Inspection Reports for The Mulberry at Waverly
11041 North 137th St, NE, 68462
Back to Facility ProfileDeficiencies (last 11 years)
Deficiencies (over 11 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Nebraska average
Nebraska average: 4.2 deficiencies/year
Deficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
83% occupied
Based on a July 2018 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Jun 17, 2024
Visit Reason
This Notice of Disciplinary Action was issued due to violations related to the facility's failure to follow protocol concerning incomplete assessments when determining the death of two residents, as documented in the CMS-2567 Report dated June 17, 2024.
Findings
The facility is prohibited from admitting residents until compliance is demonstrated. The license is placed on probation for 180 days starting July 9, 2024, with requirements to submit a Plan of Correction and periodic reports on residents with changes in condition.
Report Facts
Probation period days: 180
Report due date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | Administrator | Mentioned as part of Health Facilities Licensure Unit |
| Linda Stenvers | Administrative Specialist | Certified mailing of the Notice of Disciplinary Action |
Inspection Report
Renewal
Capacity: 54
Deficiencies: 0
Feb 20, 2024
Visit Reason
This document is a Nursing Home Licensure Renewal Application for The Mulberry at Waverly, submitted to renew the facility's license to operate as a Skilled Nursing Facility.
Findings
The document certifies that The Mulberry at Waverly meets statutory requirements for licensure renewal as a Skilled Nursing Facility with dual certification. It includes ownership details and confirms compliance with renewal requirements.
Report Facts
Total licensed beds: 54
Renewal application date: Feb 20, 2024
License expiration date: Mar 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathy Klingsporn | Administrator | Named in the Nursing Home Licensure Renewal Application |
| Chris Collins | Director of Nursing | Named in the Nursing Home Licensure Renewal Application |
| Ari Silberstein | Authorized Representative | Signed the Nursing Home Licensure Renewal Application on 2/20/24 |
Notice
Capacity: 54
Deficiencies: 0
Aug 2, 2023
Visit Reason
The document serves as a license issuance notice for The Mulberry At Waverly Skilled Nursing Facility due to a change of ownership, confirming the effective date of the new license and providing renewal information.
Findings
The notice confirms that the facility meets statutory requirements for licensure and provides the license expiration date. It includes ownership information and instructions for displaying the license.
Report Facts
Total licensed beds: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Pihlgren | Administrator | Named as facility administrator on the Nursing Home Licensure Application and in the license issuance letter. |
| Christina Collins | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Application. |
| Dan Taylor | RN, Administrator | Contact person for license questions mentioned in the license issuance letter. |
| Timothy Tesmer | Chief Medical Officer | Signed the license issuance letter. |
Inspection Report
Renewal
Capacity: 54
Deficiencies: 0
Jan 25, 2023
Visit Reason
The document is a Nursing Home Licensure Renewal Application for Azria Health Waverly, submitted to renew the facility's license.
Findings
The document verifies that Azria Health Waverly meets statutory requirements for licensure renewal and includes ownership verification and occupancy permit details.
Report Facts
Total licensed beds: 54
Renewal Licensure Fee: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Philgren | Administrator | Named in the renewal application as facility administrator |
| Christina Collins | Director of Nursing | Named in the renewal application as director of nursing |
| Aaron Kaminer | Named in ownership verification letter and as authorized representative on renewal application | |
| Steve Hornung | Named in ownership verification letter and as authorized representative on renewal application |
Inspection Report
Annual Inspection
Census: 45
Capacity: 54
Deficiencies: 10
Jul 11, 2018
Visit Reason
An unannounced annual survey was conducted at Waverly Care Center from July 11 to July 18, 2018, by the Department of Health and Human Services Division of Public Health to assess compliance with regulatory requirements.
Findings
The facility was found to be in substantial compliance with most care and safety regulations, with no violations related to resident hygiene, mobility, abuse protection, care planning, dental care, narcotic diversion, or transfer equipment. However, deficiencies were cited related to baseline care plan development, supervision of vulnerable residents, dietary staffing, infection control hand hygiene, fire safety, sprinkler system policies, fire evacuation plans, fire door inspections, and generator fuel testing.
Severity Breakdown
SS=D: 3
SS=F: 7
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to develop an admission/baseline care plan for one sampled resident within 48 hours of admission. | SS=D |
| Failed to provide adequate supervision for a vulnerable resident during transport, resulting in a safety incident. | SS=D |
| Failed to employ a full-time qualified Dietary Manager/Food Service Director. | SS=F |
| Failed to ensure proper hand hygiene during medication administration and blood glucose monitoring, risking cross contamination. | SS=D |
| Failed to maintain wheeled appliances under kitchen exhaust hood in approved location after cleaning, risking fire suppression coverage. | SS=F |
| Failed to have a complete fire watch policy for sprinkler system impairments lasting more than 10 hours. | SS=F |
| Failed to ensure kitchen staff were trained on the use of the kitchen exhaust hood fire suppression system and fire procedures. | SS=F |
| Failed to provide a complete fire evacuation plan that prevents evacuation routes from passing through the fire origin or smoke compartment. | SS=F |
| Failed to implement an inspection and testing program for all fire rated doors to ensure proper operation. | SS=F |
| Failed to conduct annual fuel quality testing for the emergency generator. | SS=F |
Report Facts
Deficiencies cited: 10
Facility census: 45
Total licensed capacity: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Lange | Administrator | Named as facility administrator in the report. |
| RN D | Registered Nurse | Observed administering medications and blood glucose monitoring with deficient hand hygiene. |
| RN C | Registered Nurse | Unable to locate baseline care plan for Resident #48. |
| LPN B | Licensed Practical Nurse | Unable to locate baseline care plan for Resident #48. |
| Cook J | Dietary Staff | Temporarily in charge of dietary department without knowledge of role; lacked full-time dietary manager qualifications. |
| Maintenance Staff A | Confirmed deficiencies related to kitchen hood appliance placement, sprinkler system fire watch policy, fire evacuation plan, and fire door inspections. | |
| Administrator ADM1 | Administrator | Confirmed lack of full-time dietary manager and other staffing issues. |
| Administrator ADM2 | Administrator | Confirmed lack of full-time dietary manager and staffing arrangements. |
Inspection Report
Renewal
Capacity: 54
Deficiencies: 0
Mar 8, 2018
Visit Reason
This document is a Nursing Home Licensure Renewal Application and related renewal certification for Waverly Care Center, verifying the facility's license renewal and compliance with state requirements.
Findings
The documents confirm that Waverly Care Center meets statutory requirements for licensure renewal as a Skilled Nursing Facility with a licensed capacity of 54 beds. No deficiencies or violations are noted in the renewal application or certification.
Report Facts
Number of beds to be relicensed: 54
Renewal fee: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named in Nursing Home Licensure Renewal Application |
| Deanna Qualset | Director of Nursing, R.N. | Named in Nursing Home Licensure Renewal Application |
| Bruce J. Mackey Jr. | President & CEO | Named as officer of ownership entity |
| Richard A. Doyle | Treasurer & Chief Financial Officer | Named as officer of ownership entity |
| R. Scott Herzig | Senior Vice President & Chief Operating Officer | Named as officer of ownership entity |
| Katherine E. Potter | Vice President, General Counsel & Assistant Secretary | Named as officer of ownership entity |
| Jennifer B. Clark | Corporate Secretary | Named as officer of ownership entity |
| Gerard M. Martin | Director | Named as director/trustee of ownership entity |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 7, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Waverly Care Center on March 7, 2018, regarding allegations of failure to provide care to prevent pressure sores, therapeutic diets, three meals a day, and sufficient staffing.
Findings
The investigation found the facility was in compliance with all relevant regulatory requirements for prevention of pressure sores, provision of therapeutic diets, ensuring three meals a day, and sufficient staffing to meet resident needs. No violations were identified.
Complaint Details
The complaint included four allegations: failure to prevent pressure sores, failure to provide therapeutic diets, failure to ensure three meals a day, and failure to ensure sufficient staffing. All allegations were found to be unsubstantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report as Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 54
Deficiencies: 6
Aug 6, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Waverly Care Center from August 6, 2017 to August 10, 2017. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.
Findings
The facility was found to have no violations related to abuse, resident privacy, care according to practitioner's orders, staffing sufficiency, or pain management. However, deficiencies were cited related to sanitary food procurement and preparation, life safety code violations including hazardous area door gaps, sprinkler system maintenance and testing, fire drills not conducted under varied conditions, and incomplete emergency generator inspections and documentation.
Complaint Details
The complaint allegations included failure to protect residents from abuse, maintain privacy, provide care according to practitioner's orders, ensure sufficient staffing, and assist with pain management. The investigation found no violations related to these allegations.
Severity Breakdown
SS=F: 4
SS=D: 1
: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Dust accumulation on tops of refrigerator and freezer doors and failure to follow handwashing standards in the kitchen. | — |
| Oxygen storage room door was not smoke-tight, allowing potential smoke and fire migration. | SS=F |
| No sprinkler wrench in the spare sprinkler box, delaying potential sprinkler head repairs. | SS=D |
| Incomplete policy regarding sprinkler system out of service procedures, lacking notification requirements. | SS=F |
| Fire drills were not held under varied conditions during 1 of 3 shifts for 4 of 4 quarters reviewed. | SS=F |
| Failed to conduct all required weekly inspections and monthly testing documentation of the emergency generator. | SS=F |
Report Facts
Deficiencies cited: 6
Facility census: 46
Total licensed capacity: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named as facility administrator in the report. |
| Eve Lewis | Program Manager | Signed letter related to complaint investigation findings. |
| Maintenance Staff A | Interviewed regarding life safety door gap, sprinkler wrench absence, fire drill scheduling, and generator maintenance. | |
| Cook A | Observed failing to wash hands properly during food preparation. | |
| Director of Nursing | DON | Interviewed regarding handwashing standards. |
Inspection Report
Annual Inspection
Census: 44
Capacity: 54
Deficiencies: 11
May 19, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Waverly Care Center from May 18, 2016 to May 25, 2016 by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found deficient in multiple areas including failure to provide individualized activity programs for residents, failure to identify causes of repetitive skin tears, improper sanitization of glucometers, blocked corridor doors, malfunctioning delayed egress hardware, inadequate fire drills, obstructed exit paths, lack of emergency generator remote shutdown, missing oxygen use signage, incomplete generator testing documentation, and improper electrical receptacles for medical equipment.
Complaint Details
The visit was complaint-related, investigating allegations that the facility failed to maintain comfortable water temperatures and failed to resolve grievances/complaints. Both allegations were found unsubstantiated.
Severity Breakdown
SS=E: 4
SS=F: 5
SS=D: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to provide a therapeutic activity program based on individualized interests for two residents. | SS=D |
| Failed to identify underlying rationale of repetitive skin tears to revise preventative interventions for one resident. | SS=D |
| Failed to ensure glucometer was sanitized properly to prevent cross contamination of blood borne pathogens for three residents. | SS=E |
| Corridor doors were blocked open, rendering them incapable of resisting passage of smoke. | SS=F |
| Delayed egress hardware on exit doors failed to release with application of pressure. | SS=F |
| Fire drills were not held at random times under varied conditions for four of four quarters reviewed. | SS=F |
| Exit path in the Havelock Corridor was obstructed by unattended housekeeping cart and mop bucket. | SS=E |
| Failed to provide an emergency generator shut down switch located outside the generator area. | SS=F |
| Failed to post 'oxygen in use' sign on Resident Room 115. | SS=E |
| Failed to conduct and document weekly and monthly inspection and testing of the emergency generator. | SS=F |
| Failed to ensure line operated medical equipment was plugged into a hospital grade electrical receptacle. | SS=E |
Report Facts
Deficiencies cited: 11
Residents affected: 44
Licensed capacity: 54
Residents affected by oxygen signage deficiency: 23
Residents affected by exit path obstruction: 21
Residents affected by electrical receptacle deficiency: 23
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 14, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding insufficient staffing and failure to prevent skin breakdown at Waverly Care Center.
Findings
The investigation found that staffing levels were sufficient and residents' needs were met. However, the facility failed to maintain cushions in working order to prevent skin breakdown, but corrective actions were in place and no citation was issued.
Complaint Details
The complaint alleged insufficient staffing to provide resident cares and failure to prevent skin breakdown. Staffing was found sufficient and no violation was cited. The skin breakdown issue was acknowledged but corrected, resulting in no citation.
Deficiencies (1)
| Description |
|---|
| Failure to provide care and treatment to prevent skin breakdown related to maintaining cushions in working order. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit, Division of Public Health-DHHS | Signed the report and provided contact information. |
Inspection Report
Routine
Census: 52
Deficiencies: 10
Apr 22, 2015
Visit Reason
Routine inspection of Waverly Care Center to assess compliance with regulations governing licensure of skilled nursing facilities, intermediate care facilities, and life safety code standards.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy by displaying medical information publicly, maintenance issues such as scraped walls and missing towel bars, unsafe bed frame padding causing injury risk, inadequate fire safety measures including faded exit signage, insufficient egress lighting, lack of emergency lighting testing, improperly conducted fire drills, unsupervised sprinkler control valves, uninspected sprinkler valve installation, and missing oxygen use signage.
Severity Breakdown
SS=D: 2
SS=E: 2
SS=F: 6
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to protect Resident 28's privacy by displaying medical diagnosis in a public area. | SS=D |
| Walls in resident rooms and bathrooms had scrapes, holes, gouges, and missing towel bars in multiple rooms. | SS=E |
| Resident 16's bed frame had exposed sharp edges due to split foam padding, causing injury risk. | SS=D |
| Facility failed to provide visible delayed egress signage on exit door in Havelock Hall. | SS=E |
| Exit discharge lighting inadequate; failure of a single light fixture left sidewalk in courtyard in darkness. | SS=F |
| Facility failed to test and document monthly and annual emergency lighting inspections. | SS=F |
| Fire drills were not conducted at random times during all shifts as required. | SS=F |
| Sprinkler control valve (PIV) was not electronically supervised to fire alarm panel. | SS=F |
| Newly installed sprinkler valve (PIV) was incorrectly placed and not inspected or tested. | SS=F |
| Missing 'oxygen in use' signage on doors of rooms with oxygen concentrators. | SS=F |
Report Facts
Facility census: 52
Residents affected by delayed egress signage deficiency: 23
Facility census: 51
Inspection Report
Renewal
Capacity: 54
Deficiencies: 0
Apr 14, 2015
Visit Reason
This document is a Nursing Home Licensure Renewal Application and related occupancy permit for Waverly Care Center, indicating the facility's license renewal and compliance with state regulations.
Findings
The documents confirm the facility's licensure renewal status, ownership structure, and occupancy permit with a maximum capacity of 54 beds. No deficiencies or violations are noted in the provided materials.
Report Facts
Total licensed beds: 54
Occupancy permit date: Apr 14, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named in Nursing Home Licensure Renewal Application |
| Deanna Qualset | Director of Nursing, R.N. | Named in Nursing Home Licensure Renewal Application |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Aug 20, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint at Waverly Care Center regarding failure to complete treatments according to practitioner's orders, failure to provide care for bladder elimination, failure to protect residents from abuse, and failure to protect residents from injury.
Findings
The facility was found to have no violations related to the allegations. Treatments were completed as ordered, care for bladder elimination was adequate, residents were protected from abuse with proper education and protocols in place, and residents were protected from injury with appropriate interventions and reviews of incident logs.
Complaint Details
The complaint allegations included failure to complete treatments according to practitioner's orders, failure to provide care and treatment for bladder elimination, failure to protect residents from abuse, and failure to protect residents from injury. All allegations were found to have no violations after investigation.
Report Facts
Resident census: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Philippi | Registered Nurse | Representative of the Department of Health and Human Services conducting the investigation |
| Victoria Smith | Registered Nurse | Representative of the Department of Health and Human Services conducting the investigation |
| Eve Lewis | Program Manager | Office of Long Term Care Facilities, Licensure Unit, Division of Public Health, signed the correspondence |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Apr 22, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint survey regarding allegations that the facility fails to protect residents from abuse.
Findings
The facility was found to protect residents from abuse with no violations related to the issue. Observations, interviews, and reviews of records showed interventions were in place to protect residents.
Complaint Details
The complaint alleged failure to protect residents from abuse. The investigation found no violation and the allegation was not substantiated.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Young | Registered Nurse | Conducted the complaint investigation survey. |
| Eve Lewis | Program Manager | Signed the inspection report letter. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 50
Deficiencies: 19
Mar 31, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Waverly Care Center on March 31, 2014-April 3, 2014, focusing on allegations of unsafe environment for residents at risk for elopement and protection from misappropriation.
Findings
The facility was found to provide a safe environment for residents at risk for elopement and protect residents from misappropriation. However, the facility failed to thoroughly investigate and report an incident of alleged neglect for one resident. Additional deficiencies were found related to social services, housekeeping, life safety code violations, and documentation inaccuracies.
Complaint Details
The complaint alleged the facility failed to provide a safe environment for residents at risk for elopement and failed to protect residents from misappropriation. The investigation found the facility did provide a safe environment and protect residents from misappropriation but failed to thoroughly investigate and report an incident of alleged neglect for one resident.
Severity Breakdown
SS=D: 2
SS=E: 3
SS=F: 13
Deficiencies (19)
| Description | Severity |
|---|---|
| Failed to have evidence that an incident of alleged neglect for one resident was thoroughly investigated and reported. | SS=D |
| Failed to provide bereavement support for one resident. | SS=D |
| Failed to maintain walls, ceilings, doors, sinks and stools in residents' rooms and/or bathrooms. | SS=E |
| Failed to ensure accurate coding of pneumococcal vaccination in Minimum Data Set for 7 residents. | SS=E |
| Failed to develop a care plan regarding elopement risk for one resident and failed to establish measurable goals for two residents. | SS=E |
| Failed to provide a one-hour rated ceiling in corridors or beauty shop; failed to provide documentation of fire resistance for unsprinklered wooden patio cover. | SS=F |
| Allowed linen doors to be held open by unapproved devices and failed to maintain doors to latch within the door frame because of air flow in laundry room. | SS=F |
| Delayed egress signage on dining room exit door was obstructed and gate in enclosed patio was blocked. | SS=F |
| Failed to provide illumination of exit discharge sidewalk to public way, leaving portion of path without illumination. | SS=F |
| Failed to provide emergency lighting of at least 1½ hour duration in Main Dining Room, leaving some areas in darkness. | SS=F |
| Failed to provide exit signs above door leading to service corridor and at cased opening in Dining Room; failed to indicate continuous path of egress from Nurse's Station. | SS=F |
| Failed to maintain single station smoke detectors in resident rooms; detectors were outdated and no weekly testing documentation. | SS=F |
| Failed to confirm or verify location approval of sprinkler curb shut off box or Post Indicator Valve (PIV) by local fire department. | SS=F |
| Failed to assure sprinkler heads were provided with escutcheons, penetrations around pipes were sealed, and sprinkler heads were not obstructed. | SS=F |
| Failed to ensure staff were trained on use of kitchen hood suppression system and procedure for fire under kitchen hood. | SS=F |
| Failed to provide documentation for flame retardant rating for fabric curtain on exit door in Main Dining Room. | SS=F |
| Failed to conduct annual load bank test for generator. | SS=F |
| Electrical adaptors, power strip cords and extension cords were used inappropriately and electrical panel box was blocked. | SS=F |
| Alcohol Based Hand Rub dispensers installed adjacent to ignition source. | SS=F |
Report Facts
Facility census: 49
Total capacity: 50
Deficiency count: 18
Occupant load: 70
Inspection dates: 2014-03-31 to 2014-04-03
Inspection date: Apr 22, 2014
Revisit date: Jun 4, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named in complaint investigation letter |
| Kathleen Philippi | Registered Nurse | Surveyor for complaint investigation |
| Victoria Smith | Registered Nurse | Surveyor for complaint investigation |
| Rebecca Young | Registered Nurse | Surveyor for complaint investigation |
| Eve Lewis | Program Manager | Signed complaint investigation letter |
| Don Fritz | Assistant State Fire Marshal | Approved waiver requests and correspondence |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Dec 19, 2013
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to change fall interventions after residents were identified at risk for falls and failure to send investigations of potential neglect to the State Agency within 5 working days.
Findings
The investigation found that the facility does change fall interventions after residents are identified at risk for falls and does send investigations of potential neglect to the State Agency within 5 working days. No concerns were identified.
Complaint Details
The complaint alleged failure to change fall interventions after residents were identified at risk for falls and failure to send investigations of potential neglect to the State Agency within 5 working days. Both allegations were unsubstantiated.
Report Facts
Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Travis Castner | Registered Nurse | Representative of the Department of Health and Human Services who conducted the investigation |
| Victoria Smith | Registered Nurse | Representative of the Department of Health and Human Services who conducted the investigation |
| Eve Lewis | Program Manager | Signed the report as Program Manager, Office of Long Term Care Facilities |
Inspection Report
Routine
Census: 49
Deficiencies: 2
Oct 28, 2013
Visit Reason
The inspection was conducted to assess compliance with regulations governing licensure of skilled nursing facilities, focusing on medication administration and pharmaceutical services.
Findings
The facility failed to ensure that one resident received medication as prescribed, resulting in hospitalization. The pharmacy did not supply needed medication timely, and communication processes between medication aides, nurses, and the pharmacy were inadequate.
Severity Breakdown
SS=G: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure residents are free of significant medication errors; one resident did not receive prescribed medication for 6 days leading to hospitalization. | SS=G |
| Facility failed to provide accurate pharmaceutical services, including acquiring and dispensing medications, resulting in medication not being available for a resident. | SS=G |
Report Facts
Facility census: 49
Medication doses missed: 10
Medication doses possible: 14
Hours spent on pharmacy concerns: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide | Interviewed regarding medication refill and administration issues | |
| Director of Nursing (DON) | Interviewed regarding communication and pharmacy issues | |
| Facility Administrator | Interviewed regarding pharmacy contract and medication supply issues |
Inspection Report
Routine
Census: 48
Deficiencies: 11
Jan 30, 2013
Visit Reason
Routine inspection of Waverly Care Center to assess compliance with Nebraska Administrative Code and Life Safety Code standards.
Findings
The facility was found deficient in housekeeping and maintenance services, medication administration errors related to insulin timing, life safety code compliance including fire safety construction, door latching, exit accessibility, emergency lighting, fire alarm system maintenance, sprinkler system maintenance, trash receptacle storage, oxygen safety, and electrical wiring.
Severity Breakdown
SS=E: 4
SS=F: 6
SS=D: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Housekeeping and maintenance services failed to maintain sanitary, orderly, and comfortable interior including door gouges, missing door frames, peeling flooring, and wall damage. | SS=E |
| Residents not free of significant medication errors; insulin administered too long before meals for two residents. | SS=D |
| Life safety code violation: facility failed to provide one-hour separation from combustible attic space affecting staff and residents. | SS=F |
| Doors protecting corridor openings failed to have automatic flush bolts on inactive leaf, allowing doors to be pulled open. | SS=F |
| Exit access impeded by locked courtyard gate with key not readily accessible to all staff; lack of approval for delayed egress lock timing change. | SS=F |
| Emergency lighting failed to illuminate in medication room and boiler room; no documentation of monthly or annual testing. | SS=E |
| Fire alarm system lacked documentation of smoke detector sensitivity testing and calibration as required. | SS=F |
| Sprinkler system deficiencies including sprinkler heads with paint, blocked sprinkler head, and missing hydraulic placards. | SS=F |
| Soiled linen or trash receptacles exceeded allowed capacity and were not located in protected rooms with self-closing doors. | SS=F |
| Oxygen safety hazard: unattended oxygen concentrator running with cannula on combustible bedding; no written procedure for oxygen shutoff. | SS=E |
| Electrical wiring violation: use of power strip in activity room as substitute for fixed wiring. | SS=E |
Report Facts
Facility census: 48
Resident sample size: 29
Residents affected by oxygen safety: 24
Facility capacity: 52
Residents present: 49
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Signed inspection report on 3/8/13 |
| RN C | Registered Nurse | Observed insulin administration to Resident 66 |
| LPN D | Licensed Practical Nurse | Observed insulin administration to Resident 39 |
| Maintenance Staff A | Confirmed multiple facility maintenance and fire safety deficiencies | |
| Charge Nurse | Interviewed regarding oxygen safety procedures | |
| DON | Director of Nursing | Acknowledged insulin administration timing issues and involved in corrective actions |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 2
Jul 9, 2012
Visit Reason
The inspection was conducted based on a complaint investigation regarding potential sexual abuse involving Resident 1 and a staff member.
Findings
The facility failed to protect Resident 1 from potential sexual abuse by a staff member and failed to report the allegation of abuse to the appropriate authorities. Multiple staff interviews revealed rumors and concerns about an inappropriate relationship between Resident 1 and a nurse aide. The facility conducted an internal investigation but did not report the incident as it occurred at another facility.
Complaint Details
The complaint investigation was triggered by concerns raised by staff about a nurse aide showing a picture of Resident 1 with a pop bottle placed under the sheet to appear as an erection, and rumors of an inappropriate relationship between Resident 1 and the nurse aide. The facility did not report the allegation because the incident allegedly occurred at another facility.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to protect Resident 1 from potential sexual abuse. | SS=D |
| Facility failed to report an allegation of alleged sexual abuse related to Resident 1. | SS=D |
Report Facts
Facility census: 52
Sample size: 6
Inspection Report
Life Safety
Deficiencies: 0
Jan 10, 2012
Visit Reason
A Life Safety Code (LSC) survey was conducted on January 10, 2012, to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The initial survey found the facility was not in substantial compliance with participation requirements. A revisit on February 21, 2012, confirmed the facility was still not in substantial compliance. A subsequent revisit on March 5, 2012, established that corrections had been made and the facility was then in substantial compliance.
Report Facts
Denial of payment effective date: Mar 17, 2012
Revisit dates: Feb 21, 2012
Revisit dates: Mar 5, 2012
Compliance deadline: Jul 10, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer King | Branch Manager | Signed enforcement letters and provided contact information. |
| Jane Weiler | Health Quality Review Specialist | Contact person for additional comments or concerns. |
Inspection Report
Routine
Census: 47
Deficiencies: 8
Dec 8, 2011
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including comprehensive care plans, infection control, and life safety code standards.
Findings
The facility failed to develop comprehensive care plans for residents at risk for bleeding and infection, failed to ensure proper personal hygiene cleansing for catheterized residents, and had multiple life safety code deficiencies including fire safety construction issues, door latching problems, sprinkler system maintenance issues, and electrical code violations.
Severity Breakdown
SS=D: 2
SS=E: 3
SS=F: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to develop comprehensive care plans and monitoring tools for dialysis resident at risk for bleeding due to medication use and fistula site monitoring. | SS=D |
| Failed to ensure complete personal hygiene cleansing for two catheterized residents, increasing risk of urinary tract infections. | SS=D |
| Failed to provide one hour fire separation from combustible attic space in a one-story building. | SS=F |
| Failed to provide corridor doors that stay latched tightly to resist smoke passage. | SS=F |
| Failed to provide self-closing doors for hazardous areas such as the Director of Nursing office. | SS=E |
| Failed to maintain sprinkler heads free of corrosion, paint, or foreign material, potentially impairing sprinkler function. | SS=F |
| Failed to have electrical wiring and equipment in accordance with NFPA 70, including lack of ground fault interrupter protection in bathrooms and use of multi-plug adapters. | SS=E |
| Failed to provide separation of hazardous areas from other compartments; door to boiler and housekeeping storage held open with a wood chock. | SS=E |
Report Facts
Residents receiving hemodialysis: 3
Survey sample size: 26
Facility census: 47
INR lab values: INR values for Resident 56 ranged from 1.4 to 9.8 with critical values noted.
Inspection Report
Routine
Census: 49
Deficiencies: 3
Aug 25, 2011
Visit Reason
The inspection was conducted as a routine survey to assess compliance with state licensure regulations governing skilled nursing and intermediate care facilities.
Findings
The facility failed to ensure the Dietary Manager was qualified according to state licensure requirements and failed to provide food in a form designed to meet individual resident needs, specifically regarding education of staff on resident diets and the texture of pureed food.
Severity Breakdown
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to assure the Dietary Manager was qualified to serve as director of food services as the employee had not completed educational requirements in accordance with state licensure regulations. | — |
| Facility failed to ensure dietary, nursing, and activity staff were educated on resident diets including consistency of food and drinks ordered by the physician. | SS=E |
| Facility failed to ensure that pureed food had the appropriate texture; pureed meat contained grisly particles prohibiting safe swallowing. | SS=E |
Report Facts
Facility census: 49
Sample size: 6
Duration Dietary Manager in position: 2
Number of residents on pureed diets: 8
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Feb 16, 2011
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate ADL (Activity of Daily Living) care, specifically shaving services, for residents dependent on staff for care.
Findings
The facility failed to provide ADL care, including shaving, for 4 out of 7 sampled residents dependent on staff. Observations and interviews revealed residents had facial hair growth due to lack of shaving, and staff acknowledged the need for electric razors and improved care practices.
Complaint Details
The complaint investigation found that residents dependent on staff for shaving were not receiving this care as planned. Interviews with nursing staff and observations confirmed residents had not been shaved on multiple days. The facility acknowledged the issue and purchased electric razors to address the problem.
Deficiencies (1)
| Description |
|---|
| Failure to provide ADL (Activity of Daily Living) services, including shaving, for residents dependent on staff for care. |
Report Facts
Facility census: 51
Residents not receiving ADL care: 4
Male residents shaved: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Re-educated nursing staff on shaving dependent residents and conducted competency testing |
| Licensed Practical Nurse A | LPN | Interviewed regarding Resident 7's shaving needs and care plan |
| Licensed Practical Nurse B | LPN | Interviewed about heavy care residents and shaving practices |
| Nursing Assistant A | NA | Interviewed about shaving practices and need for electric razors |
| Medication Aide B | MA | Interviewed with LPN A about Director of Nursing and administrator knowledge of electric razors |
| Registered Nurse B | RN | Interviewed about facility sending someone to buy electric razors |
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 7
Oct 28, 2010
Visit Reason
The inspection was conducted to review compliance with regulations governing skilled nursing facilities, including a review of survey results and deficiencies identified in the facility. The report includes a plan of correction submitted by the facility to address the cited deficiencies.
Findings
The facility was found deficient in multiple areas including failure to maintain survey results readily accessible to residents, inadequate care and services to promote bowel movements and prevent pressure sores, failure to prevent urinary tract infections, unsafe environment due to mechanical lift issues, improper storage of nutritional supplements, and inadequate infection control practices. The facility submitted a plan of correction addressing these issues with specific corrective actions and dates.
Severity Breakdown
SS=C: 1
SS=D: 5
SS=E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to make survey results readily accessible to residents. | SS=C |
| Failure to provide necessary care and services to promote bowel movements and function. | SS=D |
| Failure to provide proper perineal care technique to promote healing of pressure sores. | SS=D |
| Failure to ensure residents without indwelling catheters are not catheterized and to prevent urinary tract infections. | SS=D |
| Failure to maintain a safe environment regarding mechanical lifts and electrical wiring. | SS=D |
| Failure to store, prepare, distribute, and serve food under sanitary conditions. | SS=E |
| Failure to establish and maintain an infection control program to prevent spread of infection. | SS=D |
Report Facts
Facility census: 52
Survey sample size: 14
Deficiency count: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Sands-Jerke | Administrator | Signed the plan of correction and referenced in the report |
Document
Capacity: 54
Deficiencies: 0
APP2017
Visit Reason
The documents pertain to the renewal of the nursing home license for Waverly Care Center and include related ownership, accreditation, and occupancy permit information.
Findings
No inspection findings or deficiencies are reported in these documents. They primarily verify licensure renewal, ownership structure, and occupancy capacity.
Report Facts
Licensed beds: 54
Renewal fees: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| David Bergmann | Administrator | Named in the nursing home licensure renewal application. |
| Deanna Qualset | Director of Nursing | Named in the nursing home licensure renewal application. |
| Bruce J. Mackey Jr. | President & Chief Executive Officer | Named as an officer of the ownership entity Five Star Quality Care-NE, LLC. |
| R. Scott Herzig | Senior Vice President & Chief Operating Officer | Named as an officer of the ownership entity Five Star Quality Care-NE, LLC. |
| Richard A. Doyle | Treasurer & Chief Financial Officer | Named as an officer of the ownership entity Five Star Quality Care-NE, LLC. |
| Katherine E. Potter | Vice President, General Counsel & Assistant Secretary | Named as an officer of the ownership entity Five Star Quality Care-NE, LLC. |
| Jennifer B. Clark | Corporate Secretary | Named as an officer of the ownership entity Five Star Quality Care-NE, LLC. |
| Barry M. Portnoy | Director | Named as a director/trustee of the ownership entity Five Star Quality Care-NE, LLC. |
| Gerard M. Martin | Director | Named as a director/trustee of the ownership entity Five Star Quality Care-NE, LLC. |
Notice
Capacity: 54
Deficiencies: 0
APP2019
Visit Reason
This document serves as a licensure renewal application and verification for Waverly Care Center's Skilled Nursing Facility license, including certification of services and ownership information.
Findings
The documents confirm the facility's licensure renewal status, ownership structure, and occupancy permit with a maximum capacity of 54 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Lange | Administrator | Named on the Nursing Home Licensure Renewal Application. |
| Deanna Qualset | Director of Nursing | Named on the Nursing Home Licensure Renewal Application. |
| Richard A. Doyle | Treasurer & CFO | Authorized representative signing the renewal application. |
| Katherine E. Potter | President & CEO | Authorized representative signing the renewal application and listed as officer. |
Notice
Capacity: 54
Deficiencies: 0
APP2020
Visit Reason
This document serves as a renewal application for the nursing home license of Azria Health Waverly and includes verification of licensure and occupancy permit information.
Findings
The documents confirm that Azria Health Waverly meets statutory requirements for licensure as a skilled nursing facility and nursing facility dual certification, with a licensed capacity of 54 beds as per the Nebraska State Fire Marshal occupancy permit.
Report Facts
Total licensed beds: 54
Notice
Capacity: 54
Deficiencies: 0
APP2021
Visit Reason
This document serves as a renewal application for the nursing home license of Azria Health Waverly, verifying licensure and providing ownership and facility information.
Findings
The documents confirm the facility's licensure renewal status, ownership details, and occupancy permit with a maximum capacity of 54 beds. No inspection findings or deficiencies are reported.
Report Facts
Number of beds to be relicensed: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Lange | Administrator | Named in the renewal application as facility administrator. |
| Deanna Qualset | Director of Nursing | Named in the renewal application as director of nursing. |
| Noah Kaminer | Authorized Representative | Signed the renewal application as authorized representative and owner. |
| Steve Hornung | Authorized Representative | Signed the renewal application as authorized representative and owner. |
Document
Capacity: 54
Deficiencies: 0
APP2022
Visit Reason
This document set includes a nursing home licensure renewal application for Azria Health Waverly, indicating the facility is applying to renew its license for 54 beds.
Findings
The documents certify that Azria Health Waverly meets statutory requirements for licensure renewal and includes an occupancy permit confirming a maximum occupancy of 54 beds.
Report Facts
Total licensed beds: 54
Document
Capacity: 54
Deficiencies: 0
APP2025
Visit Reason
The documents pertain to the renewal of the nursing home license for The Mulberry at Waverly, including submission of the renewal application and verification of licensure status.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure renewal application submission and occupancy permit status.
Report Facts
Total licensed beds: 54
Renewal license fee: 1550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Patricia Peck | Administrator | Named on the nursing home licensure renewal application. |
| Nicole Busboom | Director of Nursing | Named on the nursing home licensure renewal application. |
| Devora Kirschner | Authorized Representative | Signed the nursing home licensure renewal application. |
| Ari Silberstein | Authorized Representative | Signed the nursing home licensure renewal application. |
Document
Capacity: 54
Deficiencies: 0
CHOW2019
Visit Reason
The documents pertain to the issuance and renewal of a Skilled Nursing Facility license for Azria Health Waverly, including a change of ownership and facility name, as well as related corporate purchase and sale agreements.
Findings
No inspection findings are reported. The documents confirm licensure status, ownership changes, and related legal agreements for the facility.
Report Facts
Total licensed beds: 54
Allocated Purchase Price: 743442
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Lange | Administrator | Named as facility administrator on licensure application (page 4). |
| Deanna Qualset | Director of Nursing | Named as Director of Nursing on licensure application (page 4). |
| Gary J. Anthone, MD | Chief Medical Officer, Director, Division of Public Health | Signed licensing and renewal documents (pages 1-3). |
| Noah Kaminer | Manager | Named as manager and indirect owner in ownership and purchase agreement documents (pages 6, 15-17). |
| Steven Hornung | Manager | Named as manager and indirect owner in ownership and purchase agreement documents (pages 6, 15-16). |
| Katherine E. Potter | President | Signed as President for Five Star Quality Care entities in purchase agreement amendments (pages 12-14). |
| Jennifer F. Francis | President | Signed as President for SPTIHS Properties Trust in purchase agreement amendments (pages 12, 13, 15). |
Notice
Deficiencies: 0
DAN102813
Visit Reason
This Notice of Disciplinary Action was issued to Waverly Care Center due to violations related to medication errors and failure to provide pharmaceutical services, resulting in probation for 90 days starting November 28, 2013.
Findings
The facility failed to prevent significant medication errors and did not provide pharmaceutical services to ensure residents had medications as ordered. The Department required a Plan of Correction addressing medication errors and pharmacotherapy procedures.
Report Facts
Probation period length: 90
Probation start date: November 28, 2013
Report due date: First report due December 9, 2013 and weekly thereafter during probation
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Recipient of reports and contact for responses regarding the Notice |
| Joseph M. Acierno | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II | Certified mailing of the Notice |
| David Bergmann | Administrator | Facility administrator addressed in the follow-up letter |
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