Episcopal Church Home: Privacy Violation During Care - MN
The April 7 incident occurred when nursing assistant NA-A entered resident R19's room at 10:05 a.m. and offered to change her brief. R19 said she needed to be changed and cleaned.
NA-A put on gloves, flattened the bed, lifted R19's gown and removed her brief. But NA-A failed to close R19's door, which remained open to the hallway. NA-A then walked into the bathroom to get a new brief, leaving R19 exposed from mid-abdomen down.
R19 rolled to her left side facing the window, with her backside toward the open door.
While NA-A wiped R19's bottom, physical therapist PT-A knocked once on the open door. PT-A did not wait for a response and walked into the room as R19's bottom was exposed. PT-A stopped, turned around and said he would come back later.
NA-A completed the personal care and put on a new brief.
When inspectors interviewed NA-A eleven minutes later, she admitted she should have closed R19's door for privacy. She agreed that PT-A had walked in and seen R19's exposed bottom.
R19 told inspectors two minutes after that interview that she wished the door had been shut during her personal care. She wondered why PT-A had just walked right in.
The resident's medical records showed she had intact cognition and was dependent on staff for toileting and personal hygiene. Her annual assessment indicated she was always incontinent of urine and frequently incontinent of bowel. Her diagnoses included chronic kidney disease and anxiety.
R19's care plan, revised three days before the incident, specified she required assistance from one person for personal hygiene and substantial to total help with toileting.
Multiple staff members confirmed to inspectors that doors should remain closed during intimate care.
Registered nurse RN-A said resident doors should be closed during personal cares to protect privacy. Licensed practical nurse LPN-A stated she expected staff to close residents' doors during care for privacy.
The director of nursing told inspectors she expected privacy to be maintained for all residents. Residents' doors should be closed during brief changes and other personal care, she said.
The facility's own policy, titled "Dignity" and dated October 15, 2024, committed the home to providing care in a way that maintains each resident's dignity, privacy and self-worth. The policy specified that residents are provided privacy during personal care, bathing, dressing, toileting and medical treatments.
The policy also required staff to knock and request permission before entering resident rooms whenever possible.
The violation occurred despite clear expectations from management and written policies designed to protect residents during vulnerable moments. The incident left R19 questioning why basic privacy protections failed when she needed them most.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. The inspection was completed April 9.
Episcopal Church Home The Gardens, located at 1860 University Avenue West in Saint Paul, serves residents who require varying levels of assistance with daily activities and medical care.
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
- View all inspection reports for Episcopal Church Home the Gardens
- Browse all MN nursing home inspections
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 13, 2026 · Our methodology
EPISCOPAL CHURCH HOME THE GARDENS in SAINT PAUL, MN was cited for violations during a health inspection on April 9, 2026.
The April 7 incident occurred when nursing assistant NA-A entered resident R19's room at 10:05 a.m.
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.
Frequently Asked Questions
- What happened at EPISCOPAL CHURCH HOME THE GARDENS?
- The April 7 incident occurred when nursing assistant NA-A entered resident R19's room at 10:05 a.m.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SAINT PAUL, MN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from EPISCOPAL CHURCH HOME THE GARDENS or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 245625.
- Has this facility had violations before?
- To check EPISCOPAL CHURCH HOME THE GARDENS's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.