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EPISCOPAL CHURCH HOME THE GARDENS

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EPISCOPAL CHURCH HOME THE GARDENS is a non profit - other facility in SAINT PAUL, MN with 60 certified beds and a 2-star overall CMS rating. The facility has 30 deficiency records on file.

1860 UNIVERSITY AVENUE WEST, SAINT PAUL, MN 55104

Phone: 6516328801

Overall Rating

2/5

Health Inspection

2/5

Staffing

N/A

Quality Measures

3/5

Long-Stay Quality

3/5

Facility Information

Provider Number
245625
Ownership
Non profit - Other
Provider Type
Medicare and Medicaid
Beds
60
Residents
57
In Hospital
No
County
Ramsey
Last Inspection
Sep 12, 2024

Staffing Data

RN Hours
N/A (nat'l avg: 0.68)
LPN Hours
N/A
CNA Hours
N/A
Total Nursing Hours
N/A (nat'l avg: 3.89)
PT Hours
N/A

What the CMS Record Reveals About EPISCOPAL CHURCH HOME THE GARDENS

EPISCOPAL CHURCH HOME THE GARDENS operates 60 certified beds in SAINT PAUL, MN with approximately 57 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (N/A★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 30 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold.

Classified as "Non profit - Other" ownership and operating as a "Medicare and Medicaid" provider, EPISCOPAL CHURCH HOME THE GARDENS falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (30 most recent)

D — Isolated - Minimal harm Nov 20, 2025 Tag: 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jan 2, 2026

D — Isolated - Minimal harm Aug 18, 2025 Tag: 0909

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.

Category: Environmental Deficiencies

Corrected: Oct 22, 2025

D — Isolated - Minimal harm Aug 18, 2025 Tag: 0849

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.

Category: Administration Deficiencies

Corrected: Oct 29, 2025

D — Isolated - Minimal harm Aug 18, 2025 Tag: 0760

Ensure that residents are free from significant medication errors.

Category: Pharmacy Service Deficiencies

Corrected: Oct 29, 2025

D — Isolated - Minimal harm Aug 18, 2025 Tag: 0700

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.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 22, 2025

D — Isolated - Minimal harm Aug 18, 2025 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Oct 29, 2025

D — Isolated - Minimal harm Aug 18, 2025 Tag: 0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Category: Resident Rights Deficiencies

Corrected: Oct 29, 2025

D — Isolated - Minimal harm May 19, 2025 Tag: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Jun 27, 2025

D — Isolated - Minimal harm Mar 26, 2025 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Jun 2, 2025

D — Isolated - Minimal harm Mar 26, 2025 Tag: 0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Jun 2, 2025

D — Isolated - Minimal harm Sep 12, 2024 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 4, 2024

E — Pattern - Minimal harm Sep 12, 2024 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Nov 4, 2024

F — Widespread - Minimal harm Sep 12, 2024 Tag: 0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Category: Nutrition and Dietary Deficiencies

Corrected: Nov 4, 2024

D — Isolated - Minimal harm Sep 12, 2024 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Nov 4, 2024

D — Isolated - Minimal harm Sep 12, 2024 Tag: 0758

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.

Category: Pharmacy Service Deficiencies

Corrected: Nov 4, 2024

D — Isolated - Minimal harm Sep 12, 2024 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 4, 2024

D — Isolated - Minimal harm Sep 12, 2024 Tag: 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Category: Quality of Life and Care Deficiencies

Corrected: Nov 4, 2024

D — Isolated - Minimal harm Sep 12, 2024 Tag: 0659

Provide care by qualified persons according to each resident's written plan of care.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Nov 4, 2024

D — Isolated - Minimal harm Mar 4, 2024 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Mar 29, 2024

F — Widespread - Minimal harm Aug 3, 2023 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Sep 12, 2023

D — Isolated - Minimal harm Aug 3, 2023 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Sep 12, 2023

G — Isolated - Actual harm Aug 3, 2023 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 12, 2023

D — Isolated - Minimal harm Aug 3, 2023 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 12, 2023

D — Isolated - Minimal harm Aug 3, 2023 Tag: 0676

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 12, 2023

D — Isolated - Minimal harm Aug 3, 2023 Tag: 0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Sep 12, 2023

D — Isolated - Minimal harm Aug 3, 2023 Tag: 0584

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.

Category: Resident Rights Deficiencies

Corrected: Sep 12, 2023

D — Isolated - Minimal harm Aug 3, 2023 Tag: 0554

Allow residents to self-administer drugs if determined clinically appropriate.

Category: Resident Rights Deficiencies

Corrected: Sep 12, 2023

D — Isolated - Minimal harm Mar 24, 2022 Tag: 0810

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Category: Nutrition and Dietary Deficiencies

Corrected: May 20, 2022

D — Isolated - Minimal harm Mar 24, 2022 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: May 20, 2022

D — Isolated - Minimal harm Mar 24, 2022 Tag: 0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Category: Resident Rights Deficiencies

Corrected: May 20, 2022

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 26.1% Yes
Percentage of long-stay residents who lose too much weight Long Stay 6.5% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 1.6% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 3.9% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 10.6% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 6.2% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 98.1% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 91.0% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay N/A Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 40.4% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 4.9% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 100.0% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 92.0% No
Percentage of long-stay residents with pressure ulcers Long Stay 4.5% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 36.2% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 10.4% Yes

Penalty History

Date Type Amount
Mar 26, 2025 Payment Denial -
Aug 3, 2023 Payment Denial -

Frequently Asked Questions

What is the overall CMS rating for EPISCOPAL CHURCH HOME THE GARDENS?
EPISCOPAL CHURCH HOME THE GARDENS has an overall CMS rating of 2 out of 5 stars. This rating combines health inspection results (2★), staffing levels (null★), and quality measures (3★).
What are the staffing levels at EPISCOPAL CHURCH HOME THE GARDENS?
EPISCOPAL CHURCH HOME THE GARDENS reports N/A total nursing hours per resident day (national average: 3.89). RN hours are N/A per resident day (national average: 0.68).
How many beds does EPISCOPAL CHURCH HOME THE GARDENS have?
EPISCOPAL CHURCH HOME THE GARDENS has 60 certified beds with approximately 57 residents. The facility is located at 1860 UNIVERSITY AVENUE WEST, SAINT PAUL, MN 55104.
Does EPISCOPAL CHURCH HOME THE GARDENS have any deficiencies on record?
Yes, EPISCOPAL CHURCH HOME THE GARDENS has 30 deficiencies on record from recent inspections. Of these, 1 are classified as causing actual harm or jeopardy.
Has EPISCOPAL CHURCH HOME THE GARDENS received any fines or penalties?
No, EPISCOPAL CHURCH HOME THE GARDENS has no fines or penalties on record.
Who owns EPISCOPAL CHURCH HOME THE GARDENS?
EPISCOPAL CHURCH HOME THE GARDENS is classified as "Non profit - Other" ownership. The facility type is "Medicare and Medicaid".
When was EPISCOPAL CHURCH HOME THE GARDENS last inspected?
The most recent health inspection for EPISCOPAL CHURCH HOME THE GARDENS was on Sep 12, 2024. The facility received a health inspection rating of 2 out of 5 stars.
What quality measures are tracked for EPISCOPAL CHURCH HOME THE GARDENS?
EPISCOPAL CHURCH HOME THE GARDENS is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial