Episcopal Church Home The Gardens
EPISCOPAL CHURCH HOME THE GARDENS in SAINT PAUL, MN — inspection on April 9, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
re-evaluation should be completed based on cognitive changes.-A physician order would be obtained
245625 04/09/2026
Episcopal Church Home the Gardens 1860 University Avenue West Saint Paul, MN 55104
During observation on 4/7/26 at 10:05 a.m., nursing assistant (NA)-A entered R19's room and offered a brief change. R19 stated that she did need to be changed and cleaned. NA-A donned gloves and put the head of the bed flat, lifted R19's gown and removed her brief. NA-A did not close R19's door, which was open to the hallway. NA-A walked into the bathroom to obtain a new brief, while R19 waited, exposed from mid abdomen down. R19 was able to roll to her left side facing the window as her back side faced the door.
While NA-A wiped R19's bottom physical therapist (PT)-A knocked once on the open door, did not wait for a response, and walked into R19's room as her bottom was exposed. PT-A stopped turned around and stated he would come back in a bit. NA-A completed peri care and placed a new brief.
During interview on 4/7/26 at 10:16 a.m., NA-A stated she should have closed R19's door for privacy and agreed that PT-A had walked in and saw R19's exposed bottom.
During interview on 4/7/26 at 10:18 a.m., R19 stated she wished the door would have been shut during peri care and was wondering why PT-A had just walked right in.
During interview on 4/7/26 at 1:55 p.m., registered nurse (RN)-A stated resident doors should be closed during personal cares to protect their privacy.
During interview on 4/8/26 at 10:23 a.m., licensed practical nurse (LPN)-A stated expected staff to close a resident's door during cares for privacy.During interview on 4/8/26 at 1:00 p.m., director of nursing (DON) expected privacy to be maintained for all residents.
Resident's door should be closed during brief changes and other personal cares.A facility policy titled Dignity dated 10/15/24, the facility was committed to providing care and services in such a way to maintain each resident's dignity, individuality, privacy, autonomy, and self-worth.
The policy further indicated, Residents are provided privacy during personal care, bathing, dressing, toileting, and medical treatments.
The policy further indicated, staff will knock and request permission before entering resident rooms whenever possible.
245625 04/09/2026
Episcopal Church Home the Gardens 1860 University Avenue West Saint Paul, MN 55104
During observation and interview on 4/6/26 at 2:03 p.m., R15 was lying in bed with the oxygen tubing/nasal cannula wrapped up and hanging off the oxygen concentrator out of R15's reach.
The oxygen concentrator was on and set to 3 lpm. R15 stated she was supposed to have her oxygen on at 5 lpm. R15 stated she did not currently feel she was in any respiratory distress but could not remember how long she was without oxygen. R15's oxygen tubing was not labeled as to when it had been last changed.
During observation on 4/7/26 at 8:19 a.m., R15 was in bed sleeping with the nasal cannula positioned on her chin rather than in her nares.
The oxygen concentrator was set to 3 lpm.
The oxygen tubing was not labeled as to when it had been last changed.
During observation on 4/7/26 at 8:21 a.m., nursing assistant (NA)-I entered R15's room and delivered her breakfast tray. R15 did not address the oxygen tubing positioned on R15's chin or setting.
During observation and interview on 4/7/26 at 8:32 a.m., NA-I and NA-B entered R15's room to boost her up in bed for breakfast. R15's oxygen tubing was now lying to the side of her on the bed.
Neither NA-I nor NA-B addressed the oxygen tubing or flow rate.
After the NAs left the room, R15 stated she took the oxygen off for breakfast and would replace it once she was done eating.
During observation and interview on 4/7/26 at 11:19 a.m., R19 in bed with the oxygen nasal cannula in her nares.
The oxygen concentrator was set at 3 liters per minute. NA-B entered R15's room and stated R15 was on continuous oxygen at 4 lpm.
When asked to confirm the flow rate, NA-B confirmed the flow rate was currently set at 3 lpm but should be on 4 and changed it to 4 lpm.
During interview on 4/7/26 at 11:27 a.m., registered nurse (RN)-A stated R15 was on continuous oxygen and that staff should encourage her to keep it on at all times. RN-A further stated she thought the flow rate could be adjusted during the day but could not find any reference to those instructions in R15's electronic health record (EHR). RN-A confirmed R15's oxygen order was for continuous oxygen at 4 lpm. RN-A further stated oxygen tubing was changed weekly and should be labeled to identify when it had been changed last. RN-A further stated NAs should not adjust oxygen flow rate and that NA-B should have notified a nurse about R15's incorrect oxygen flow rate.
During interview on 4/8/26 at 10:20 a.m., licensed practical nurse (LPN)-A stated the oxygen flow rate should match the provider order, and oxygen tubing should be labeled and dated.
LPN-A further stated NAs should not adjust the flow rate but rather notify a nurse when found to be incorrect.During interview on 4/8/26 at 1:00 p.m., director of nursing (DON) expected R15's oxygen to be administered as ordered by the provider and tubing labeled and dated when to indicate when it was last changed. DON further stated NAs were not supposed to adjust oxygen flow rate and NA-B should have notified a nurse instead. A facility policy Safe Oxygen Use and Storage dated 8/28/20, indicated staff would take measures to ensure residents were educated and encouraged to use oxygen in a safe manner and any concerns would be reported to the RN.
245625 04/09/2026
Episcopal Church Home the Gardens 1860 University Avenue West Saint Paul, MN 55104
During interview on [DATE] at 12:51 p.m., director of nursing (DON) expected R10's CPR would have been addressed timelier. DON stated the process for CPR was the clinical pharmacist would email the recommendations to the DON and each of the clinical nurse managers (CNM).
The CNM who was responsible for the resident in the recommendation would forward to the provider if appropriate or address the recommendation if it was a nursing issue. DON further stated urgent recommendations should be addressed promptly, and less urgent ones should be addressed in one to two months at the most.
During interview on [DATE] at 1:00 p.m., CP expected facilities to address the CPR within 30 days or so. CP stated should not have to issue the same recommendation without being addressed multiple times and would have expected R10's duplicate medications to have been addressed sooner than five months.
Facility policy for pharmacy recommendation review was requested but was not provided.
During interview on 4/9/26 at 12:40 p.m., administrator stated they expected all staff to handle and store food properly.
Additionally, any opened items were to be labeled, dated and sealed.
The rationale for proper food storage decreased the risk of food borne illness.A facility policy titled Episcopal Homes Refrigerator and Food Storage, directed staff to ensure opened freezer foods are sealed to prevent freezer burn and spoilage.
Furthermore, all foods must be sealed, labeled and dated.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
245625 04/09/2026
Episcopal Church Home the Gardens 1860 University Avenue West Saint Paul, MN 55104
included, Presence of wounds and/or indwelling medical devices, even if there is no known infection
The facility policy on droplet precautions dated 10/2/24, indicated to limit the movement and
room.
Provide meals, therapies, and activities in the elder's room whenever possible during the acute phase of illness with consultation with the IP.
245625 04/09/2026
Episcopal Church Home the Gardens 1860 University Avenue West Saint Paul, MN 55104
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAINT PAUL, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EPISCOPAL CHURCH HOME THE GARDENS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.