Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WAVERLY GARDENS
NORTH OAKS, MN · 60 certified beds · Last Life Safety survey September 26, 2024
CMS Certification Number 245613 · first certified August 2006
Ownership
Operated by PRESBYTERIAN HOMES & SERVICES · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MN
7 citations — more than 19% of the 338 certified nursing homes in MN. Compared within MN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
When is the next survey likely?
Well past the typical window (August 2025 to November 2025), and past the point by which nine in ten MN facilities have been surveyed. This facility’s last Life Safety survey was September 2024. Facilities in MN are typically surveyed 11–14 months after the last one (median 13), measured over 613 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
1 of the 7 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 7 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in MN, and nationally. Surveyors differ markedly between states, so the MN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 7 |
| Median facility in MN | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 25, 2022 | 0 |
| August 24, 2023 | 0 |
| September 26, 2024 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2024-09-26 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 1 | 2024-09-26 |
| K-0200 | Meet other general requirements. | 1 | 2024-09-26 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-09-26 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2024-09-26 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 1 | 2024-09-26 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2024-09-26 |
What the citations cover
- Smoke Deficiencies 3
- Egress Deficiencies 3
- Emergency Preparedness Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Egress Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 26, 2024 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (November 13, 2024) |
| K-0200 | Meet other general requirements. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (November 1, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.