Episcopal Church Home the Gardens

Name: Episcopal Church Home the Gardens
Address: 1860 UNIVERSITY AVENUE WEST, Saint Paul, MN, 55104, US
Telephone: 6516328801

1860 University Avenue West, Saint Paul, MN 55104 · Ramsey County · 60 certified beds · avg 54 residents/day · certified since Apr 15, 2015

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

6.37

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Aug 3, 2023 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Sep 12, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (33)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Apr 9, 2026	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 9, 2026	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 9, 2026	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Apr 9, 2026	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential.
Apr 9, 2026	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Apr 9, 2026	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Nov 20, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Aug 18, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Aug 18, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Aug 18, 2025	D · Potential for harm, one-off	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · from a complaint
Aug 18, 2025	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Aug 18, 2025	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · from a complaint
Aug 18, 2025	D · Potential for harm, one-off	The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. · from a complaint
May 19, 2025	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 26, 2025	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Mar 26, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Sep 12, 2024	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Sep 12, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Sep 12, 2024	D · Potential for harm, one-off	The facility did not make sure care was delivered by qualified people following each resident's written care plan — the individualized document that spells out exactly what care that resident is supposed to receive.
Sep 12, 2024	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Sep 12, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Sep 12, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Sep 12, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Sep 12, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 4, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Aug 3, 2023	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Aug 3, 2023	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 3, 2023	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Aug 3, 2023	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Aug 3, 2023	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Aug 3, 2023	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Aug 3, 2023	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Aug 3, 2023	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 6).

Year	Citations	Serious (G–L)	Worst severity that year
2023	8	1	G ▲
2024	9	0	F
2025	10	0	D
2026	6	0	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

0 fines totaling $0, plus 1 Medicare payment denial period.

Date	Type	Amount / length
Mar 26, 2025	Payment Denial	22 days from Jun 26, 2025

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Minnesota avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	6.37	4.83	3.95	top 5% in Minnesota; top 3% in the U.S.
Registered Nurse hours	0.64	1.22	0.69	bottom 5% in Minnesota; top 43% in the U.S.
Weekend total nurse staffing	5.94	4.27	3.50	top 4% in Minnesota; top 2% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.54	0.69	0.48	bottom 43% in Minnesota; top 29% in the U.S.
Total nursing staff turnover (%)	0.0	42.2	45.8	—
RN turnover (%)	0.0	38.6	42.9	—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.69, RN 0.57, weekend 5.30. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
Episcopal Home Care and Services	Organization	5% or Greater Indirect Ownership Interest	—	03/27/2013
Episcopal Homes of Minnesota	Organization	5% or Greater Indirect Ownership Interest	—	03/27/2013
Episcopal Homes on University Avenue, LLC	Organization	5% or Greater Direct Ownership Interest	100%	03/27/2013
Clem, Mary	Individual	Corporate Officer	NOT APPLICABLE	01/01/2017
Cutler, Lois	Individual	Corporate Director	NOT APPLICABLE	11/01/2016
Eh Services INC	Organization	Operational/Managerial Control	NOT APPLICABLE	03/27/2013
Forbes, Carol	Individual	Corporate Director	NOT APPLICABLE	11/01/2016
Franco, Keanan	Individual	W-2 Managing Employee	NOT APPLICABLE	10/27/2015
Gilbertson, Melissa	Individual	Corporate Director	NOT APPLICABLE	11/01/2016
Gove, Peter	Individual	Corporate Director	NOT APPLICABLE	11/01/2016
Hawthorne, Rebecca	Individual	Corporate Director	NOT APPLICABLE	11/01/2017
Henry, John	Individual	Corporate Officer	NOT APPLICABLE	10/19/2015
Hove, Thomas	Individual	Corporate Director	NOT APPLICABLE	03/27/2013
Huber, James	Individual	Corporate Director	NOT APPLICABLE	11/01/2017
McGowan, Diane	Individual	Corporate Director	NOT APPLICABLE	03/27/2013
Mork, Steven	Individual	Corporate Officer	NOT APPLICABLE	01/12/2016
Nowlin, Sarah	Individual	Corporate Director	NOT APPLICABLE	03/27/2013
Ostenso, Brian	Individual	Corporate Director	NOT APPLICABLE	11/01/2015
Plakut, Marvin	Individual	Corporate Officer	NOT APPLICABLE	03/27/2013
Slawick, Jerome	Individual	Corporate Director	NOT APPLICABLE	11/01/2016

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"If my family member is able to manage their own medications, would you allow it, and how is that decided?"
"How do you protect residents' privacy, both in their medical records and in day-to-day care?"
"How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
"Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
The Estates at Lynnhurst LLC	0.1 mi	Saint Paul, MN	★☆☆☆☆	1/5
Episcopal Church Home of Minnesota	0.1 mi	Saint Paul, MN	★☆☆☆☆	1/5
St Anthony Park Home INC	1.8 mi	Saint Paul, MN	★★☆☆☆	1/5
Lyngblomsten Care Center	1.8 mi	Saint Paul, MN	★★★☆☆	2/5
Hayes Residence	2.1 mi	Saint Paul, MN	★★☆☆☆	2/5
Carondelet Village Care Center	2.1 mi	Saint Paul, MN	★★★★★	4/5
Fairview University Trans Serv	2.8 mi	Minneapolis, MN	★★★★★	5/5
The Emeralds at St Paul LLC	3.0 mi	Saint Paul, MN	★☆☆☆☆	1/5
MN Veterans Home-Mpls	3.2 mi	Minneapolis, MN	★★★☆☆	3/5
Providence Place	3.3 mi	Minneapolis, MN	★☆☆☆☆	1/5
Shirley Chapman Sholom Home East	3.3 mi	Saint Paul, MN	★★★★☆	3/5
The Villas at St Paul	3.3 mi	Saint Paul, MN	★★☆☆☆	2/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 245625.

The Care File

Visit checklist — Episcopal Church Home the Gardens

1860 University Avenue West, Saint Paul, MN 55104 · 6516328801

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $0

Most serious findings on record:

▲ Aug 3, 2023 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
☐ "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
☐ "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
☐ "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 245625 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)