12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
17 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (6 deficiencies)
Waverly, NE
1-star overall rating with 1-star inspections with $25,642 in total fines with 12 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
11041 North 137th St, Waverly, NE
(402) 786-2626
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
54
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avid Healthcare Group
Operator or chain grouping
Approved since
1994-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.74
Registered nurse staffing
LPN hours / resident day
0.53
Licensed practical nurse staffing
Aide hours / resident day
2.52
Nurse aide staffing
Weekend hours
3.47
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
84%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.6 |
1.8
1.8 pts worse
|
1.9
1.7 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.0
0.6 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.1% |
92.8%
5.7 pts worse
|
93.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.0% |
96.1%
9.1 pts worse
|
95.5%
8.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
4.5%
2.7 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 9.0% |
4.4%
4.6 pts worse
|
11.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.1% |
5.3%
1.2 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.3% |
19.5%
13.8 pts worse
|
19.6%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
21.6%
5.1 pts better
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 2.3% |
0.3%
2 pts worse
|
0.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.3% |
20.4%
5.9 pts worse
|
16.3%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
19.9%
0.5 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.6%
0.2 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.9%
1 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.0% |
26.6%
3.6 pts better
|
19.8%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.3%
0.2 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.8% |
80.5%
23.7 pts worse
|
81.7%
24.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.9% |
11.6%
6.3 pts worse
|
12.0%
5.9 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.4%
2.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.1% |
75.9%
27.8 pts worse
|
79.7%
31.6 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.0% |
20.9%
10.1 pts worse
|
23.9%
7.1 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Pharmacy Service (3 deficiencies)
17 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (6 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-02-24
Fire Safety
Use approved construction type or materials.
Corrected 2025-02-24
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-01-19
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-02-24
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-17
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-24
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-02-24
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-17
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-02-24
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-24
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-01-19
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-02-24
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-24
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-24
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2025-01-19
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-17
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-02-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-23
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-02-23
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-02-23
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-23
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-02-23
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-23
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-02-23
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-23
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-04-06
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-04-06
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-06
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-04-06
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-20
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-04-06
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-20
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-04-06
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-04-06
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-06
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-04-06
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-06
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-06
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-04-06
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-04-06
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-04-06
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-04-06
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-04-06
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-24
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-05-12
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-12
Health
Post nurse staffing information every day.
Corrected 2025-01-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-19
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 2025-01-19
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-01-19
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-19
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-19
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-01-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-19
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-23
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 2024-09-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-29
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-17
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-11
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-02-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-23
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-23
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-02-23
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-02-23
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-23
Health
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 2024-02-23
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-02-23
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-06
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-06
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-06
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-06
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-06
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-04-06
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-06
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-06
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 2023-04-06
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-04-06
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-04-06
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-06
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-04-06
Penalties and ownership
Payment Denial · denial start 2025-02-19 · 26 days
26 day denial
Fine · fine $9,805
Fine
Fine · fine $15,837
Fine
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
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