SNF

EPISCOPAL CHURCH HOME THE GARDENS

CCN: 245625 · SAINT PAUL, MN 55104 · Ramsey County

Overview

Address
1860 UNIVERSITY AVENUE WEST, SAINT PAUL, MN 55104
Phone
6516328801
Certified beds
60
Avg daily residents
57 (95% of beds filled)
Ownership
Non-profit (other)
Provider type
Medicare and Medicaid
Medicare/Medicaid since
2015-04-15
Setting
Urban
2 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 2/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 2/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
Data not available.
— Not Available
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 3/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 3/5
Short-Stay Quality Measures — Data not available.

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2024-09-12 18 8 11 88 1 88
Cycle 2/3 (prior) 2023-08-03 9 8 1 64 1 64
Total weighted health score
82.0
lower is better

Deficiencies (30)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

29 D/E/F Actual harm — potential for minor
1 G/H/I Actual harm
Tag Description Scope/Severity Survey date Corrected
0658 Ensure services provided by the nursing facility meet professional standards of quality. D 2025-11-20 2026-01-02
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. D 2025-08-18 2025-10-29
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2025-08-18 2025-10-29
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. D 2025-08-18 2025-10-22
0760 Ensure that residents are free from significant medication errors. D 2025-08-18 2025-10-29
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. D 2025-08-18 2025-10-29
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. D 2025-08-18 2025-10-22
0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. D 2025-05-19 2025-06-27
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. D 2025-03-26 2025-06-02
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2025-03-26 2025-06-02
0659 Provide care by qualified persons according to each resident's written plan of care. D 2024-09-12 2024-11-04
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2024-09-12 2024-11-04
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2024-09-12 2024-11-04
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. D 2024-09-12 2024-11-04
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. D 2024-09-12 2024-11-04
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F 2024-09-12 2024-11-04
0880 Provide and implement an infection prevention and control program. E 2024-09-12 2024-11-04
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2024-09-12 2024-11-04
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2024-03-04 2024-03-29
0554 Allow residents to self-administer drugs if determined clinically appropriate. D 2023-08-03 2023-09-12
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. D 2023-08-03 2023-09-12
0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. D 2023-08-03 2023-09-12
0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. D 2023-08-03 2023-09-12
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2023-08-03 2023-09-12
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. G 2023-08-03 2023-09-12
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. D 2023-08-03 2023-09-12
0880 Provide and implement an infection prevention and control program. F 2023-08-03 2023-09-12
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. D 2022-03-24 2022-05-20
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2022-03-24 2022-05-20
0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. D 2022-03-24 2022-05-20

Penalties (2)

Fines issued
0
last 3 years
Payment denials
2
Date Type Fine amount
2025-03-26 Payment Denial —
2023-08-03 Payment Denial —

Source: CMS Nursing Home Penalties.

Ownership & Corporate Structure

Owner / manager organizations (5)

Organization Role Association
EPISCOPAL HOMES ON UNIVERSITY AVENUE, LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 03/27/2013
EPISCOPAL HOME CARE AND SERVICES 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 03/27/2013
EPISCOPAL HOMES OF MINNESOTA 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 03/27/2013
EH SERVICES INC OPERATIONAL/MANAGERIAL CONTROL since 03/27/2013
WELLS FARGO BANK 5% OR GREATER MORTGAGE INTEREST since 05/01/2013

Owner / manager individuals (16)

Name Role Association
CUTLER, LOIS CORPORATE DIRECTOR since 11/01/2016
FORBES, CAROL CORPORATE DIRECTOR since 11/01/2016
GILBERTSON, MELISSA CORPORATE DIRECTOR since 11/01/2016
GOVE, PETER CORPORATE DIRECTOR since 11/01/2016
HAWTHORNE, REBECCA CORPORATE DIRECTOR since 11/01/2017
HOVE, THOMAS CORPORATE DIRECTOR since 03/27/2013
HUBER, JAMES CORPORATE DIRECTOR since 11/01/2017
MCGOWAN, DIANE CORPORATE DIRECTOR since 03/27/2013
NOWLIN, SARAH CORPORATE DIRECTOR since 03/27/2013
OSTENSO, BRIAN CORPORATE DIRECTOR since 11/01/2015
SLAWICK, JEROME CORPORATE DIRECTOR since 11/01/2016
CLEM, MARY CORPORATE OFFICER since 01/01/2017
HENRY, JOHN CORPORATE OFFICER since 10/19/2015
MORK, STEVEN CORPORATE OFFICER since 01/12/2016
PLAKUT, MARVIN CORPORATE OFFICER since 03/27/2013
FRANCO, KEANAN W-2 MANAGING EMPLOYEE since 10/27/2015

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Both
Sprinkler systems
Yes
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

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Show 99 rows
Source Metric Value Raw key
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day — Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day — Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day — Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day — Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day — Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote 26 Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 57.1 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day — Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day — Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day — Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day — Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day — Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating — Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating — Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating — Chain Average QM Rating
Provider Information Chain Average Staffing Rating — Chain Average Staffing Rating
Provider Information Chain ID — Chain ID
Provider Information Chain Name — Chain Name
Provider Information City/Town SAINT PAUL City/Town
Provider Information CMS Certification Number (CCN) 245625 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Ramsey County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 2015-04-15 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 2 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 44.9563 Latitude
Provider Information Legal Business Name EPISCOPAL HOMES ON UNIVERSITY AVENUE, LLC Legal Business Name
Provider Information Location 1860 UNIVERSITY AVENUE WEST,SAINT PAUL,MN,55104 Location
Provider Information Long-Stay QM Rating 3 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -93.179 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home — Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 60 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain — Number of Facilities in Chain
Provider Information Number of Fines 0 Number of Fines
Provider Information Number of Payment Denials 2 Number of Payment Denials
Provider Information Nursing Case-Mix Index — Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio — Nursing Case-Mix Index Ratio
Provider Information Overall Rating 2 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type Non profit - Other Ownership Type
Provider Information Physical Therapist Staffing Footnote 6 Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 1860 UNIVERSITY AVENUE WEST Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name EPISCOPAL CHURCH HOME THE GARDENS Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 610 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 3 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 88 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 11 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 8 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2024-09-12 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 88 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 18 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 8 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2023-08-03 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 64 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 1 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 64 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 9 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend — Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover — Registered Nurse turnover
Provider Information Registered Nurse turnover footnote 26 Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day — Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day — Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day — Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day — Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day — Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote 6 Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day — Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating — Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote 2 Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating — Staffing Rating
Provider Information Staffing Rating Footnote 2 Staffing Rating Footnote
Provider Information State MN State
Provider Information Telephone Number 6516328801 Telephone Number
Provider Information Total Amount of Fines in Dollars 0.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend — Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 2 Total Number of Penalties
Provider Information Total nursing staff turnover — Total nursing staff turnover
Provider Information Total nursing staff turnover footnote 26 Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 82.000 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Both With a Resident and Family Council
Provider Information ZIP Code 55104 ZIP Code