Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Episcopal Church Home The Gardens during CMS and state inspections, most recent first.
A deficiency was cited when a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights was not upheld by the facility.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure the bed rail was correctly installed and maintained.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care, resulting in a deficiency related to the provision of end-of-life services.
The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, and failed to ensure that bed rails and mattresses were safely attached to the bed frame as required.
A resident with significant cognitive and physical impairments reported to multiple staff that she experienced rough handling and yelling from staff, causing her pain and distress. Several staff were aware of these allegations, with some reporting to supervisors and others not reporting at all. One staff member reported the incident to the state agency independently, but not on behalf of the facility. The facility's required immediate reporting and investigation procedures were not followed, and the grievance log contained no record of the complaints.
A resident with Parkinson's disease, dementia, and kidney disease experienced multiple falls, and although new interventions were identified after each incident, these were not consistently added to the care plan or communicated to staff. As a result, important safety measures such as frequent checks and the use of a fall mat were not reliably implemented, leading to gaps in care.
A resident with multiple chronic conditions had a skin tear on the right forearm that was not consistently assessed or treated after initial physician orders were discontinued. Staff interviews and documentation review revealed that the wound was not monitored or addressed according to facility policy, and weekly skin checks were not performed as required.
The facility failed to monitor refrigerator, dishwasher, and breakfast food temperatures across six unit kitchens, leading to undated and potentially unsafe food consumption. Observations revealed missing or incomplete temperature logs, and interviews highlighted confusion among staff about monitoring responsibilities. A resident reported sour-tasting milk, underscoring the issue. The RD acknowledged the need for training nursing assistants on temperature monitoring and the importance of dating opened food containers.
The facility failed to follow proper infection control practices, as observed when a nursing assistant did not change gloves after providing peri-care to a resident and continued to assist with dressing and transfers. Additionally, a standing lift sling shared by residents was not sanitized between uses, contrary to facility policy. These actions were confirmed as infection control issues by an LPN.
A resident with a history of coronary artery disease and skin conditions had a PRN order for Nystatin powder, which was improperly administered by a nursing assistant. The NA applied the medication without authorization, as only nurses are permitted to assess and document PRN medication needs. The facility's policy on medication administration was not provided.
Two residents in a facility were not provided adequate assistance with personal hygiene, specifically shaving, despite their dependence on staff for such care. One resident with severe cognitive impairment was observed with long facial hair, which she disliked, while another resident, who preferred to be clean-shaven, was found with a full-face beard. Staff interviews revealed inconsistencies in offering shaving assistance, contrary to the facility's policy on maintaining cleanliness and grooming.
A resident with severe cognitive impairment and multiple medical conditions was observed leaning to the right in various chairs without staff intervention to reposition her. Despite being dependent on staff for daily activities and having a history of falls, her care plan lacked interventions for positioning. Staff were aware of her tendency to lean but did not take action to address it, contrary to the facility's policy of providing necessary care.
A facility failed to consistently monitor orthostatic blood pressures for a resident on antipsychotic medication, despite physician orders and facility policy requiring monthly checks. The resident, with a history of dementia and bipolar disorder, was at increased risk of falls due to potential side effects of the medication. Staff interviews confirmed the importance of these checks but revealed incomplete documentation without any noted refusals by the resident.
A resident's medication cabinet was found open and unsecured, containing multiple medications and a glucometer, while the resident was not in the room. A nurse admitted to leaving the cabinet open after being distracted, acknowledging the need for it to be locked to prevent unauthorized access. The facility's policy requires medication cabinets to be locked to ensure safe storage and administration.
Two residents at a long-term care facility experienced repeated falls due to the facility's failure to update and implement effective fall prevention strategies. One resident, with severe cognitive impairment and multiple medical conditions, had 20 falls without new interventions being added to her care plan. Another resident, who was independent with mobility, also experienced multiple falls with injuries, but her care plan was only updated once. Staff interviews revealed inconsistencies in applying fall interventions and conducting necessary assessments.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or observations involving individual residents.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Assess, Obtain Consent, and Properly Install Bed Rail
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care as required.
Failure to Ensure Safe Attachment and Inspection of Bed Equipment
Penalty
Summary
The facility failed to regularly inspect all bed frames, mattresses, and bed rails for safety. Additionally, bed rails and mattresses were not ensured to be safely attached to the bed frame as required. This deficiency was identified through direct observation and review of facility practices regarding the maintenance and safety checks of beds and related equipment.
Failure to Immediately Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to the state agency and the facility administrator, as required. The resident, who had significant cognitive and physical impairments including dementia, hypovolemia, cirrhosis, and dependence on staff for daily care, reported to multiple staff members that she experienced rough handling and yelling from staff during care. She described being treated roughly by two nursing assistants, which caused her pain for several days, and stated that one staff member consistently yelled at her. The resident communicated these concerns to various staff members, but was unable to provide specific dates due to her cognitive and physical limitations. Multiple staff interviews revealed that several staff members were aware of the resident's complaints of rough care and verbal abuse. Some staff reported these concerns to their supervisors or nurse managers, while others did not report them, either because they did not witness the incidents firsthand or because they believed the resident frequently complained. One staff member reported the allegations to the state agency independently, but not on behalf of the facility, citing a lack of trust in the facility's willingness to investigate or act on such reports. The facility's grievance log did not contain any entries related to the resident's complaints during the relevant period. The nurse manager and administrator both indicated that they had not received specific reports of abuse or rough care regarding the resident, and the nurse manager admitted to not investigating rumors of possible abuse. The facility's policy required immediate reporting of suspected abuse, neglect, or mistreatment to both the facility and the state agency, but this protocol was not followed in this case. As a result, the required immediate reporting and investigation of the abuse allegation did not occur as mandated.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise and update the care plan for a resident with Parkinson's disease, dementia, and kidney disease who was at high risk for falls. Despite multiple falls and new interventions being identified in incident reports, these interventions—such as frequent visual checks, hourly safety checks, and the use of a fall mat—were not consistently incorporated into the resident's care plan or nursing assistant care sheets. Nursing staff and assistants reported that they were not given specific instructions or documentation regarding the frequency of checks, and unfamiliar staff could miss critical interventions like placing the fall mat, as it was not documented in the care plan. The resident experienced several falls over a period of time, with each incident resulting in new interventions being recommended in incident reports. However, these interventions were not systematically added to the care plan, leading to inconsistent implementation by staff. Interviews with nursing assistants and an LPN confirmed that important safety measures were omitted from the care plan, and the DON acknowledged that new interventions should have been added in a timely manner. The facility's care planning policy was requested but not provided.
Failure to Assess and Monitor Skin Tear
Penalty
Summary
The facility failed to comprehensively assess and monitor a skin tear for a resident with multiple diagnoses, including heart failure, COPD, and peripheral vascular disease. The resident had a documented skin tear on the right forearm upon admission, with an initial physician order for wound care that was discontinued after a period. Following the discontinuation, there were no further treatment orders or consistent monitoring of the wound, as evidenced by gaps in the treatment administration record and weekly skin audits that either omitted the wound or lacked detailed descriptions and measurements. Observations confirmed the presence of an open wound on the resident's right forearm, which was not being treated or monitored according to physician orders or facility policy. Interviews with nursing staff and review of documentation revealed that the wound had been present since the resident's return from the hospital, but no ongoing treatment or comprehensive assessment was in place. Nursing assistants and LPNs acknowledged the lack of treatment and inconsistent skin checks, and the DON stated that weekly skin assessments and prompt reporting of new skin concerns to the physician were expected. The facility's own skin care policy required routine and as-needed assessments and interventions to promote healing and prevent further skin problems, but these procedures were not followed for this resident.
Failure to Monitor Food and Equipment Temperatures
Penalty
Summary
The facility failed to implement a process to monitor temperatures in refrigerators, dishwashers, and breakfast foods across all six unit kitchens. This deficiency was identified through observations and interviews, revealing that temperature logs were either missing or incomplete for industrial and unit refrigerators, as well as dishwashers. The registered dietician (RD) acknowledged the absence of a kitchen manager and the transition of responsibilities from kitchen staff to nursing staff, which contributed to the lack of monitoring. The RD also noted that nursing assistants required training on proper food temperature monitoring. During observations, it was found that several unit refrigerators contained open and undated food and beverage containers, such as milk and liquid eggs, which were not labeled with dates to ensure safe consumption. This issue was highlighted when a resident reported that the milk served to them tasted sour. Interviews with nursing assistants and kitchen staff revealed confusion over who was responsible for monitoring temperatures, with discrepancies in understanding between the staff members. The RD confirmed that the expectation was for nursing assistants to monitor breakfast food temperatures and that all opened food or drink containers should be dated and discarded within seven days. The facility's policy on date marking and labeling, dated March 2016, required all food held for more than 24 hours to be labeled. However, a policy on refrigeration and dishwasher temperature monitoring was requested but not provided, indicating a gap in the facility's procedures to ensure food safety for its residents.
Infection Control Deficiencies in Glove Use and Equipment Sanitization
Penalty
Summary
The facility failed to ensure proper infection control practices during personal care for a resident identified as R35. During an observation, two nursing assistants, NA-H and NA-I, assisted R35 with personal care after the resident used a bedpan. NA-H wore gloves while providing peri-care but did not change them afterward. Instead, she continued to assist R35 with dressing and transferring to a wheelchair using the same gloves, which were potentially contaminated. NA-H acknowledged her failure to change gloves, which was confirmed as an infection control issue by the clinical coordinator, LPN-C. Additionally, the facility did not sanitize a standing lift sling shared by residents, including R35 and R9. After using the standing lift to transfer R35, NA-H cleaned the lift but not the sling, which was then used to transfer R9 without sanitization. NA-H and NA-I confirmed that while the standing lifts were sanitized after each use, the slings were not, and they were only washed weekly by the laundry. LPN-C stated that the slings should be sanitized after every use, and the failure to do so was an infection control concern. The facility's policies on standard precautions and infection control for equipment and care items were not followed. The policies required gloves to be changed after contact with body fluids and for reusable equipment to be sanitized between uses. The failure to adhere to these policies resulted in potential cross-contamination and infection control issues, as observed during the survey.
Unqualified Staff Administered PRN Medication
Penalty
Summary
The facility failed to ensure that unqualified staff did not administer as-needed (PRN) medication for a resident. The resident, who was cognitively intact, had a history of coronary artery disease, peripheral vascular disease, hypertension, and diabetes. The resident's clinical records indicated a diagnosis of local infection of the skin and irritant contact dermatitis due to fecal and urinary incontinence. The resident had a PRN order for Nystatin powder to be applied under the breast every 12 hours for a skin rash. However, the Medication Administration Record for September showed no documentation of the medication being administered. During an observation, a nursing assistant (NA) was seen applying Nystatin powder to the resident's skin, despite not being authorized to administer medicated creams or powders. The NA stated that she was instructed by nurses on how to apply the powder but acknowledged that only nurses could assess and document the need for PRN medications. Interviews with a registered nurse (RN) and a clinical coordinator/licensed practical nurse (LPN) confirmed that nursing assistants were not trained or authorized to perform assessments or administer PRN medications. The facility's policy on medication administration was requested but not provided.
Failure to Provide Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide adequate assistance with personal hygiene for two residents, R6 and R44, who were dependent on staff for activities of daily living. R6, who had severe cognitive impairment and required extensive assistance, was observed with long facial hair, which she expressed a desire to have removed. Despite the care plan indicating the need for assistance with grooming, staff interviews revealed inconsistencies in the provision of care, with some staff acknowledging the expectation to offer shaving but failing to do so consistently. R44, who had moderate cognitive impairment and was dependent on staff for personal hygiene, was observed with a full-face beard despite preferring to be clean-shaven. He reported not receiving help with shaving despite requesting it. Staff interviews indicated that shaving was typically offered on bath days, but R44's preference for being clean-shaven was not consistently respected, leading to a situation where he felt shaving was forced upon him. The facility's policy on elder rights and standard of care emphasized the need for assistance with shaving to maintain cleanliness and grooming. However, the observations and interviews highlighted a failure to adhere to this policy, resulting in neglect of personal hygiene needs for both residents. This neglect was noted as a concern for dignity, particularly for female residents, as stated by the staff.
Failure to Address Resident Positioning Needs
Penalty
Summary
The facility failed to assess and implement interventions for a resident who was unable to maintain proper positioning. The resident, who had severe cognitive impairment, Parkinson's Disease, vascular dementia, and legal blindness, was observed multiple times leaning to the right in various chairs without staff assistance to reposition her. Despite being dependent on staff for activities of daily living and having a history of falls with injury, the resident's care plan lacked interventions to address her positioning needs. During observations, staff members, including a nurse and a nursing assistant, did not attempt to reposition the resident or provide support to help her sit upright. Interviews with staff revealed an awareness of the resident's tendency to lean but no active measures were taken to address it. The nurse manager acknowledged the absence of positioning interventions in the care plan and suggested the possibility of consulting hospice for therapy assistance. The facility's policy indicated that residents should receive necessary care to maintain their wellbeing, but this was not reflected in the care provided to the resident.
Failure to Monitor Orthostatic Blood Pressures for Resident on Antipsychotics
Penalty
Summary
The facility failed to monitor orthostatic blood pressures for a resident (R51) who was prescribed antipsychotic medication, specifically Risperidone, to manage conditions such as schizoaffective disorder and bipolar disorder. The resident's medical history included dementia, bipolar disorder, anxiety, major depression, arthritis, diabetes, heart failure, and a history of falling. Despite the physician's orders for monthly orthostatic blood pressure checks, these were only documented in 5 out of 13 months since the resident's admission. Interviews with facility staff, including LPNs and an RN, revealed that the expectation was for all vital signs, including orthostatic blood pressures, to be documented in the electronic medical record (EMR). The staff acknowledged the importance of these checks due to the potential side effects of antipsychotic medications, which can alter blood pressure and increase fall risk. However, the staff could not provide a reason for the incomplete documentation and confirmed that the resident did not refuse the checks. The facility's policy on psychoactive medication, revised in 2018, required monthly orthostatic blood pressure checks for all residents receiving antipsychotic medication. Despite this policy, the checks were not consistently performed or documented for R51, indicating a failure to adhere to established protocols and potentially compromising the resident's safety.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were safely and securely stored for a resident with moderate cognitive impairment and multiple health conditions, including peripheral vascular disease, diabetes, anxiety, depression, and hyperlipidemia. The resident was dependent on staff for dressing, toileting, bathing, and transfers, but could eat independently. The resident's care plan indicated poor safety awareness and impaired cognitive function. During an observation, the medication cabinet in the resident's room was found open and unsecured, containing 19 cards of medications, about 10 lidocaine patches, and a glucometer, while the resident was not present in the room. A registered nurse admitted to leaving the cabinet open after being distracted by another resident, acknowledging that the cabinet should have been locked to prevent unauthorized access to the medications. A clinical nurse further emphasized the dangers of unsecured medication cabinets, noting that anyone could take the medications, which could be harmful if residents have allergies or difficulty swallowing. The facility's policy on medication storage requires that medication cabinets be kept locked to ensure orderly and effective medication preparation and administration, in line with infection control standards.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to implement and update appropriate fall interventions for two residents, R40 and R51, who were at high risk for falls. R40, who had severe cognitive impairment and multiple medical conditions including Parkinson's Disease and vascular dementia, experienced 20 falls since a new care plan intervention was put in place. Despite the high frequency of falls, R40's care plan lacked new interventions since February 2024, and the existing interventions were not effectively preventing falls. Observations and interviews revealed that R40 often did not have her call light within reach, and her fall interventions, such as alarms and walker placement, were inconsistently applied. R51, who had intact cognition and was independent with mobility, also experienced multiple falls with injuries, including a rib injury and a toe fracture. Despite having a history of falls and being on antipsychotic medication, R51's care plan was only updated once following a fall, and the interventions were not consistently revised to address the root causes of the falls. The facility's policy required staff to document falls, update care plans, and implement new interventions, but these actions were not consistently carried out for R51. Interviews with facility staff, including nursing assistants and a nurse manager, indicated a lack of consistent assessment and intervention following falls. Staff acknowledged that R40's fall interventions were outdated and not working, and there was a failure to conduct neuro assessments for falls involving head injuries. The facility's failure to update and implement effective fall prevention strategies for R40 and R51 resulted in repeated falls and injuries, highlighting deficiencies in the facility's fall management practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Episcopal Church Home Of Minnesota | 0.1 mi | — | 17 | 1 |
| The Estates At Lynnhurst Llc | 0.1 mi | — | 0 | 0 |
| St Anthony Park Home Inc | 1.8 mi | — | 1 | 0 |
| Lyngblomsten Care Center | 1.8 mi | — | 0 | 0 |
| Hayes Residence | 2.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.