Cycle 1
Health 2024-09-12 · Fire 2024-09-12
18 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Saint Paul, MN
Episcopal Church Home The Gardens
2-star overall rating with 2-star inspections with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1860 University Avenue West, Saint Paul, MN
(651) 632-8801
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2015-04-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Weekend hours
0.00
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
97.3%
0.8 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.9%
2.3 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 10.6% |
4.3%
6.3 pts worse
|
11.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.5% |
4.1%
2.4 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.9% |
12.4%
7.5 pts better
|
19.6%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
17.5%
7.1 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 40.4% |
22.5%
17.9 pts worse
|
16.3%
24.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.1% |
18.6%
7.5 pts worse
|
14.9%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
2.3%
0.7 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.9% |
2.6%
1.3 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.2% |
24.8%
11.4 pts worse
|
19.8%
16.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.4%
0.9 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
88.6%
2.4 pts better
|
81.7%
9.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
82.7%
9.3 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-03 · Fire 2023-08-03
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-03-24 · Fire 2022-03-24
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-12
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-30
F · Potential for more than minimal harm
2024-09-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-30
F · Potential for more than minimal harm
2023-08-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-15
F · Potential for more than minimal harm
2023-08-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-12
F · Potential for more than minimal harm
2022-03-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-20
F · Potential for more than minimal harm
2022-03-24
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-05-20
F · Potential for more than minimal harm
2022-03-24
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-05-20
F · Potential for more than minimal harm
2022-03-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-05-20
F · Potential for more than minimal harm
2022-03-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-05-20
C · Minimal harm
2022-03-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-05-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-02
D · Potential for more than minimal harm
2025-08-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-08-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-08-18
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-08-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-08-18
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-08-18
F909 · Environmental Deficiencies
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2025-10-22
D · Potential for more than minimal harm
2025-05-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-03-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-03-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-02
F · Potential for more than minimal harm
2024-09-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-12
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-09-12
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-03-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-29
G · Actual harm
2023-08-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-12
F · Potential for more than minimal harm
2023-08-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-03
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-03
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-09-12
D · Potential for more than minimal harm
2022-03-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-03-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-20
D · Potential for more than minimal harm
2022-03-24
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-05-20
Penalties and ownership
What sits behind the stars
$0
2025-03-26
Payment Denial
Payment Denial · denial start 2025-06-26 · 22 days
22 day denial
$0
2023-08-03
Payment Denial
Payment Denial · denial start 2023-09-12 · 3 days
3 day denial
Ownership
Episcopal Homes On University Avenue, LLC
5% Or Greater Direct Ownership Interest · Organization
Clem, Mary
Corporate Officer · Individual
Cutler, Lois
Corporate Director · Individual
Eh Services Inc
Operational/Managerial Control · Organization
Episcopal Home Care And Services
5% Or Greater Indirect Ownership Interest · Organization
Episcopal Homes Of Minnesota
5% Or Greater Indirect Ownership Interest · Organization
Forbes, Carol
Corporate Director · Individual
Franco, Keanan
W-2 Managing Employee · Individual
Gilbertson, Melissa
Corporate Director · Individual
Gove, Peter
Corporate Director · Individual
Hawthorne, Rebecca
Corporate Director · Individual
Henry, John
Corporate Officer · Individual
Hove, Thomas
Corporate Director · Individual
Huber, James
Corporate Director · Individual
Mcgowan, Diane
Corporate Director · Individual
Mork, Steven
Corporate Officer · Individual
Nowlin, Sarah
Corporate Director · Individual
Ostenso, Brian
Corporate Director · Individual
Plakut, Marvin
Corporate Officer · Individual
Slawick, Jerome
Corporate Director · Individual
Wells Fargo Bank
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Episcopal Church Home of Minnesota
Saint Paul, MN
2-star overall rating with 1-star inspections with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
The Estates at Lynnhurst LLC
Saint Paul, MN
2-star overall rating with 2-star inspections with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
St Anthony Park Home Inc
Saint Paul, MN
2-star overall rating with 1-star inspections with $13,580 in total fines with 18 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out