Episcopal Church Home The Gardens

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

dated [DATE REDACTED] indicated Resident R2 had a BIMs score of 4 indicating Resident R2 was severely cognitively impaired. Resident R2 was totally dependent upon staff for dressing, bathing, toileting, and hygiene cares. He was dependent upon staff for all transferring in and out of bed. Resident R2's pertinent diagnoses were coronary artery disease (damage or disease in the hearts major blood vessels), chronic pain, symptoms and signs with cognitive functions and awareness. Resident R2's care plan dated 2/27/25 indicated Resident R2's required assistance of two staff members and assistance with the Sara Steady (mechanical lift) for toileting and to have a urinal at bedside. Resident R2's care plan dated 3/19/25 indicated Resident R2 sometimes experienced confusion, weakness, and inability to communicate needs. Staff was to encourage Resident R2 to use his urinal or the bathroom and would provide him reassurance and redirection. Upon interview on 8/14/25 at 4:18 p.m. FM-C stated she could not recall the date, but she overheard an NA telling Resident R2 to urinate in his pad. She reported this to the director of nursing DON and the NA was talked to. FM-C stated she watched the video camera in his room, and she does not see him being offered toileting or his urinal. She witnessed staff changing his pad and at times does not witness staff in his room at all overnight. They don't honor our request to have him taken to the bathroom. Upon interview

on 8/18/25 at 9:40 a.m. Resident R2 stated he did not like to urinate in his pad, but he has no choice. Resident R2 would not elaborate on his statement. Upon observation and interview on 8/18/25 at 11:30 a.m. Resident R3 and family member (FM-D) were in Resident R3's room. Resident R3 was in her recliner. Resident R3 stated she waited for staff often and has had skin breakdown due to waiting in a wet brief, but not currently. She stated she not aware that she had the choice to use the toilet. She asked multiple times during the interview if she could use the bathroom instead of urinating in her brief. FM-D stated he was not certain that Resident R3 could transfer to the toilet as he had not seen her or heard her using the bathroom in months. FM-D stated he would talk to management about having her use the bathroom when she requests. Resident R3's care plan dated 4/16/25 indicated Resident R3's toilet use was

an extensive assistance of 1-2 with transferring to the toilet with a gait belt. Resident R3 would state the need for toileting, wears a brief. Usually incontinent of bowel and bladder. Apply moisture barrier with each incontinence or brief change. Report symptoms of constipation to the nurse. Resident R3's quarterly MDS dated [DATE REDACTED] indicated Resident R3 had a BIMs score of 15 indicating Resident R3 was cognitively intact. Resident R3 required maximum assistance with toileting, bathing, dressing, and hygiene and transferring from her bed to a chair. Resident R3's pertinent diagnoses were degenerative disease of the nervous system (progressive decline and death or nerve cells), chronic pain, cerebrovascular disease (disease that affects the blood vessels in the brain), hemiplegia (one side weakness following a stroke) following cerebral infarction and unspecified dementia.

Upon interview on 8/18/25 at 2:02 p.m. the DON stated it was not o.k. to tell a resident to urinate or go to

the bathroom in their incontinent brief. When the NA's are busy, they need to reach out to the nurses to assist them. Upon interview on 8/18/25 at 3:15 p.m. the Regional Operations Manager (filling in for the Administrator) stated telling residents to urinate in their incontinent brief was not the standard of care the facility endorsed. A facility policy regarding dignity was requested however none was received.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Episcopal Church Home the Gardens

1860 University Avenue West Saint Paul, MN 55104

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

precautions will be developed to decrease the number of falls whenever possible. It is the goal of the facility to achieve the resident's maximum potential of physical functioning, prevent injury, reduce falls, and enhance the resident's self-worth and dignity.Procedure:1. A Fall Risk Assessment will be completed at a minimum upon admission, quarterly in conjunction with the MDS schedule, upon significant change in status.2. Identified Fall risks will have appropriate interventions and precautions implemented and communicated to staff.3. Initiate, review and/or revise the care plan as appropriate.4. The IDT will, at a minimum of quarterly, review the resident's fall risk and care plan.5. The resident, responsible party and MD/NP will participate in the development of the plan to reduce falls.6. A post fall assessments will occur to

review contributing factors and preventrecurrence of falls.7. Falls will be discussed at IDT daily stand up, Safety Committee and Quality Assurance meetings as warranted.8. Manufacturer's recommendations will be followed for fall prevention devices as needed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Episcopal Church Home the Gardens

1860 University Avenue West Saint Paul, MN 55104

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

cerebrovascular disease (disease that affects the blood vessels in the brain), hemiplegia (one side weakness following a stroke) following cerebral infarction and unspecified dementia. Resident R3's Physical Device

Review Comprehensive dated 7/21/25 indicated the devices used were right and left mobility bars. The reason for the use of the device was Resident R3 was non-ambulatory, she had alteration in safety awareness due to cognitive impairment, history of falls, difficulty with balance and trunk control displayed. Resident R3 was able to demonstrate the ability to use the device appropriately. The device benefited her as it served as a mobility enabler, repositioning tool, and safety. The device was considered to be a therapeutic intervention to achieve proper body positioning, balance and mobility and was used for a mobility enabler and positioning.

The devices were not utilized as a fall prevention. The risks versus benefits were described as benefit: siderails are used when getting in and out of bed and for repositioning while in bed. The risk was all devices have the ability to cause injuries when not used properly. The summary of the device used indicated side rails were used when getting in and out of bed, and for repositioning while in bed. Resident R3's medical diagnosis, size and weight, cognition, communication, and mobility were not assessed for the medical device evaluation or if Resident R3 could remove the device on her own indicating the device was not a restraint. In addition,

the risk and benefits documented did not include if the resident and or representative was educated. Upon

observation and interview on 8/14/25 at 11:18 a.m. Resident R3 was seated in her reclining chair, she had permanently affixed half-length bilateral bed rails on her bed. Resident R3 stated she required the rails for all movement in bed. Upon interview on 8/14/15 at 11:09 a.m. licensed practical nurse (LPN)-A stated the facility assessed bed rails on all the residents on each quarterly assessment. The residents and/or representative is educated on the risks and benefits however the facility did not have a place to document

the education. The facility did not try any alternative methods prior to the use of the bed rails and the bed rails are used for safety of the residents while in bed. Upon interview on 8/18/25 at 2:02 p.m. the director of nursing (DON) stated during the survey when surveyor requested bed rail information the facility realized

they did not have all the criteria of the bed rail safety policy and removed most of the bed rails from residents except for a select few whose family were onsite and opposed the removal. The facility was going to start the side rails assessments from scratch following the survey. The DON stated the facility did not try alternative methods prior to installing the bed rails, asking what else are you going to use? She stated none of the rails the facility had on the bed were considered restraints because the residents were able to get in and out of bed. Upon interview on 8/18/25 at 3:15 p.m. the regional operations manager (filling in for the Administrator) stated the facility realized during the survey process that the facility was not following through on their process in regard to bed rails and on 8/15/25 removed most of the bed rails from the residents bed until new assessments could be completed. The facility sent an email to all the residents and/or resident representatives. A facility policy titled Bed Safety Policy dated 1/1/18 indicated half-side rails will be used only after an assessment has been made indicating a benefit to the resident's functional status.

Continued use of the half-side rail will be reassessed periodically to determine if the side rails enhance the resident's mobility while in bed or restricts the resident's freedom of movement.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Episcopal Church Home the Gardens

1860 University Avenue West Saint Paul, MN 55104

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm

responsible for error12. Preventative ActionAll reports must be turned in to the Director of nursing immediately. Eachmedication/treatment error will also be reviewed by the Medical Director and theConsulting Pharmacist. DON will counsel staff and any disciplinary issues will bedealt with according to facility policy. Education will be provided to the staff if necessary and a copy will be kept.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Episcopal Church Home the Gardens

1860 University Avenue West Saint Paul, MN 55104

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

hospice registered nurse (RN)-A stated she was not aware of the doubling of the patches on 8/1/25, but was aware of the 8/7/25 incident as FM-A notified her. RN-A stated she did not know of a hospice coordinator at the facility, she just spoke with the nurse on each floor of any orders, updates or concerns

she had. Upon interview on 8/14/25 at 1:35 p.m. the Administrator in training stated she was not certain if

the facility had a hospice coordinator. She stated to ask the DON as she had been at the facility for a long time. Upon interview on 8/14/25 at 1:35 p.m. the DON stated the facility did not have one actual person as

the coordinator, it was a team effort. The social worker worked on referrals and admissions and the nurse manager work with the hospice companies once they are onboard. The facilities contract with hospice dated 3/14/22 indicated:Facility Representative: Facility shall designate a member of Facility's interdisciplinary team who is responsible for working with Hospice to coordinate care provided by Facility staff and Hospice staff to any Hospice Patient under Hospice's care. Such interdisciplinary team member shall be responsible for the following: (i) collaborating with Hospice and coordinating Facility staff participating in the hospice care planning process for those Hospice Patients who are under Hospice's care; (ii) communicating with Hospice and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the Hospice Patient and family; (iii) ensuring that Facility communicates with the Hospice medical director, the Hospice Patient's attending physician, and other practitioners participating in the provision of care to the Hospice Patient as needed to coordinate the hospice care with the medical care provided by other physicians. A facility hospice policy was requested however none was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Episcopal Church Home the Gardens

1860 University Avenue West Saint Paul, MN 55104

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

dated 8/15/25 with documentation of four residents on the fourth floor. The heading was bed and the form indicating zone 1, zone 2, zones 3 and 4 zone pass was checked after each zone. No other information was documented regarding the rails. Upon interview on 9:50 a.m. the maintenance director stated the maintenance department adds the rails to the beds upon nursing requests. The rails are stored in safe storage and them for safety when they are installed. The nurses notify maintenance of any concerns once

the rails are on the beds. No other monitoring was completed by maintenance. Upon interview on 8/18/25 at 2:02 p.m. the director of nursing (DON) stated during the survey when surveyor requested side rail information the facility realized they did not have all the criteria of the side rail safety policy in place and that included any audits from the maintenance department. Upon interview on 8/18/25 at 3:15 p.m. the regional operations manager (filling in for the Administrator) stated the facility realized during the survey process that the facility was not following through on their process regarding side rails. In addition, there was not documentation of audits from the maintenance department. She stated the TELS system (the software system that notifies maintenance of tasks to complete) did not have the side rail safety inspector turned on to notify the staff. A facility policy titled Bed Safety Policy dated 1/1/18 indicated Maintenance monitors all bed rails for gaps between the mattress and bed rail, checks the mechanics of each side rail. Repair or replacement of the side rail is completed by the Maintenance department. Maintenance and/or the Health Unit Coordinator, or other designee, will replace any mattress with large gaps between the mattress and side rail.

Event ID:

Facility ID:

If continuation sheet