Cycle 1
Health 2025-06-18 · Fire 2025-06-18
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Waverly, TN
Ahc Waverly
1-star overall rating with 2-star inspections with $48,110 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
895 Powers Blvd, Waverly, TN
(931) 296-7552
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1990-04-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.05
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.94
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.53
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,644
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
2.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Baseline 5.10% · Performance 8.40% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 64.52% · Performance 68.12% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.74
Baseline 2.84 hours · Performance 3.21 hours · Measure score 0.74 · Achievement 0 · Improvement 0.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.22% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 3.77% · Lower 95% interval 5.72% |
| Discharge to community | 63.65% |
50.57%
13.1 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 50% · Lower 95% interval 45.7% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 3.03% |
0.77%
2.3 pts worse
|
Numerator 1 · Denominator 33 |
| Discharge self-care score | 32% |
53.69%
21.7 pts worse
|
Numerator 8 · Denominator 25 |
| Discharge mobility score | 20% |
50.94%
30.9 pts worse
|
Numerator 5 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 33 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.4% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 16% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 3.66% |
8.2%
4.5 pts worse
|
Numerator 3 · Denominator 82 |
| Staff flu vaccination coverage | 33.33% |
42%
8.7 pts worse
|
Numerator 31 · Denominator 93 |
| Discharge function score | 36% |
56.45%
20.5 pts worse
|
Numerator 9 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 55.1% |
89.9%
34.8 pts worse
|
93.4%
38.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 60.4% · Q3 47.8% · Q4 43.8% · 4Q avg 55.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.3% |
94.5%
11.2 pts worse
|
95.5%
12.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.6%
1.5 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.8% · Q3 6.5% · Q4 4.2% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 39.1% |
11.8%
27.3 pts worse
|
11.4%
27.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 59.5% · Q4 97.7% · 4Q avg 39.1% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
6.2%
4.3 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 62.7% |
32.2%
30.5 pts worse
|
19.6%
43.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.2% · Q2 72.1% · Q3 55.9% · Q4 48.6% · 4Q avg 62.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 38.0% |
18.1%
19.9 pts worse
|
16.7%
21.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.9% · Q2 34.5% · Q3 36.0% · Q4 44.0% · 4Q avg 38.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.6% |
19.9%
11.3 pts better
|
16.3%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.5% |
15.3%
8.8 pts better
|
14.9%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 2.5% · Q3 8.8% · Q4 8.8% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.9%
0.4 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.2% · Q4 2.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
20.2%
0.7 pts worse
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 21.1% · Q3 23.0% · Q4 22.2% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 13.8% |
5.4%
8.4 pts worse
|
5.1%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 16.9% · Q3 14.5% · Q4 12.4% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 29.4% |
79.6%
50.2 pts worse
|
81.7%
52.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 22.0% · Q3 31.0% · Q4 33.7% · 4Q avg 29.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.3% |
11.2%
7.1 pts worse
|
12.0%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 17.9% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.6%
1.6 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 26.9% |
79.8%
52.9 pts worse
|
79.7%
52.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 26.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.0% |
22.2%
3.2 pts better
|
23.9%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.0% · Observed 17.9% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-17 · Fire 2024-07-17
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-08-17 · Fire 2023-08-17
12 health deficiencies
Top issue: Administration (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-06-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-11
D · Potential for more than minimal harm
2024-07-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-17
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-13
D · Potential for more than minimal harm
2023-08-17
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-08-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-12
D · Potential for more than minimal harm
2025-06-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-12
D · Potential for more than minimal harm
2025-06-18
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-07-12
D · Potential for more than minimal harm
2025-06-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-12
E · Potential for more than minimal harm
2024-07-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-07-17
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-08-13
J · Immediate jeopardy
2023-08-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-12
E · Potential for more than minimal harm
2023-08-17
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-09-12
E · Potential for more than minimal harm
2023-08-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-09-12
E · Potential for more than minimal harm
2023-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-12
E · Potential for more than minimal harm
2023-08-17
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-12
Penalties and ownership
What sits behind the stars
$48,110
2023-08-17
Fine
Fine · fine $48,110
Fine
Ownership
Nearby options
Other facilities in reach
#1
Humphreys County Care And Rehabilitation
Waverly, TN
2-star overall rating with 2-star inspections with $19,865 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Signature Healthcare Of Erin
Erin, TN
1-star overall rating with 1-star inspections with $210,753 in total fines with 1 recent health deficiencies
#3
Camden Healthcare & Rehab Center
Camden, TN
1-star overall rating with 1-star inspections with $105,447 in total fines with 5 recent health deficiencies
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