Cycle 1
Health 2023-05-11 · Fire 2023-05-11
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Waverly, VA
Waverly Rehabilitation And Healthcare Center
3-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
456 E Main St, Waverly, VA
(804) 834-3975
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Yad Healthcare
Operator or chain grouping
Approved since
1988-11-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.23
Registered nurse staffing · state 0.69 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 1.00 · national 0.87
Aide hours / resident day
1.77
Nurse aide staffing · state 2.12 · national 2.35
Total nurse hours
2.86
All reported nurse hours · state 3.81 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
2.43
Weekend nurse staffing · state 3.31 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.25
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 49% · national 45%
Total nurse turnover
80%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,539
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.34
Baseline 18.60% · Performance 19.42% · Measure score 4.34 · Achievement 4.34 · Improvement 0
Healthcare-associated infections
0
Baseline 6.26% · Performance 7.88% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 80.49% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.23
Baseline 2.36 hours · Performance 3.29 hours · Measure score 2.23 · Achievement 0.75 · Improvement 2.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.57% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 91 · Observed rate 15.38% · Lower 95% interval 8.49% |
| Discharge to community | 42.74% |
50.57%
7.8 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 31.67% · Lower 95% interval 32.75% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 67 · Denominator 67 |
| Falls with major injury | 1.49% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 67 |
| Discharge self-care score | 46.34% |
53.69%
7.3 pts worse
|
Numerator 19 · Denominator 41 |
| Discharge mobility score | 39.02% |
50.94%
11.9 pts worse
|
Numerator 16 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 5.97% |
2.29%
3.7 pts worse
|
Numerator 4 · Denominator 67 · Adjusted rate 5.12% |
| Healthcare-associated infections requiring hospitalization | 7.88% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 12.31% · Lower 95% interval 4.75% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 92 |
| Staff flu vaccination coverage | 12.82% |
42%
29.2 pts worse
|
Numerator 15 · Denominator 117 |
| Discharge function score | 51.22% |
56.45%
5.2 pts worse
|
Numerator 21 · Denominator 41 |
| Transfer of health information to provider | 90.48% |
95.95%
5.5 pts worse
|
Numerator 19 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 23.08% |
25.2%
2.1 pts worse
|
Numerator 9 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.5
0.2 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.4
1.5 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
91.2%
0.4 pts better
|
93.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.0% · Q2 96.1% · Q3 96.0% · Q4 92.3% · 4Q avg 91.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
94.0%
4.2 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.6%
1.8 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 6.8% · Q3 6.0% · Q4 2.9% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.7% |
15.7%
12 pts worse
|
11.4%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 28.7% · Q3 25.8% · Q4 28.9% · 4Q avg 27.7% |
| Percentage of long-stay residents who lose too much weight | 13.3% |
5.7%
7.6 pts worse
|
5.4%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 13.8% · Q3 12.1% · Q4 14.4% · 4Q avg 13.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.7% |
20.2%
2.5 pts worse
|
19.6%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 23.7% · Q3 22.9% · Q4 21.2% · 4Q avg 22.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.6% |
15.0%
8.6 pts worse
|
16.7%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 19.7% · Q3 24.2% · Q4 28.4% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 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 | 9.4% |
17.5%
8.1 pts better
|
16.3%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 15.2% · Q3 9.9% · Q4 4.4% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.5% |
15.7%
5.2 pts better
|
14.9%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 16.7% · Q3 5.7% · Q4 7.6% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 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 | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 24.7% |
22.2%
2.5 pts worse
|
19.8%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 24.4% · Q3 25.0% · Q4 22.8% · 4Q avg 24.7% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
5.2%
1.6 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 7.5% · Q3 7.7% · Q4 6.4% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 29.9% |
74.6%
44.7 pts worse
|
81.7%
51.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 34.3% · Q3 27.0% · Q4 21.9% · 4Q avg 29.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
11.7%
0.7 pts better
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 11.4% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.9% |
1.2%
2.7 pts worse
|
1.6%
2.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 0.0% · Q3 0.0% · Q4 9.7% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.4% |
73.6%
22.2 pts worse
|
79.7%
28.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
22.0%
1.4 pts worse
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 22.7% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-03-11 · Fire 2021-03-11
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-06-07 · Fire 2018-06-07
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
13 fire-safety deficiencies
Top issue: Emergency Preparedness (8 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-05-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-05-11
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-06-30
F · Potential for more than minimal harm
2018-06-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2018-08-02
F · Potential for more than minimal harm
2018-06-07
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2018-08-02
D · Potential for more than minimal harm
2018-06-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2018-08-02
D · Potential for more than minimal harm
2018-06-07
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2018-08-02
D · Potential for more than minimal harm
2018-06-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-08-02
C · Minimal harm
2018-06-07
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-06-28
C · Minimal harm
2018-06-07
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2018-06-28
C · Minimal harm
2018-06-07
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2018-06-28
C · Minimal harm
2018-06-07
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-06-28
C · Minimal harm
2018-06-07
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2018-06-28
C · Minimal harm
2018-06-07
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2018-06-28
C · Minimal harm
2018-06-07
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2018-06-28
C · Minimal harm
2018-06-07
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2018-06-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-04-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-04-10
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-05-20
D · Potential for more than minimal harm
2023-11-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-12-14
E · Potential for more than minimal harm
2023-05-11
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-06-12
D · Potential for more than minimal harm
2021-03-11
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 2021-04-11
D · Potential for more than minimal harm
2021-03-11
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 2021-04-11
D · Potential for more than minimal harm
2021-03-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-04-11
D · Potential for more than minimal harm
2021-03-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-04-11
E · Potential for more than minimal harm
2018-06-07
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 2018-07-16
D · Potential for more than minimal harm
2018-06-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2018-07-16
D · Potential for more than minimal harm
2018-06-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2018-07-16
D · Potential for more than minimal harm
2018-06-07
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 2018-07-16
D · Potential for more than minimal harm
2018-06-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2018-07-16
D · Potential for more than minimal harm
2018-06-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-07-16
D · Potential for more than minimal harm
2018-06-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-07-16
D · Potential for more than minimal harm
2018-06-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-07-16
D · Potential for more than minimal harm
2018-06-07
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 2018-07-16
D · Potential for more than minimal harm
2018-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-07-16
Penalties and ownership
What sits behind the stars
Ownership
Waverly Operating Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Alter, Tzvi
5% Or Greater Indirect Ownership Interest · Individual
Alter, Tzvi
Corporate Officer · Individual
Seeley, Audrey
W-2 Managing Employee · Individual
Sukenik, Charne
Corporate Director · Individual
Sukenik, Charne
W-2 Managing Employee · Individual
Nearby options
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#2
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Petersburg, VA
3-star overall rating with 2-star inspections with 16 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
River View On The Appomattox Health & Rehab Center
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1-star overall rating with 1-star inspections with abuse icon flag with 28 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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