Cycle 1
Health 2025-09-04 · Fire 2024-06-05
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Waverly, TN
Humphreys County Care And Rehabilitation
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
104 Fort Hill Road, Waverly, TN
(931) 296-2532
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
91
Certified beds
Average residents
73
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.60
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.85
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.83
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
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,617
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.73
Composite VBP score used to determine payment impact.
Payment multiplier
1.0025
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.36
Baseline 18.48% · Performance 20.34% · Measure score 2.36 · Achievement 2.36 · Improvement 0
Healthcare-associated infections
6.86
Baseline 5.95% · Performance 5.78% · Measure score 6.86 · Achievement 6.86 · Improvement 1.21
Total nurse turnover
5.79
Baseline 50.00% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 3.48
Adjusted total nurse staffing
4.48
Baseline 3.83 hours · Performance 4.35 hours · Measure score 4.48 · Achievement 4.48 · Improvement 2.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 9.09% · Lower 95% interval 7.43% |
| Discharge to community | 53.97% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 51.28% · Lower 95% interval 45.28% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.75% |
95.27%
3.5 pts better
|
Numerator 79 · Denominator 80 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 80 |
| Discharge self-care score | 54.41% |
53.69%
0.7 pts better
|
Numerator 37 · Denominator 68 |
| Discharge mobility score | 64.71% |
50.94%
13.8 pts better
|
Numerator 44 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 2 · Denominator 80 · Adjusted rate 2.62% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 2.35% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 5.56% |
8.2%
2.6 pts worse
|
Numerator 8 · Denominator 144 |
| Staff flu vaccination coverage | 23.53% |
42%
18.5 pts worse
|
Numerator 40 · Denominator 170 |
| Discharge function score | 69.12% |
56.45%
12.7 pts better
|
Numerator 47 · Denominator 68 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 32 · Denominator 32 |
| Resident COVID-19 vaccinations up to date | 40.54% |
25.2%
15.3 pts better
|
Numerator 15 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.6
0.3 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
1.6
1.6 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
89.9%
5 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 79.3% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
94.5%
2.4 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.6%
1.1 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 5.0% · Q3 7.0% · Q4 5.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.1% |
11.8%
3.3 pts worse
|
11.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 22.4% · Q3 15.1% · Q4 8.9% · 4Q avg 15.1% |
| Percentage of long-stay residents who lose too much weight | 10.2% |
6.2%
4 pts worse
|
5.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 12.5% · Q3 12.0% · Q4 8.0% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
32.2%
6.7 pts better
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 27.5% · Q3 21.6% · Q4 28.0% · 4Q avg 25.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.9% |
18.1%
4.8 pts worse
|
16.7%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 26.2% · Q3 23.8% · Q4 19.0% · 4Q avg 22.9% · 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 | 37.7% |
19.9%
17.8 pts worse
|
16.3%
21.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 56.1% · Q4 26.6% · 4Q avg 37.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.3% |
15.3%
19 pts worse
|
14.9%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 47.6% · Q3 40.5% · Q4 19.0% · 4Q avg 34.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.9%
1 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.9% · Q3 0.0% · Q4 3.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.9%
0.6 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.4% |
20.2%
10.2 pts worse
|
19.8%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 26.9% · Q3 24.5% · Q4 41.8% · 4Q avg 30.4% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.4%
1.4 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.8% · Q3 3.8% · Q4 1.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.8% |
79.6%
10.2 pts better
|
81.7%
8.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 60.4% · 4Q avg 89.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
11.2%
2 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 11.5% · Expected 14.0% · 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 | 60.0% |
79.8%
19.8 pts worse
|
79.7%
19.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.1% |
22.2%
9.1 pts better
|
23.9%
10.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.1% · Observed 16.4% · Expected 29.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2022-07-28
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-07-28 · Fire 2019-12-11
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-20
D · Potential for more than minimal harm
2024-06-05
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-07-08
D · Potential for more than minimal harm
2024-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-28
D · Potential for more than minimal harm
2022-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-08-12
F · Potential for more than minimal harm
2019-12-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-01-15
D · Potential for more than minimal harm
2019-12-11
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-01-15
Inspection history
Recent health citations
G · Actual harm
2025-09-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-04
F · Potential for more than minimal harm
2025-09-04
F922 · Environmental Deficiencies
Health
Have enough backup water supply for essential areas of the nursing home.
Corrected 2025-10-04
E · Potential for more than minimal harm
2025-09-04
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-09-04
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 2025-10-04
D · Potential for more than minimal harm
2025-09-04
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-09-04
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 2025-10-04
D · Potential for more than minimal harm
2025-09-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-09-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-09-04
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-10-04
D · Potential for more than minimal harm
2025-09-04
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 2025-10-04
D · Potential for more than minimal harm
2025-09-04
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 2025-10-04
D · Potential for more than minimal harm
2025-09-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-04
E · Potential for more than minimal harm
2024-06-05
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 2024-06-28
D · Potential for more than minimal harm
2024-06-05
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-05
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 2024-06-28
D · Potential for more than minimal harm
2024-06-05
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 2024-06-28
D · Potential for more than minimal harm
2024-06-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-05
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 2024-06-28
D · Potential for more than minimal harm
2024-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-28
F · Potential for more than minimal harm
2022-07-28
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 2022-08-15
D · Potential for more than minimal harm
2022-07-28
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-28
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 2022-08-22
Penalties and ownership
What sits behind the stars
$16,720
2025-09-04
Fine
Fine · fine $16,720
Fine
$3,145
2023-10-02
Fine
Fine · fine $3,145
Fine
Ownership
Eads, Judy
Operational/Managerial Control · Individual
Eads, Judy
Contracted Managing Employee · Individual
Hensley, Christine
Corporate Director · Individual
Key Management Associates
Operational/Managerial Control · Organization
Yates, Cindy
W-2 Managing Employee · Individual
Nearby options
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Ahc Waverly
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#3
Camden Healthcare & Rehab Center
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