Waverly Gardens

In the surveyor’s words

From the most serious findings on record at Waverly Gardens, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600May 29, 2026

  The facility failed to ensure 1 of 3 residents (R1) reviewed for abuse, was free from abuse during cares on 5/16/26, when licensed practical nurse (LPN)-A performed a manual removal of impacted feces from the rectum without consent and continued after R1 asked LPN-A to stop. The immediate jeopardy began on 5/16/26, when the facility failed to ensure R1 was free from abuse during cares when licensed practical nurse (LPN)-A performed a manual removal of impacted feces from the rectum without consent and continued after R1 requested he stop. The administrator and director of nursing (DON) were notified of the immediate jeopardy on 5/27/26 at 5:00 p.m. […]

• Actual harm, isolatedF689Feb 7, 2024

  Based on interview and document review, the facility failed to comprehensively assess and provide the provision of supervision of self transfer to prevent and/or mitigate the risk of falls for 1 of 3 residents (R2) who had a history of falls. This resulted in actual harm for R2 who fell and sustained back and rib fractures. Findings include: R2's Minimum Data Set (MDS) dated [DATE], indicated R2 was a [AGE] year-old admitted on [DATE] with diagnoses including dementia, diabetes, history of transient ischemic attack (temporary disruption of blood flow to the brain), muscle weakness, difficulty in walking, unsteadiness on feet, other abnormalities of gait and mobility, weakness, and repeated falls. […]

• No harm, potential for more than minimal, isolatedF609May 29, 2026

  Based on interview and document review, the facility failed to report an allegation of abuse to the State Agency (SA) within two hours for 1 of 1 resident (R1) who was witnessed being abused by a staff member. Findings include: Facility Vulnerable Adult (VA) Maltreatment Report filed with State Agency (SA) dated 5/18/26 at 5:36 p.m., identified estimated date and time of most recent occurrence was 5/16/26 at 8:00 p.m. in resident bathroom. Description of incident: Allegation of sexual contact by daughter today on 5/18/26. VA complained of rectal pain before, during, and after administration of bowel evacuation regime. Daughter stated VA called her crying around 8:30 p.m. on 5/16/26 stated he hurt me! He hurt me! He put his fingers in my rectum and vagina. […]

• No harm, potential for more than minimal, isolatedF610May 29, 2026

  Based on interviews and document review the facility failed to thoroughly investigate an allegation of staff to resident abuse and protect residents during the investigation for 1 of 1 residents (R1) who reported abuse. Findings include: R1's Minimum Data Set (MDS) dated [DATE], identified she was admitted to the facility on [DATE], from the hospital. R1 had moderately impaired cognition and no behaviors. R1 had functional limitations in range of motion (ROM) in upper and lower extremities on one side. R1 required substantial/maximal assistance with personal hygiene and lying to sit on bed, was dependent on staff for all transfers, repositioning in bed, toileting hygiene, and lower body dressing. R1 used a manual wheelchair for mobility. […]

• No harm, potential for more than minimal, isolatedF657Sep 26, 2024

  Based on interview and document review, the facility failed to hold, at a minimum, quarterly care conference meetings with the resident and their representative to allow the resident and/or representative the opportunity to review and participate in the revision of the care plan for 1 of 2 residents (R13) reviewed for care conferences. Findings include: R13's quarterly Minimum Data Set (MDS), dated [DATE], indicated R13 was admitted to the care facility on 8/28/24 and was cognitively intact. R13's electronic medical record (EMR) indicated the most current care conference was documented on 1/23/24. The care conference note, dated 1/23/24, indicated the care conference was held on 1/5/24 with R13's family, clinical staff, life enrichment, social services and R13 present. […]