan explicitly warned of dangerous oxygen level drops. Nursing assistants made unauthorized equipment adjustments instead of following established notification procedures.
The facility's oxygen management failures extended beyond equipment settings to basic monitoring responsibilities. Multiple staff members observed improperly positioned oxygen equipment without intervention, and required weekly tubing changes went undocumented.
R15's case illustrated how respiratory care breakdowns can accumulate. The resident was found without oxygen access, with incorrect flow rates, improperly positioned equipment, and unlabeled tubing that should have been changed weekly.
The inspection occurred on April 9, 2026, as part of a routine health survey. Federal inspectors classified the oxygen therapy violations as causing minimal harm or potential for actual harm, affecting few residents.
For R15, whose oxygen levels drop dangerously when respiratory support is removed, each protocol failure represented a potential medical crisis. Her cognitive awareness meant she understood when her oxygen was missing, but her physical dependence on staff left her unable to correct the problems herself.
The resident's experience highlighted the critical importance of respiratory care protocols in nursing facilities, where staff training and adherence to medical orders can mean the difference between stable breathing and respiratory distress for vulnerable residents with chronic lung conditions.
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: August 4, 2026 · Our methodology
EPISCOPAL CHURCH HOME THE GARDENS in SAINT PAUL, MN was cited for violations during a health inspection on April 9, 2026.
She said she wasn't currently in respiratory distress but couldn't remember how long she had been without oxygen.
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.