The Mulberry at Waverly

Waverly, NE · 54 beds · For profit - Corporation

0 Trust Score
Grade: F CRITICAL Risk → Stable

Red Flags

  • 1-star health inspection rating (lowest possible)
  • 2 citation(s) at the highest severity level — immediate risk to residents
  • 84% total nursing staff turnover

Green Flags

No positive signals identified yet.

Quick Facts

★☆☆☆☆
CMS Overall
★☆☆☆☆
Health Inspection
12
1.8x state avg
Deficiencies
$25,642
Fines (3-yr)
★★★☆☆
Staffing

Violation Timeline

June 23, 2025

1 deficiency
F0760 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure that residents are free from significant medication errors.

April 7, 2025

2 deficiencyies
F0695 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide safe and appropriate respiratory care for a resident when needed.

F0921 Potential Harm Scope/Severity: F

Environmental Deficiencies

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Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

December 4, 2024

9 deficiencyies
F0636 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

F0732 Potential Harm Scope/Severity: F

Nursing and Physician Services Deficiencies

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Post nurse staffing information every day.

F0880 Potential Harm Scope/Severity: D

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

F0584 Potential Harm Scope/Severity: E

Resident Rights Deficiencies

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Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

F0609 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

F0689 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0759 Potential Harm Scope/Severity: E

Pharmacy Service Deficiencies

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Ensure medication error rates are not 5 percent or greater.

F0760 Potential Harm Scope/Severity: E

Pharmacy Service Deficiencies

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Ensure that residents are free from significant medication errors.

F0812 Potential Harm Scope/Severity: F

Nutrition and Dietary Deficiencies

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Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

August 27, 2024

2 deficiencyies
F0684 Potential Harm Scope/Severity: E

Quality of Life and Care Deficiencies

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Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0725 Potential Harm Scope/Severity: E

Nursing and Physician Services Deficiencies

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Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

August 7, 2024

2 deficiencyies
F0684 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0686 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate pressure ulcer care and prevent new ulcers from developing.

June 16, 2024

1 deficiency
F0684 Immediate Jeopardy Scope/Severity: J

Quality of Life and Care Deficiencies

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Provide appropriate treatment and care according to orders, resident’s preferences and goals.

February 11, 2024

2 deficiencyies
F0684 Immediate Jeopardy Scope/Severity: J

Quality of Life and Care Deficiencies

Show details

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0689 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

January 9, 2024

1 deficiency
F0580 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

See full violation history →

Staffing

0.81
RN hrs/res/day
0.58
LPN hrs/res/day
2.74
CNA hrs/res/day
3.79
Weekend hrs/res/day
84%
Total nurse turnover
67%
RN turnover

A nurse checks on each resident roughly every 5.8 hours on average.

Fines & Penalties

  • Payment Denial Dec 4, 2024
    Payment Denial
  • Fine Jun 16, 2024
    $9,805
  • Fine Dec 11, 2023
    $15,837
  • Payment Denial Mar 8, 2023
    Payment Denial
Total $25,642

Ownership

For profit - Corporation Chain: AVID HEALTHCARE GROUP
  • DOURO VALLEY INVESTMENT, LLC

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 08/02/2023

    NO PERCENTAGE PROVIDED Organization
  • NE 11 HOLDINGS OPCO LLC

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 08/02/2023

    NO PERCENTAGE PROVIDED Organization
  • BRASS NE TRUST

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 08/02/2023

    NO PERCENTAGE PROVIDED Organization
  • BSD BEIS HEALTH TRUST

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 08/02/2023

    NO PERCENTAGE PROVIDED Organization
  • COPPER NE TRUST

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 08/02/2023

    NO PERCENTAGE PROVIDED Organization
  • GOLD NE TRUST

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 08/02/2023

    NO PERCENTAGE PROVIDED Organization
  • NE SNF HOLDINGS LLC

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 08/02/2023

    NO PERCENTAGE PROVIDED Organization
  • SF 4140 OLDE WASHINGTON BLVD REAL PROPERTY LLC

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 08/01/2023

    NO PERCENTAGE PROVIDED Organization
  • SILVER NE TRUST

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 08/02/2023

    NO PERCENTAGE PROVIDED Organization
  • TULIP INVESTMENTS NE LLC

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 08/02/2023

    NO PERCENTAGE PROVIDED Organization
  • WEISZ, DAVID

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 08/02/2023

    NO PERCENTAGE PROVIDED Individual
  • SILBERSTEIN, ARI

    CORPORATE OFFICER

    Since since 08/02/2023

    Individual
  • PIHLGREN, LINDSEY

    W-2 MANAGING EMPLOYEE

    Since since 08/02/2023

    Individual