01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-04-09 | 13 | 2026-04-09 | 2 |
| Cycle 2 | 2024-09-12 | 11 | 2024-09-12 | 8 |
| Cycle 3 | 2023-08-03 | 9 | 2023-08-03 | 15 |
CMS CCN 2456252026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Episcopal Church Home The Gardens
1860 University Avenue West · Saint Paul, MN 55104 · Ramsey County
Certified beds60CMS provider file
Recent citation rows58current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
58 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 14 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-09 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2026-05-112026-04-09 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2026-05-112026-04-09 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-05-112026-04-09 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2026-05-112026-04-09 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-05-112026-04-09 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-05-112026-04-09 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-05-112026-04-09 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2026-05-112025-11-20 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2026-01-02 · complaint2025-08-18 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-10-29 · complaint2025-08-18 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-10-29 · complaint2025-08-18 · HEALTHF0700Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-22 · complaint2025-08-18 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-10-29 · complaint2025-08-18 · HEALTHF0849Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-29 · complaint2025-08-18 · HEALTHF0909Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-22 · complaint2025-05-19 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-06-27 · complaint2025-03-26 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-06-02 · complaint2025-03-26 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-06-02 · complaint2024-09-12 · HEALTHF0659Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Provide care by qualified persons according to each resident's written plan of care.
Correction field: Deficient, Provider has date of correction · 2024-11-042024-09-12 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-11-042024-09-12 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-11-042024-09-12 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-11-04 · complaint2024-09-12 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-11-042024-09-12 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-11-0403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-03-26 | Payment Denial | $0 | 22 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- EPISCOPAL HOMES ON UNIVERSITY AVENUE, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/27/2013
- EPISCOPAL HOME CARE AND SERVICESOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/27/2013
- EPISCOPAL HOMES OF MINNESOTAOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/27/2013
- WELLS FARGO BANKOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 05/01/2013
- FRANCO, KEANANIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 10/27/2015
- CUTLER, LOISIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2016
- FORBES, CAROLIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2016
- GILBERTSON, MELISSAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2016
- GOVE, PETERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2016
- HAWTHORNE, REBECCAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2017
- HOVE, THOMASIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/27/2013
- HUBER, JAMESIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2017
- MCGOWAN, DIANEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/27/2013
- NOWLIN, SARAHIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/27/2013
- OSTENSO, BRIANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2015
- SLAWICK, JEROMEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2016
- CLEM, MARYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2017
- HENRY, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/19/2015
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.69per resident day
RN hours0.57per resident day
Weekend nurse hours5.30per resident day
Staff turnover—%CMS reported field
06 / LOCAL RECORDS
Open the Saint Paul ledger →Other published facilities nearby
Capital View Transitional Care Center32 beds · CMS overall 5/57 citation rowsCarondelet Village Care Center45 beds · CMS overall 5/534 citation rowsCerenity Care Center On Humboldt93 beds · CMS overall 2/549 citation rowsCerenity Marian Of St Paul Llc90 beds · CMS overall 4/526 citation rowsEbenezer Integrated Care & Rehab62 beds · CMS overall 4/530 citation rowsEpiscopal Church Home Of Minnesota131 beds · CMS overall 1/560 citation rowsGood Samaritan Society - Maplewood71 beds · CMS overall 3/553 citation rowsHayes Residence40 beds · CMS overall 2/525 citation rows