Cycle 1
Health 2025-05-08 · Fire 2025-05-08
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Waverly, IA
Woodland Terrace
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1922 Fifth Avenue NW, Waverly, IA
(319) 352-4540
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
87
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-04-01
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
0.94
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.73
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.14
CMS adjusted RN staffing hours
Adjusted total hours
5.01
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
35%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,319
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9900
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
4.96
Baseline 5.31% · Performance 6.35% · Measure score 4.96 · Achievement 4.96 · Improvement 0
Total nurse turnover
2.35
Performance 54.08% · Measure score 2.35 · Achievement 2.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.67
Baseline 4.07 hours · Performance 4.12 hours · Measure score 3.67 · Achievement 3.67 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.87% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 5.06% · Lower 95% interval 7.01% |
| Discharge to community | 62.96% |
50.57%
12.4 pts better
|
Better than the National Rate · Eligible stays 73 · Observed rate 69.86% · Lower 95% interval 54.42% |
| Medicare spending per beneficiary | 0.54 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 39 · Denominator 39 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 39 |
| Discharge self-care score | 38.71% |
53.69%
15 pts worse
|
Numerator 12 · Denominator 31 |
| Discharge mobility score | 29.03% |
50.94%
21.9 pts worse
|
Numerator 9 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 39 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 0% · Lower 95% interval 3.09% |
| Staff COVID-19 vaccination coverage | 5% |
8.2%
3.2 pts worse
|
Numerator 10 · Denominator 200 |
| Staff flu vaccination coverage | 42.39% |
42%
0.4 pts better
|
Numerator 117 · Denominator 276 |
| Discharge function score | 41.94% |
56.45%
14.5 pts worse
|
Numerator 13 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 19 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 58.33% |
25.2%
33.1 pts better
|
Numerator 14 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
95.2%
2.5 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.7%
About the same
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.8% · Q3 2.5% · Q4 3.6% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
4.0%
1.7 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.0% · Q3 2.7% · Q4 1.3% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
4.9%
1.6 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.0% · Q3 1.8% · Q4 1.6% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.2% |
20.6%
5.6 pts worse
|
19.6%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 23.3% · Q3 26.8% · Q4 27.4% · 4Q avg 26.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 37.2% |
19.8%
17.4 pts worse
|
16.7%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 40.0% · Q3 34.0% · Q4 36.8% · 4Q avg 37.2% · 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 | 16.8% |
18.5%
1.7 pts better
|
16.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 20.6% · Q3 19.0% · Q4 10.5% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
18.3%
0.6 pts better
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 24.6% · Q3 18.2% · Q4 15.0% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.7%
0.1 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.6% · Q3 1.1% · Q4 1.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.5%
0.6 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 1.3% · Q3 1.2% · Q4 1.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.6% |
26.0%
6.6 pts worse
|
19.8%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 35.0% · Q3 32.6% · Q4 31.9% · 4Q avg 32.6% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.3%
1.7 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.4% · Q3 5.7% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
84.3%
13 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 98.0% · Q3 97.6% · Q4 97.6% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
13.1%
13.1 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.9%
1 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.1% |
73.3%
24.8 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.0% |
21.3%
4.3 pts better
|
23.9%
6.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 14.6% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-07-13 · Fire 2023-07-13
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-06
F · Potential for more than minimal harm
2024-05-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-04
E · Potential for more than minimal harm
2024-05-30
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 2024-06-06
E · Potential for more than minimal harm
2024-05-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-06
F · Potential for more than minimal harm
2023-07-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-20
F · Potential for more than minimal harm
2023-07-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-25
E · Potential for more than minimal harm
2023-07-13
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-23
E · Potential for more than minimal harm
2023-07-13
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 2023-07-19
E · Potential for more than minimal harm
2023-07-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-25
E · Potential for more than minimal harm
2023-07-13
K321 · Smoke Deficiencies
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 2023-07-19
E · Potential for more than minimal harm
2023-07-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-07-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-07-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-18
D · Potential for more than minimal harm
2023-07-13
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-07-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-27
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 2025-09-18
E · Potential for more than minimal harm
2025-05-08
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 2025-05-21
D · Potential for more than minimal harm
2025-05-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-05-08
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 2025-05-21
D · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-21
B · Minimal harm
2025-05-08
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-05-21
B · Minimal harm
2025-05-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-21
D · Potential for more than minimal harm
2024-05-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-18
C · Minimal harm
2024-05-30
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-06-18
G · Actual harm
2024-04-04
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 2024-04-17
D · Potential for more than minimal harm
2023-07-13
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 2023-08-04
D · Potential for more than minimal harm
2023-07-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-08-04
Penalties and ownership
What sits behind the stars
Ownership
Fagre, Lee
Operational/Managerial Control · Individual
Geise, Paula
Operational/Managerial Control · Individual
Shea, Veronica
Operational/Managerial Control · Individual
Zumbach, Peggy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Shell Rock Senior Living
Shell Rock, IA
1-star overall rating with 1-star inspections with $17,167 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Denver Sunset Home
Denver, IA
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Clarksville Skilled Nursing & Rehab Center
Clarksville, IA
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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