Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waverly Hills Post Acute during CMS and state inspections, most recent first.
A resident with dementia, seizure disorder, repeated falls, and high fall risk was care-planned for a low bed with brakes locked, a fall mat, and call light within reach, and was totally dependent on staff for transfers and bed positioning. Despite this, staff accounts indicated the bed was often kept at about waist height, and several staff reported not seeing a fall mat at the bedside. The resident was later found supine on the floor with her head and torso under the bed, the bed frame resting on her chest and head, and the corded bed remote under her back, requiring staff to raise the bed to remove her. A detective observed that a fall alert device on the bed was not plugged in and that the call light was tucked behind the nightstand, out of the resident’s reach, though it worked when tested. EMS and police documented compression marks on the resident’s torso and face consistent with the bed frame and piston. The facility’s own safety policy required implementation of interventions to reduce accident risks, but records showed no care-plan revision with additional bed-related safety measures after prior falls and no documentation that existing interventions were consistently implemented, leading surveyors to cite a deficiency for failure to prevent accidents and maintain a hazard-free environment.
Two uncapped disposable razors were found unsecured and unattended in a restroom accessible to a resident with moderately impaired cognition and multiple psychiatric diagnoses. Facility policy required sharps to be secured, but staff confirmed the razors should not have been left out.
The facility did not follow physician orders or ensure proper documentation for oxygen therapy for three residents. One resident with respiratory conditions was repeatedly observed with the head of bed flat despite orders to keep it elevated, while two other residents received oxygen therapy without any physician order or care plan documentation. Nursing staff and the DON confirmed these lapses during interviews.
The facility did not include agency staff hours in its PBJ submission for one quarter, resulting in inaccurate staffing data being reported to CMS. This omission led to a one-star staffing rating and low weekend staffing figures, as confirmed by the Administrator during an interview.
Surveyors identified multiple infection control deficiencies, including failure to track pathogens in surveillance reports, improper storage of an ice scoop in a nourishment room, and lack of enhanced barrier precautions during wound care for a resident with multiple diagnoses. Staff interviews confirmed these lapses were not in line with facility policy.
The facility failed to maintain sanitary conditions in food storage and preparation areas, with observations of unlabeled, undated, and expired food items, as well as unsanitary conditions in the kitchen and nourishment refrigerators. Interviews confirmed that these practices were against facility policies.
The facility failed to maintain a sanitary and comfortable environment in shared bathrooms, as personal items like wash basins and bedpans were found unlabeled and improperly stored. Dietary items were also improperly stored in bathrooms, and personal hygiene items were not labeled or contained. The administrator confirmed these deficiencies, which affected residents with various medical conditions, including cognitive impairments.
The facility failed to uphold resident dignity during dining as CNAs entered rooms without knocking or announcing themselves and used informal pet names instead of preferred names. The Administrator confirmed that staff should knock and use residents' preferred names, highlighting a deficiency in maintaining dignity.
Two residents in the facility did not receive their prescribed medications due to a failure to follow physician orders. One resident, with anxiety and other conditions, was given the wrong dosage of Xanax, while another resident with serious infections missed doses of Vancomycin and Cefepime. The errors were attributed to a lack of communication and oversight, particularly involving agency nurses, leading to a deficiency in care.
A facility failed to provide appropriate dialysis care for a resident with ESRD by not obtaining physician's orders and not adequately assessing and monitoring dialysis sites. The facility's policy required monitoring of the vascular access site for thrill, bruit, and signs of infection, but documentation was lacking for a period in July 2024. Interviews confirmed the absence of required documentation and monitoring, indicating a lapse in following the care plan and facility policy.
The facility failed to secure medications properly, as a medication cart was left unlocked and unattended by an RN, and medications were left unsecured at the bedside of two residents. The incidents were confirmed through observations and staff interviews, highlighting lapses in medication storage protocols.
Failure to Maintain Bed Safety and Hazard-Free Environment Resulting in Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to implement and follow care-planned safety interventions for a resident with significant cognitive and physical impairments. The resident had diagnoses including Alzheimer’s disease, dementia, psychotic disorder with delusions, anxiety, obsessive-compulsive behavior, peripheral vascular disease, convulsions/seizure disorder, and a history of repeated falls. The care plan identified the resident as at risk for falls related to unstable balance, decreased safety awareness, impaired decision-making skills, and lack of coordination, and included interventions such as keeping the bed in the low position with brakes locked and, later, a fall mat to the left side of the bed. A fall risk assessment documented the resident as high risk for falls, and prior falls from bed had resulted in at least one laceration requiring sutures and antibiotic treatment. Despite these known risks and documented interventions, there was no evidence that the care plan was revised to add further bed-related safety interventions after repeated falls from bed. On the night of the fatal incident, the resident, who was dependent on staff for transfers, bed positioning, and turning, was last seen by a CNA around 3:40–3:45 a.m., when incontinence care was provided and the resident was reported to be “alive and fine in bed.” The same CNA later stated that at that time the bed was typically at about “waist high,” rather than in the lowest position. Around 4:50–4:55 a.m., the CNA found the resident lying supine on the floor, partially underneath the bed, with the bed in the lowest position and the corded bed control stretched across the resident’s neck area and pinned under her back near the left shoulder. Witness statements from CNAs and nursing staff, as well as EMS and police narratives, consistently described the resident’s head and torso as being under the bed frame, with visible compression marks on the chest, abdomen, and face consistent with the bed frame and piston, and a chunk of hair lodged in a bolt on the lower bed frame. Staff reported that the bed had to be raised using the remote, which was under the resident, before the resident could be pulled out from under the bed. Investigative interviews and external reports identified additional environmental and supervision-related hazards. A detective observed that a fall alert system was attached to the bed rail but was not plugged in or set up to provide any alert if the resident attempted to get out of bed or fell. The detective also found the call light tucked behind the nightstand, out of the resident’s reach, although it functioned when tested. Multiple staff, including CNAs, nurses, the OT, and the physician, confirmed that the resident could not walk, could not turn herself in bed, was a two-person assist, and was totally dependent on staff for bed position and care. Several staff stated they had never seen a fall mat at the bedside, despite the care plan calling for one, and confirmed that the bed was supposed to be kept in the lowest position due to the resident’s fall risk. The DON and previous administrator acknowledged that the resident was found under the bed with marks consistent with the bed frame and that the bed should have been all the way down to the floor, while also indicating that the incident was considered an accident and that no report had been made to the state survey agency. The surveyors concluded that the facility failed to ensure that care-planned safety interventions (bed in low position, fall mat) were implemented and that the environment (including bed equipment, fall alarm, and call light accessibility) was free of accident hazards, resulting in a serious injury and death for this resident. The facility’s own policy on “Safety and Supervision of Resident” stated that the environment should be made as free from accident hazards as possible and that interventions to reduce accident risks included communicating specific interventions to all relevant staff, providing training, and ensuring interventions are implemented. However, the record showed that after multiple falls, including one with injury, the care plan was not updated with additional bed-related safety measures beyond a single fall mat, and there was no documentation that the existing interventions (bed in low position, brakes locked, fall mat, call light within reach) were consistently implemented. Staff interviews revealed discrepancies about who initiated CPR and who raised the bed, but they consistently indicated that the resident was dependent, that the bed was expected to be in the lowest position, and that the resident’s ability to use the call light or bed remote was limited or absent. External responders (EMS and police) documented that staff did not know how long the resident had been pinned, that the bed’s corded control was found under the resident, and that the fall alert system and call light were not positioned to protect or assist the resident. These combined findings formed the basis for the cited deficiency at F689 for failure to prevent accidents and maintain an environment free of accident hazards.
Unsecured Sharps Left Accessible to Resident with Cognitive Impairment
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by leaving two uncapped disposable razors unsecured and unattended in a resident's restroom. Facility policy required that contaminated sharps be discarded into a designated container, but during two separate observations, the razors were found on the back of the sink in a red cup, accessible to the resident. This was confirmed by staff during the survey, who acknowledged that razors should not be left out and accessible. The resident involved had a history of Bipolar Disorder, Mild Cognitive Impairment, Delusional Disorders, Dementia, and Cognitive Communication Deficiency. The resident's most recent assessment indicated moderately impaired cognition and a need for supervision and assistance with activities of daily living. The care plan addressed cognitive loss and behavioral concerns, but the unsecured razors presented an accident hazard given the resident's condition.
Failure to Follow Physician Orders and Provide Safe Oxygen Therapy
Penalty
Summary
The facility failed to follow physician's orders and provide appropriate care and services regarding oxygen therapy for three residents. For one resident with acute and chronic respiratory failure, COPD, and dependence on supplemental oxygen, observations on multiple occasions revealed the resident was lying in bed with the head of bed (HOB) flat, despite physician orders and care plan directives to keep the HOB elevated to promote oxygenation and prevent shortness of breath. Both nursing staff and the Director of Nursing confirmed the HOB should have been elevated as ordered. Two other residents were observed receiving oxygen therapy via binasal cannula at various flow rates, but neither had a physician's order, care plan documentation, or medication administration record indicating oxygen therapy was prescribed. Nursing staff confirmed the absence of orders for oxygen therapy for these residents, and the DON acknowledged that a physician's order is required for oxygen administration. These findings were based on policy review, medical record review, direct observation, and staff interviews.
Failure to Accurately Report Agency Staffing Hours in PBJ Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing data to CMS for one of four quarters reviewed, specifically Quarter 2 of 2025. According to facility policy, all direct care staffing information, including staff hired directly, agency staff, and contract employees, must be reported electronically through the Payroll-Based Journal (PBJ) system. Review of the PBJ Staffing Data Report for the specified quarter revealed a one-star staffing rating and excessively low weekend staffing. During an interview, the Administrator confirmed that agency staff hours were not included in the PBJ submission for that quarter, as these hours must be manually entered and were omitted, resulting in inaccurate reporting.
Infection Control Deficiencies: Pathogen Tracking, Ice Storage, and Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection prevention and control program in several key areas. The Infection Preventionist/Assistant Director of Nursing did not track pathogens in the Monthly Infection Surveillance Report, as required by facility policy, and the surveillance form lacked a column to document the specific organisms being tracked. This was confirmed during an interview, and no documentation was provided to show that infection organisms were being monitored. Additionally, staff failed to maintain proper ice storage practices; an observation revealed that an ice scoop was left partially submerged in melted ice inside the ice storage container in one of the nourishment rooms, contrary to facility policy which requires the scoop to be kept in a covered container when not in use. Both a CNA and the DON confirmed that this was not in compliance with established procedures. Furthermore, the facility did not implement enhanced barrier precautions as required for a resident with a wound. The resident, who had diagnoses including Parkinson's Disease, protein-calorie malnutrition, and muscle weakness, had a care plan and physician's order specifying the need for enhanced barrier precautions during high-contact care activities. However, during an observed wound care procedure, the Wound Care Nurse performed hand hygiene and donned gloves but failed to wear an isolation gown before direct resident contact, despite confirming that an isolation gown should have been used for this resident under enhanced barrier precautions.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service areas, as evidenced by several observations and policy reviews. The facility's policies on food storage and cleaning were not adhered to, resulting in unlabeled and undated food items, expired foods, and unsanitary conditions. Specifically, a 4-tier metal cart in the kitchen was found with food particles and a dried dark brown substance, and it contained undated bread and buns. Additionally, a pack of garlic bread was found with an expired use-by date. Containers for cornmeal, flour, and sugar were observed with old food particles and dark brown areas, and meal delivery carts were noted to have food particles and dried spillage. The kitchen floors were also found to have standing water, grease, dirt, and food particles. In the employee break room, the resident nourishment mini refrigerator contained an undated glass of fermented orange juice and spilled liquids. The temperature log for the refrigerator/freezer was incomplete for several days. Interviews with the Interim Director of Nursing, Certified Dietary Manager, and Registered Dietician confirmed that all foods should be labeled and dated, no expired food or liquids should be present, and the kitchen and nourishment refrigerators should be clean and maintained. The failure to adhere to these standards resulted in the noted deficiencies.
Deficiencies in Sanitation and Storage in Shared Bathrooms
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for several residents, as evidenced by observations in shared bathrooms. The facility's policy on infection prevention and control requires that reusable items and equipment be cleaned and disinfected according to established procedures. However, during observations, it was noted that personal items such as wash basins and bedpans were not properly labeled or stored, as they were found stacked and uncontained in shared bathrooms. Certified Nurse Assistant (CNA) D confirmed that these items should be labeled and stored in plastic bags, which was not the case. Further observations revealed that dietary items, including plastic medication cups and dietary bowls, were improperly stored in resident bathrooms instead of being returned to the dietary department. This was confirmed by CNA D, who acknowledged that these items should not be in the bathrooms. Additionally, personal hygiene items such as toothbrushes and denture cups were found unlabeled and uncontained, with a soiled adult brief observed on the floor beside the commode. The facility's administrator confirmed that these items should be properly labeled and stored, and that trash should be emptied regularly to prevent overflow. The residents involved in these observations had various medical conditions, including cognitive impairments and dependencies on staff for personal hygiene and toileting. The failure to adhere to proper storage and sanitation procedures in shared bathrooms compromised the facility's ability to provide a safe and comfortable environment for these residents. The administrator acknowledged the deficiencies and confirmed the expected standards for storage and cleanliness, which were not met during the survey observations.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain or enhance residents' dignity and respect during dining, as observed in the actions of three Certified Nursing Assistants (CNAs) identified as A, B, and C. The facility's policy on promoting and maintaining resident dignity, dated November 20, 2023, emphasizes the importance of treating residents with respect and dignity. However, during dining observations on the 300 hall, CNAs were noted to enter resident rooms without knocking or announcing themselves, and they used informal pet names instead of addressing residents by their preferred names. For instance, CNA A entered rooms and addressed residents with terms like "darling" and "hun," while CNA B used "baby" and "buddy" without knocking or announcing their presence. Further observations revealed that CNA B repeatedly failed to knock or announce herself when entering or reentering rooms, and CNA C also entered a resident's room without knocking or announcing herself. During an interview, the facility's Administrator confirmed that staff should knock and announce themselves before entering a resident's room and should address residents by their preferred names, not pet names. These actions by the CNAs were inconsistent with the facility's policy and contributed to the deficiency in maintaining resident dignity and respect.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents, leading to medication administration errors. Resident #23, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, Depression, and Osteoporosis, did not receive the prescribed Xanax 0.25 mg twice daily from July 12 to July 15, 2024. Instead, the resident was given Xanax 0.5 mg once daily due to a failure to update the medication order. The Interim Director of Nurses (DON) acknowledged that the physician orders were not followed and attributed the error to agency nurses not being aware of the updated order. Resident #213, admitted with conditions such as Osteomyelitis of Vertebra and Intraspinal Abscess, did not receive the prescribed antibiotics Vancomycin and Cefepime on July 11, 2024. The Regional Nurse Consultant (RNC) confirmed that the Vancomycin was not administered because the nurse was unaware of the medication's location, and the Cefepime dose was missed. The RNC and Interim DON both confirmed that the physician orders were not followed, and the medications should have been administered as prescribed. The report highlights the facility's failure to adhere to its medication administration policies, which require medications to be administered per the physician's signed order and discrepancies to be reported to nurse management. The lack of communication and oversight, particularly with agency nurses, contributed to the failure to provide the prescribed medications to the residents, resulting in a deficiency in care.
Failure to Monitor Dialysis Care for Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with End Stage Renal Disease (ESRD) by not obtaining physician's orders and not adequately assessing and monitoring dialysis sites. The facility's policy required monitoring of the vascular access site for thrill, bruit, and signs of infection, as well as documentation of these assessments every shift. However, the facility was unable to provide documentation of physician's orders for dialysis care prior to a specific date and failed to document the required monitoring of the resident's dialysis access sites from early to mid-July 2024. The resident, who was cognitively intact, had a permacath in the right chest wall and a dialysis shunt in the left upper arm. Despite the care plan specifying the need for monitoring the access site for bruit and thrill, and notifying the physician of any abnormalities, the facility did not document these assessments. Interviews with the Interim Director of Nursing and the Regional Nurse Consultant confirmed the lack of documentation and monitoring for the specified period, indicating a lapse in following the care plan and facility policy.
Medication Storage and Security Deficiency
Penalty
Summary
The facility failed to ensure proper storage and security of medications, as evidenced by an incident involving a Registered Nurse (RN) who left a medication cart unlocked, unattended, and out of sight in one of the medication storage areas. This was confirmed through observation and interviews with the RN and the Administrator, both acknowledging that the medication cart should not have been left in such a state. Additionally, medications were found unsecured and unattended at the bedside of two residents. One resident, who was cognitively intact and required moderate assistance with daily activities, had a medication cup with tablets and capsules left on their dresser. Another resident, who was moderately cognitively impaired and required supervision, had a medication cup with pills left on their bedside dresser. A Licensed Practical Nurse (LPN) admitted to leaving the medications at the bedside, and the Interim Director of Nursing confirmed that medications should not be left at the bedside during administration.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waverly
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Humphreys County Care And Rehabilitation | 1.8 mi | ★★★★★ | 22 | 0 |
| Signature Healthcare Of Erin | 15 mi | ★★★★★ | 4 | 0 |
| Camden Healthcare & Rehab Center | 18.5 mi | ★★★★★ | 0 | 0 |
| Dickson Health And Rehab | 22.5 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare, Dickson | 22.5 mi | ★★★★★ | 4 | 0 |
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