The Mulberry at Waverly

11041 North 137th St
Waverly, NE, 68462
4027862626
CCN: 285143
1
Overall
1
Health
3
Staffing
2
Quality
ChainAVID HEALTHCARE GROUP
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
DOURO VALLEY INVESTMENT, LLC5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
NE 11 HOLDINGS OPCO LLC5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
BRASS NE TRUST5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
BSD BEIS HEALTH TRUST5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
COPPER NE TRUST5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
GOLD NE TRUST5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
NE SNF HOLDINGS LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
SF 4140 OLDE WASHINGTON BOULEVARD REAL PROPERTY LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
SILVER NE TRUST5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
TULIP INVESTMENTS NE LLC5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
WEISZ, DAVID5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED
SILBERSTEIN, ARICORPORATE OFFICERNOT APPLICABLE
PIHLGREN, LINDSEYW-2 MANAGING EMPLOYEENOT APPLICABLE
Penalties (3)
DateTypeAmount
2024-12-05Payment Denial26 days
2024-06-17Fine$10K
2023-12-12Fine$16K
Health Deficiencies (41)
2025-06-24 · Health
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
2025-04-08 · Health
F
F921 · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
2024-12-05 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
E
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
F
F732 · Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F636 · Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
E
F584 · Resident Rights Deficiencies
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.
2024-08-28 · Health
E
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
E
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2024-08-08 · Health
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2024-06-17 · Health
J
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2024-02-12 · Health
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
J
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2024-01-10 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F688 · Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F625 · Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
C
F582 · Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2023-12-12 · Health
F
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
2023-03-09 · Health
D
F888 · Infection Control Deficiencies
Ensure staff are vaccinated for COVID-19
D
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
D
F726 · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.79
3.68
RN Hrs/Resident/Day
0.74
0.54
LPN Hrs/Resident/Day
0.53
0.81
CNA Hrs/Resident/Day
2.52
2.33
PT Hrs/Resident/Day
0.00
0.12
Data as of 2026-03-01