Waverly Gardens

Penalties

• May 29, 2026 — Fine ($113,312)

Inspection findings

1. Jun 18, 2026 MDH complaint investigation · 1 finding
   • Severity not stated

     H56132528C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

2. May 29, 2026 Health · 3 findings
   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jul 2, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jul 2, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Jul 2, 2026 · CMS health inspection

3. Sep 26, 2024 Fire Safety · 11 findings
   • Not serious Scope/severity C

     E0018 Emergency Preparedness Deficiencies

     Establish procedures for tracking staff and patients during an emergency.

     Corrected Nov 13, 2024 · CMS fire safety

   • Not serious Scope/severity C

     F0575 Resident Rights Deficiencies

     Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

     Corrected Nov 13, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Nov 13, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

     Corrected Nov 13, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected Nov 13, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0200 Egress Deficiencies

     Meet other general requirements.

     Corrected Nov 1, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Nov 1, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0293 Egress Deficiencies

     Have properly located and lighted "Exit" signs.

     Corrected Nov 1, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Nov 1, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Nov 1, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0362 Smoke Deficiencies

     Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

     Corrected Nov 1, 2024 · CMS fire safety

4. Feb 7, 2024 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Mar 5, 2024 · CMS health inspection

5. May 25, 2022 Health · 3 findings
   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jun 28, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jun 28, 2022 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jun 28, 2022 · CMS health inspection

6. Jul 22, 2020 MDH complaint investigation · 1 finding
   • Severity not stated

     H5613025C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• FLETCHER, JONATHAN — adp of the snf, NOT APPLICABLE, since 02/01/2025
• FLETCHER, JONATHAN — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 03/26/2026
• FLETCHER, JONATHAN — corporate director, NOT APPLICABLE, since 02/01/2025
• FLETCHER, JONATHAN — corporate officer, NOT APPLICABLE, since 02/01/2025
• FLETCHER, JONATHAN — operational/managerial control, NOT APPLICABLE, since 02/01/2025
• MEYER, MARK — corporate officer, NOT APPLICABLE, since 03/30/2001
• MEYER, MARK — operational/managerial control, NOT APPLICABLE, since 03/11/2011
• MEYER, MARK — adp of the snf, NOT APPLICABLE, since 03/11/2011
• PEDERSON, JANE — adp of the snf, NOT APPLICABLE, since 04/01/2021
• PEDERSON, JANE — operational/managerial control, NOT APPLICABLE, since 04/01/2021
• PEDERSON, MARK — corporate director, NOT APPLICABLE, since 01/01/2023
• PETERSON, HEIDI — adp of the snf, NOT APPLICABLE, since 01/01/2023
• PETERSON, HEIDI — corporate director, NOT APPLICABLE, since 01/01/2023
• PETERSON, HEIDI — operational/managerial control, NOT APPLICABLE, since 01/01/2023
• SAMMON, KATHERINE — adp of the snf, NOT APPLICABLE, since 11/21/2022
• SAMMON, KATHERINE — operational/managerial control, NOT APPLICABLE, since 11/21/2022
• COMPUTERSHARE CORPORATE TRUST COMPANY, NA — 5% or greater security interest, NOT APPLICABLE, since 07/01/2024
• COMPUTERSHARE CORPORATE TRUST COMPANY, NA — 5% or greater mortgage interest, NOT APPLICABLE, since 07/01/2024
• PHS MANAGEMENT, LLC — adp of the snf, NOT APPLICABLE, since 02/17/2026
• PHS MANAGEMENT, LLC — operational/managerial control, NOT APPLICABLE, since 03/11/2011
• PRESBYTERIAN HOMES AND SERVICES — 5% or greater direct ownership interest, 100%, since 03/17/2020