The Vardell Report.Episcopal Church Home the Gardens

Across 8 inspections from August 2023 to April 2026, state surveyors documented 33 findings at Episcopal Church Home the Gardens; 33 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

8

2023–2026, standard and complaint

Findings

33

Deficiencies cited by state inspectors

Corrected

33

Of 33 findings, with a recorded correction date

Penalties

1

1 closed

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Apr 92026

   Standard health inspection

   6 findings

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected May 11, 2026
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected May 11, 2026
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected May 11, 2026
   • F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected May 11, 2026
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected May 11, 2026
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected May 11, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Nov 202025

   Complaint investigation

   1 finding

   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Jan 2, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Aug 182025

   Complaint investigation

   6 findings

   • F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Oct 29, 2025
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Oct 29, 2025
   • F700Try 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.Level DNo actual harm, potential for moreCorrected Oct 22, 2025
   • F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Oct 29, 2025
   • F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Oct 29, 2025
   • F909Regularly 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.Level DNo actual harm, potential for moreCorrected Oct 22, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. May 192025

   Complaint investigation

   1 finding

   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Jun 27, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Mar 262025

   Complaint investigation

   2 findings

   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Jun 2, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jun 2, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

6. Sep 122024

   Standard health inspection

   8 findings

   The same visit included a complaint investigation.

   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Nov 4, 2024
   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Nov 4, 2024
   • F659Provide care by qualified persons according to each resident's written plan of care.Level DNo actual harm, potential for moreCorrected Nov 4, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Nov 4, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Nov 4, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Nov 4, 2024
   • F758Implement 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.Level DNo actual harm, potential for moreCorrected Nov 4, 2024
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Nov 4, 2024

   Enforcement Action

   Denial of payment imposed March 26, 2025. Status: Closed, July 18, 2025. CMS does not tie a penalty to a survey; listed with the standard health inspection of September 12, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

7. Mar 42024

   Complaint investigation

   1 finding

   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 29, 2024

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

8. Aug 32023

   Standard health inspection

   8 findings

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Sep 12, 2023
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Sep 12, 2023
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
   • F584Honor 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.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
   • F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Sep 12, 2023
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Sep 12, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Accident Hazards and Supervision, Cited in Three Inspections

   Inspectors cited F689 in August 2023, September 2024 and August 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242525252526F689 across all 8 inspections, oldest to newest
2. 2

   Infection Control, Cited in Three Inspections

   Inspectors cited F880 in August 2023, September 2024 and April 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242525252526F880 across all 8 inspections, oldest to newest
3. 3

   Residents Taking Their Own Medication, Cited in Two Inspections

   Inspectors cited F554 in August 2023 and April 2026. This citation covers whether a resident who keeps and takes their own medication has been assessed as safe to do so. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242525252526F554 across all 8 inspections, oldest to newest
4. 4

   Reporting Suspected Abuse, Cited in Two Inspections

   Inspectors cited F609 in August 2023 and May 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242525252526F609 across all 8 inspections, oldest to newest
5. 5

   Quality of Care, Cited in Two Inspections

   Inspectors cited F684 in September 2024 and March 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242525252526F684 across all 8 inspections, oldest to newest
6. 6

   Medication Labeling and Storage, Cited in Two Inspections

   Inspectors cited F761 in August 2023 and September 2024. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242525252526F761 across all 8 inspections, oldest to newest
7. 7

   Kitchen and Food Safety, Cited in Two Inspections

   Inspectors cited F812 in September 2024 and April 2026. This citation covers how food is stored, prepared and served. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324242525252526F812 across all 8 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in three inspections, most seriously at level G.

2. 02

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in three inspections, most seriously at level F.

3. 03

   How do you decide whether a resident may keep and take their own medications?

   Residents Taking Their Own Medication: cited in two inspections, most seriously at level D.

4. 04

   How are staff trained to report suspected abuse or neglect, and who reports it to the state?

   Reporting Suspected Abuse: cited in two inspections, most seriously at level D.

5. 05

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in two inspections, most seriously at level D.

6. 06

   How are medications stored and secured, and who checks the medication carts?

   Medication Labeling and Storage: cited in two inspections, most seriously at level D.

7. 07

   May we see the kitchen, and what do your own sanitation checks look like week to week?

   Kitchen and Food Safety: cited in two inspections, most seriously at level F.

8. 08

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

9. 09

   What led to the 2025 denial of payment, and what would you want a family to know about it?

   Denial of payment was imposed March 26, 2025; it ended July 18, 2025.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Minnesota state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Minnesota state survey agency

  Inspection Aug 3, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Minnesota state survey agency

  Inspection Mar 4, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Minnesota state survey agency

  Inspection Sep 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Minnesota state survey agency

  Inspection Mar 26, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Minnesota state survey agency

  Inspection May 19, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Minnesota state survey agency

  Inspection Aug 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Minnesota state survey agency

  Inspection Nov 20, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Minnesota state survey agency

  Inspection Apr 9, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 245625

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.