Episcopal Church Home The Gardens

Inspection history (33)

• April 9, 2026 · D

  Citation F0695

  Federal surveyors cited this nursing home on 2026-04-09 under CMS tag F0695 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide safe and appropriate respiratory care for a resident when needed. The deficiency was recorded as corrected on 2026-05-11. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-04-09.GOV

• April 9, 2026 · D

  Citation F0554

  Federal surveyors cited this nursing home on 2026-04-09 under CMS tag F0554 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Allow residents to self-administer drugs if determined clinically appropriate. The deficiency was recorded as corrected on 2026-05-11. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-04-09.GOV

• April 9, 2026 · D

  Citation F0756

  Federal surveyors cited this nursing home on 2026-04-09 under CMS tag F0756 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. The deficiency was recorded as corrected on 2026-05-11. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-04-09.GOV

• April 9, 2026 · D

  Citation F0583

  Federal surveyors cited this nursing home on 2026-04-09 under CMS tag F0583 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Keep residents' personal and medical records private and confidential. The deficiency was recorded as corrected on 2026-05-11. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-04-09.GOV

• April 9, 2026 · F

  Citation F0812

  Federal surveyors cited this nursing home on 2026-04-09 under CMS tag F0812 (CMS scope/severity F: widespread, no actual harm, potential for more than minimal harm) for Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. The deficiency was recorded as corrected on 2026-05-11. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-04-09.GOV

• April 9, 2026 · E

  Citation F0880

  Federal surveyors cited this nursing home on 2026-04-09 under CMS tag F0880 (CMS scope/severity E: pattern, no actual harm, potential for more than minimal harm) for Provide and implement an infection prevention and control program. The deficiency was recorded as corrected on 2026-05-11. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2026-04-09.GOV

• November 20, 2025 · D

  Citation F0658

  Federal surveyors cited this nursing home on 2025-11-20 under CMS tag F0658 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Ensure services provided by the nursing facility meet professional standards of quality. The deficiency was recorded as corrected on 2026-01-02. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-11-20.GOV

• August 18, 2025 · D

  Citation F0689

  Federal surveyors cited this nursing home on 2025-08-18 under CMS tag F0689 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. The deficiency was recorded as corrected on 2025-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-08-18.GOV

• August 18, 2025 · D

  Citation F0700

  Federal surveyors cited this nursing home on 2025-08-18 under CMS tag F0700 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2025-10-22. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-08-18.GOV

• August 18, 2025 · D

  Citation F0909

  Federal surveyors cited this nursing home on 2025-08-18 under CMS tag F0909 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2025-10-22. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-08-18.GOV

• August 18, 2025 · D

  Citation F0550

  Federal surveyors cited this nursing home on 2025-08-18 under CMS tag F0550 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. The deficiency was recorded as corrected on 2025-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-08-18.GOV

• August 18, 2025 · D

  Citation F0849

  Federal surveyors cited this nursing home on 2025-08-18 under CMS tag F0849 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2025-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-08-18.GOV

• August 18, 2025 · D

  Citation F0760

  Federal surveyors cited this nursing home on 2025-08-18 under CMS tag F0760 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Ensure that residents are free from significant medication errors. The deficiency was recorded as corrected on 2025-10-29. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-08-18.GOV

• May 19, 2025 · D

  Citation F0609

  Federal surveyors cited this nursing home on 2025-05-19 under CMS tag F0609 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. The deficiency was recorded as corrected on 2025-06-27. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-05-19.GOV

• March 26, 2025 · D

  Citation F0684

  Federal surveyors cited this nursing home on 2025-03-26 under CMS tag F0684 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide appropriate treatment and care according to orders, resident’s preferences and goals. The deficiency was recorded as corrected on 2025-06-02. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-03-26.GOV

• March 26, 2025 · D

  Citation F0657

  Federal surveyors cited this nursing home on 2025-03-26 under CMS tag F0657 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. The deficiency was recorded as corrected on 2025-06-02. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2025-03-26.GOV

• September 12, 2024 · D

  Citation F0761

  Federal surveyors cited this nursing home on 2024-09-12 under CMS tag F0761 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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. The deficiency was recorded as corrected on 2024-11-04. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-12.GOV

• September 12, 2024 · D

  Citation F0689

  Federal surveyors cited this nursing home on 2024-09-12 under CMS tag F0689 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. The deficiency was recorded as corrected on 2024-11-04. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-12.GOV

• September 12, 2024 · D

  Citation F0758

  Federal surveyors cited this nursing home on 2024-09-12 under CMS tag F0758 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for 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 l…. The deficiency was recorded as corrected on 2024-11-04. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-12.GOV

• September 12, 2024 · D

  Citation F0677

  Federal surveyors cited this nursing home on 2024-09-12 under CMS tag F0677 (CMS scope/severity D: isolated, no actual harm, potential for more than minimal harm) for Provide care and assistance to perform activities of daily living for any resident who is unable. The deficiency was recorded as corrected on 2024-11-04. Source: CMS Care Compare Health Deficiencies (as of 2026-06-01).

  View original record (opens in a new tab)Source: CMS Care Compare · Updated 2024-09-12.GOV

Penalties

Total fines on file: $0

Staffing

Latest: 5.56 nurse staffing hours per resident per day (2026-06-01)

Ownership

Non profit - Corporation

1. Parent organization: Episcopal Homes On University Avenue, LLC

   parent · PAC 5092932103