Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waverly Gardens during CMS and state inspections, most recent first.
A resident with impaired cognition, stroke-related deficits, and constipation was subjected to manual stool removal by an LPN after a suppository did not work. Staff interviews and the resident’s statements indicated she said stop and begged the LPN to stop while he continued the procedure, and she later described the care as painful, violating, and demeaning. The LPN said he manually removed the stool in the bathroom, did not complete an abdominal assessment, and did not contact the provider for further direction.
Failure to Timely Report Allegation of Abuse: A resident with impaired cognition, stroke-related deficits, and constipation was undergoing bowel care when an LPN manually removed stool and the resident repeatedly cried out to stop. The resident, NA, and family reported the LPN placed fingers in the resident’s rectal and possibly vaginal area and continued despite distress. Although staff documented family concerns earlier, the allegation was not reported to the DON until later and was not sent to the SA within the required timeframe.
A resident with stroke-related deficits, impaired cognition, and extensive care needs reported that an LPN inserted his finger into her anus during bowel care and continued despite her crying and asking him to stop. The family also reported the procedure was painful and distressing. The facility’s response was incomplete: the DON was not aware of an earlier progress note about the family’s complaint, no immediate rectal assessment was done, the initial body audit did not include the peri-rectal area, and resident interviews were delayed and limited to only a small sample of residents.
The facility failed to hold quarterly care conferences for a resident, as required by policy. The last documented conference was in January, despite the resident being admitted in August and being cognitively intact. Staff interviews confirmed the oversight, with a scheduled conference not occurring due to the representative's unavailability. Although video calls were arranged, they were not documented as formal care conferences.
The facility failed to implement ROM programs for three residents, leading to incomplete documentation and unaddressed mobility needs. Despite care plans outlining daily ROM exercises, tasks were often marked as 'not applicable' or 'resident refused' without explanation. Staff interviews revealed time constraints and lack of resident presence as reasons for incomplete tasks. The Director of Nursing confirmed the deficiency, and the facility's ROM policy was not provided.
A facility failed to act on a consultant pharmacist's recommendations for a resident receiving high-risk medications, including sliding scale insulin and PRN Ativan. The pharmacist's recommendations, documented in May and June, were not signed by a provider until September, due to communication lapses and process failures. The resident had multiple diagnoses and was on hospice care, highlighting the importance of timely medication review.
The facility did not post accessible contact information for the Ombudsman, leaving residents unaware of how to contact this advocate. During a survey, it was confirmed that no such information was visible in the facility, and the DON and administrator acknowledged this oversight. No policy was provided regarding the posting of Ombudsman information.
Abuse During Manual Stool Removal
Penalty
Summary
The facility failed to ensure a resident was free from abuse during bowel care when an LPN performed manual removal of impacted stool from the rectum without consent and continued after the resident asked him to stop. The resident had moderately impaired cognition, was dependent on staff for transfers and toileting hygiene, and had a history of constipation. Her diagnoses included stroke, atrial fibrillation, hemiplegia/hemiparesis, adjustment disorder, and mixed anxiety and depressed mood. Her care plan identified limited physical mobility and the need for two staff with a stand lift for transfers. On the day of the incident, the resident had not had a bowel movement for several days and had received constipation medications and a rectal suppository. Progress notes documented that a rectal check found hard stool and that manual evacuation was performed with removal of large amounts of stool. Staff interviews described that the resident cried, said stop, and begged the LPN to stop while he continued the manual removal for additional time. The resident later reported that the procedure was painful, that she felt violated, embarrassed, and demeaned, and that she believed the nurse was smiling and laughing at her during the care. Multiple staff interviews confirmed that the resident was distressed during the procedure and that the LPN did not stop when she requested it. Staff also stated the procedure was invasive and should have been stopped when the resident expressed pain. The LPN stated he manually removed the stool in the bathroom, did not complete an abdominal assessment, did not administer an enema before manual removal, and did not contact the provider for further direction. The report also states the facility failed to ensure the resident was free from abuse during cares, and the immediate jeopardy was identified based on this event.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within two hours after a resident was witnessed being abused by an LPN during bowel care. The resident had a history of stroke, hemiplegia, impaired cognition, constipation, and dependence for most personal care and transfers. She was also identified in the care plan as being at risk for abuse and neglect. During bowel management on 5/16/26, she received a rectal suppository and later required manual removal of stool after no results were obtained. Multiple accounts in the record described the resident becoming distressed during the manual stool removal. The resident stated the nurse placed his fingers in her rectum and vagina, that he was smiling while hurting her, and that she begged him to stop. A nursing assistant stated she observed the resident crying, shaken, and repeatedly saying stop while the LPN continued the procedure for approximately two to three minutes. Another nursing assistant and family member reported the resident called her daughter crying and saying he hurt me and put his fingers in my rectum and vagina. The LPN stated he manually removed stool with a gloved hand, that the resident said it was hurting, and that he would have stopped if she had asked him to stop, but he also acknowledged the procedure was not completed according to facility policy. The allegation was not reported to the DON until 5/18/26 when the daughter raised concerns to staff, even though staff documentation showed family concerns about painful digital removal of stool had already been recorded on 5/17/26. The facility’s report to the State Agency was filed later, with the allegation dated as occurring on 5/16/26. Interviews with staff and family showed the resident remained tearful, fearful, and emotionally affected by the incident, and she expressed worry about the nurse returning. The record also showed the resident had ongoing anxiety, refusal of some cares, and repeated discussion of the event after it occurred.
Failure to Thoroughly Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse and failed to protect residents during the investigation for a resident who reported sexual abuse during bowel care. The resident had a recent stroke, atrial fibrillation, hemiplegia/hemiparesis, adjustment disorder with mixed anxiety and depressed mood, moderately impaired cognition, and required extensive assistance with personal care, transfers, toileting, and dressing. She used a manual wheelchair and was frequently incontinent of bladder and occasionally incontinent of bowel with constipation. Her care plan identified her as at risk for abuse and/or neglect and directed staff to keep her safe and follow the facility vulnerable adult policy. The allegation arose after the resident received treatment for constipation that included a rectal suppository and manual stool removal. Progress notes documented that the resident’s daughter complained the procedure was painful and that the family was dissatisfied with the nurse who performed it. The resident later stated that the nurse inserted his finger into her anus, kept circling it, and continued despite her crying and asking him to stop. She reported that he smiled at her while she was being hurt and later described feeling embarrassed, vulnerable, and fearful that he might return and retaliate. The facility’s report to the State Agency identified the allegation as sexual abuse and stated the most recent occurrence was in the resident bathroom. The investigation documented interviews with the alleged perpetrator, two NAs, and six residents out of 60, but the record also showed gaps in the response. The DON stated she was not aware of the incident until the family voiced concerns on 5/18/26 and that she was not aware of the 5/17/26 progress note describing the family’s complaint until later. The DON also stated no physical exam was completed at the time of the allegation, the resident’s rectal area was not assessed in the initial body audit, and resident interviews were not started until 5/22/26. The DON and administrator stated that all residents who could be interviewed should have been interviewed, and that residents unable to speak for themselves should have been checked for signs of distress, but this was not done at the time of the allegation.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conference meetings with a resident and their representative, as required by their policy. The resident, identified as R13, was admitted to the facility on 8/28/24 and was cognitively intact. The last documented care conference for R13 occurred on 1/5/24, despite the facility's policy mandating quarterly reviews. Interviews with staff revealed that a care conference was scheduled but did not occur due to the unavailability of R13's representative, and the oversight was not corrected. During interviews, the nurse manager and social worker confirmed the lapse in holding the required care conference. The social worker acknowledged her responsibility to schedule these conferences and admitted that no documented care conference had taken place for R13 since January. Although video calls between R13 and their family were arranged, these were not documented as formal care conferences. The facility's policy clearly states that care plans should be reviewed quarterly and with any significant change, emphasizing the importance of these meetings for resident care.
Failure to Implement ROM Programs for Residents
Penalty
Summary
The facility failed to implement interventions to prevent further development of decreased range of motion (ROM) for three residents, identified as R2, R4, and R28, who were reviewed for positioning and mobility. R2, who had a moderate cognitive impairment and multiple diagnoses including Parkinson's disease and epilepsy, was supposed to participate in an ambulation program and an active ROM program for both upper and lower extremities. However, documentation revealed that these programs were not consistently completed, with numerous instances marked as 'not applicable' or 'resident refused' without any documented rationale. R4, with severe cognitive impairment and diagnoses such as Alzheimer's and depression, had a care plan that included a daily ROM program for both upper and lower extremities. Despite this, the ROM tasks were not consistently completed, and similar to R2, there was a lack of documentation explaining why the tasks were marked as 'not applicable' or incomplete. R28, who had a moderate cognitive impairment and conditions like a stroke and hemiplegia, was also supposed to receive a passive ROM program for the left upper and lower extremities. The documentation showed that these tasks were frequently not completed, with many instances marked as 'not applicable' or 'resident refused' without explanation. Interviews with staff, including nursing assistants and registered nurses, revealed that ROM programs were sometimes not completed due to time constraints or if the resident was not on the unit. The Director of Nursing confirmed that the ROM programs for these residents were not being completed as ordered and emphasized the importance of these programs in maintaining residents' functional levels. The facility's ROM policy was requested but not provided, further highlighting the deficiency in ensuring proper care and documentation for residents' mobility needs.
Failure to Act on Pharmacist Recommendations for Medication Management
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations for a resident identified as R11, who was reviewed for unnecessary medications. R11 had multiple diagnoses, including heart failure, diabetes, dementia, and anxiety, and was receiving high-risk drug classes such as antipsychotics, antianxiety, antidepressants, opioids, antiplatelets, and hypoglycemic medications. The resident was also on hospice care. The consultant pharmacist recommended reassessing the use of sliding scale insulin (SSI) and PRN Ativan due to potential risks highlighted by the AGS Beers criteria and CMS guidelines. However, these recommendations were not acted upon in a timely manner. The consultant pharmacist's recommendations were documented in the Consultant Pharmacist Communication to Physician (CPCP) forms dated 5/13/24 and 6/11/24. These forms were not signed by the physician or provider until 9/24/24, indicating a delay in addressing the pharmacist's concerns. The facility's process involved the Director of Nursing (DON) forwarding these forms to the appropriate provider for review and signature, which did not occur as expected. The DON acknowledged the oversight and was unable to explain why the forms were not processed sooner. Interviews with the consultant pharmacist, nurse practitioner (NP), and DON revealed gaps in communication and process adherence. The consultant pharmacist stated that it was the facility's responsibility to ensure the recommendations were forwarded to the appropriate provider. The NP mentioned being out of town during the months when the recommendations were made, which contributed to the delay. The facility's policy required all pharmacist recommendations to be reviewed with the primary physician or NP before implementation, but this was not followed, leading to the deficiency.
Failure to Post Ombudsman Contact Information
Penalty
Summary
The facility failed to post accessible contact information for all pertinent State agencies and the Ombudsman, which is a requirement for ensuring residents have the necessary resources to file complaints or seek advocacy. During a resident council meeting, four residents who regularly attended these meetings expressed their unawareness of the Ombudsman and the location of any related information within the facility. This lack of awareness was confirmed during the survey conducted from September 23 to September 26, 2024, where no postings or contact information for the Ombudsman were observed in the facility. The Director of Nursing (DON) and the administrator acknowledged the absence of posted Ombudsman information, initially believing that social services had the information. However, it was not accessible to residents or visitors unless specifically requested. The administrator later provided a business card for the Ombudsman but confirmed it was not posted. The DON reiterated the importance of having this information available as the Ombudsman serves as an advocate for residents. No policy regarding the posting of Ombudsman information was provided upon request.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Oaks
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cerenity Care Center White Bear Lake | 3.4 mi | ★★★★★ | 8 | 1 |
| Harmony Gardens | 7.2 mi | ★★★★★ | 7 | 0 |
| Langton Shores | 7.5 mi | ★★★★★ | 1 | 0 |
| The Villas At New Brighton | 7.6 mi | ★★★★★ | 17 | 1 |
| New Brighton Care Center | 7.9 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.