Waverly Gardens
WAVERLY GARDENS in NORTH OAKS, MN — inspection on May 29, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 5/27/26 at 8:15 a.m., DON stated staff were expected follow the facility process/policy/protocol for constipation.
The nurse would be expected to complete initial and ongoing physical assessments which included listening to bowel sounds, checking for abdominal tenderness, distention, nausea, review BM log, and document findings. DON stated R1 was impacted with stool when she came to their facility, staff were not informed R1 had not had a BM when admitted to the facility. R1 had a vaso vagal episode in the hospital that was determined it was due to bearing down during a BM.
When a resident failed to have a BM for three days, nurses were expected to have completed a rectal check to determine impaction.
Once impaction was confirmed, nurses were expected to follow the protocol and start with administration of senna. DON stated LPN-A would have been expected to complete basic abdominal assessment and document. LPN-A should have followed the facility protocol and administered an enema prior to manual removal of the stool.
When family voiced concerns related to a resident's bowel pattern, the nurse would have been expected to provide education, explain what and why he was doing to lower anxiety, bring trust and provide a clear picture of the next steps so that they would have been aware of what to expect. LPN-A administered two senna (takes up to 24 hours to work), on the same day a suppository was administered (takes more than a few hours and up to 12 hours to have results depending on the severity of the
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Waverly Gardens 5919 Centerville Road North Oaks, MN 55127
right away. NA-B stated in the past she had to beg him to help when she required assistance with a
done to them. NA-B since 5/19/26, we have been required to have two staff in room to care for R1, to
a.m., a family member (FM) stated she informed LPN-A R1 needed to poop and needed his help, she was told he was busy. LPN-A appeared frustrated, upset, and stated loudly, placed R1 on the bed and administered a suppository at approximately 7:30 p.m. At 8:00 p.m. R1 stated I think I have to poop.
NA-A answered the call light and indicated she would take her to the bathroom. FM informed NA she needed to leave and went home to rest. At 8:39 p.m. R1 called her crying and sounded scared stating help me, he hurt me, he hurt me, he hurt me; he had his fingers in my vagina and anus hanging from the lift machine, tears coming down my checks and said you're hurting me, and he wouldn't stop, turned around, and saw him grinning at me. FM asked R1 if she wanted her to come back to facility and she stated just want to know if I'm safe from him, reassurance was given.
The following morning (5/17/26) FM arrived at facility and talked to RN-D, explained what happened with my mother the previous evening and RN-D replied she would have to ask her supervisor about the incident, checked documentation, verified R1 had stool removed, and stated the nurse should have not manually removed stool without order. R1 talked about this incident all day over and over again and had not realized the day before the extent and how awful this incident had been for her. FM stated on Monday (5/17/26), she brought the incident up again to LPN-D.
This nurse went into R1's room and talked to her about what happened on 5/16/26, and indicated she planned on going directly to the DON and report this. At approximately 2:00 p.m., the DON was in R1's room, spent over one hour taking notes while she visited with her. R1 had the same story every time. DON stated this would be reported to the state of Minnesota, was very serious, and the nurse would be placed on administrative leave for at least one week while an investigation would be completed. DON opened the door and R1 saw LPN-A outside her door and stated, he's here! The DON stated yes, he had picked up a shift and we are handling it. A [NAME] count investigator entered the room and R1 stated are you here to arrest me? The investigator asked if we wanted to press charges and R1 stated I don't think so. R1's behavior had changed since the incident, she's afraid he will come back. R1 continued to be affected by this incident, refused cares, toileting, getting out of bed, and not wanting to eat much. FM stated she had asked DON if R1 had a rectal tear and she stated we would have known by know if she had one, no.
The incident on 5/16/26 with the male nurse LPN-A had been psychologically traumatizing to her and the family both. R1 talked about the incident all the time, at least three times a day, and yesterday was the first day she had not mentioned it. R1 was afraid LPN-A would come back and go to her window, smother /suffocate her, the psychological and emotional piece is very real and huge with her.
This was a wrench that had been thrown into an already difficult situation since she had her stroke. We are worried that after the investigation is over, he will be coming back to work. LPN-A can never be around her mother again. R1 was perfectly fine 6 weeks ago. FM stated she was gone only 40 minutes on 5/16/26, and R1 called her screaming, crying, and sounded scared stating help me, he hurt me, he hurt me with his fingers in her vagina and anus and wouldn't stop. R1 stated
245613 05/29/2026
Waverly Gardens 5919 Centerville Road North Oaks, MN 55127
substantiated cases of abuse/neglect (nurse aide registry, board of nursing).
Follow-up action plan:
resident and resident's designated representative for resolution.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.