Azria Health Waverly: Data Analysis and Ratings

CMS Five Star Rating(1 out of 5):

 11041 NORTH 137TH ST WAVERLY, NE 68462

  402-786-2626

Data date: April 01, 2023

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The Most Important Data about Azria Health Waverly

We've looked at a lot of nursing homes, this is what we think you need to see first and if you don't want to spend a lot of time. (It's the tl;dr section.)

There is no indication of abuse occuring at Azria Health Waverly. (CMS flags facilities where abuse has either happened or is very likely.)

CMS 5-Star Overall Rating: (1 out of 5):
(The national average overall star rating is 3 stars.)

Current Trend: Worsening

Total Nursing Hours Spent Per Resident Per Day: 2.93
(The national average is 3.74 )

Best Nursing Homes in NE

According to our analysis, Azria Health Waverly is ranked #24 out of 29 skilled nursing homes within a 25 mile radius. See detailed information from recent inspection reports, nursing hours analysis, surverys, and information on owners and operators. Click here to view the ranked list of nursing homes near Azria Health Waverly.

What is this page all about?

Below is everything shred of information that we can find about Azria Health Waverly, along with our best effort to make sense of the data. Our purpose here is to help you to make good decisions when picking a nursing home and to keep you informed once you have chosen a home. We know from personal experience that choosing a nursing home is not something you do once and then you forget about it. In fact, it gets worse. Once you select a nursing home and get through the initial steps of figuring out how to pay for it, then the real worries start. Are they taking good care of me or my loved one? This is the question that will keep you up at night: Can I really trust these people? We wish we could answer this question, we can't. What he can do is churn through the tons of data and try and help you to make sense of it. We hope it helps.

General Data Card

These are the basic data points for the facility.

Data date: April 01, 2023

Address: 11041 NORTH 137TH ST

WAVERLY, NE 68462

Phone: 402-786-2626

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Ranking: Azria Health Waverly is ranked #8 out of 11 facilities within a 10 mile radius and #24 out of 29 facilities within a 25 mile radius.

Medicare Provider Number: 285143

Participating in Medicare Since: June 01, 1994

No. of Certified Beds: 52

No. of Residents: 44

Occupancy: 84.62 % (as of 05/21/2023 )

Amount fined in recent period: $26,000.00

Complaints filed: 0

Ratings History for Azria Health Waverly

Review of Azria Health Waverly Ratings and Inspection Scores

CMS regularly inspects every skilled nursing facility. (The timing is supposed to be annually, but since the beginning of the Covid pandemic, these inspections have not occured as frequently.) The results of the multi-day inspection is reduced to a series of scores which are then translated into the star ratings. The health inspection scores are an absolute value, so you can compare one facility's score directly to another. The Overall Star rating is based on the facility's performance as compared to other facilities in the same state, so you cannot easily compare one facility's Overall star rating to a facility in another state.

Ratings

Overall Rating 1:
Health Inspection Rating 2:
Quality Rating 4:
Staffing Rating 1:

Inspection Scores

Cycle 1 Score (as of November 17, 2021) 112
Cycle 2 Score (as of October 31, 2019) 44
Cycle 3 Score (as of July 18, 2018) 44
Weighted All Cycles Score 78

It has been 16 months since the most recent inspection.

What Goes Into the Nursing Home's 5-Star Rating

CMS has put a lot of effort into creating its very elaborate 5-Star Quality Rating System specifically to provide a quick way for residents and family members to easily understand how well a nursing home is performing and to make comparing nursing homes easier. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and best performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.

The rating system has five separate ratings including:

  • Overall rating
  • Health Inspection rating
  • Staff rating
  • RN Staffing rating
  • Quality Measures rating

Nursing homes are rated from 1-star to 5-stars with 1-star being the best rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS. See the latest cut rates on this table.

Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :

  1. Begin with the Health Inspection Rating
  2. Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
  3. Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
  4. Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
  5. Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.

Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)

Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.

Most Recent Nursing Home Inspections

CMS is required to inspect each senior nursing facility at least annually. These inspections take several days. Additional follow-up inspections as conducted as needed or for certain purposes. Inspections stopped for more than seven months in 2020 due to the Covid pandemic. That stoppage has caused all inspections to be delayed as the inspectors continue to deal with a backlog. The table below shows the latest inspections for Azria Health Waverly including health, fire, and inspection control inspections:

Inspection Type Inspection Date
Fire Safety Standard November 15, 2021
Fire Safety Standard November 01, 2019
Fire Safety Standard July 26, 2018
Health Complaint November 17, 2021
Health Standard November 17, 2021
Health Standard October 31, 2019
Health Standard July 18, 2018
Infection Control October 26, 2020
Infection Control June 24, 2020

Owner and Operator Information for Azria Health Waverly

Our database of owners and operators shows all direct owners of the nursing nurse, any managers and directors, and the most adjacent indirect owners of the facility (that is, if the direct owner is company, then the owners of that company.) Lists of nursing home owners are available and you can search for nursing home owners and operators on our site.

Business Entity Name:

BCP WAVERLY, LLC

Owners:

Managers and Directors:

Analysis of Nursing Hours Spent Per Patient

CMS provides detailed information about how long nursing staff spends with residents. This data includes nursing subcategories of Registered Nurse, Licensed Practical Nurse, and non-nursing Certified Nursing Assistants. More hours spend per patient should can indicate a better facility or it could indicate more complicated situations.

The nursing staff of Azria Health Waverly spends LESS time on average with its residents than the state average and LESS time than the national average for total nursing homes spent per resident.

Type Facility State / National Avg
Registered Nurse (RN)
Hours 0.39 0.71 / 0.65
Case Mix 0.43 0.33 / 0.39
Adjusted 0.35 NA / NA
Licensed Practical Nurse (LPN)
Hours 0.74 0.68 / 0.88
Case Mix 0.79 NA / NA
Adjusted 0.69 NA / NA
Certified Nursing Assistants (CNA)
Hours 1.81 2.52 / 2.21
Case Mix 2.03 NA / NA
Adjusted 1.81 NA / NA
Total Licensed Staff
Hours 1.13 1.39 / 1.53
Physical Therapist (PT)
Hours 0.01 0.05 / 0.07
Total Nursing Homes Spent per Resident on Average
Hours 2.93 3.91 / 3.74
Case Mix 3.25 3.01 / 3.16
Adjusted 2.85 NA / NA

Quality Measures

Quality measures are based both on patient survey information and on the results of actual claims that are filed with CMS. It is not clear what period is covered in the measures.

Desc. Perc. State Avg. / Comparison
Percentage of short-stay residents who were rehospitalized after a nursing home admission (qm521) 16.7% 20.2%
Better
Percentage of short-stay residents who had an outpatient emergency department visit (qm522) 0.0% 10.8%
Better
Number of hospitalizations per 1000 long-stay resident days (qm551) 3.2% 1.6%
Worse
Number of outpatient emergency department visits per 1000 long-stay resident days (qm552) 1.1% 1.0%
Worse
Percentage of long-stay residents whose need for help with daily activities has increased (qm401) 16.2% 14.7%
Worse
Percentage of long-stay residents who lose too much weight (qm404) 3.0% 5.8%
Better
Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) 50.0% 48.5%
Worse
Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) 4.9% 2.4%
Worse
Percentage of long-stay residents with a urinary tract infection (qm407) 0.6% 3.8%
Better
Percentage of long-stay residents who have depressive symptoms (qm408) 9.8% 4.0%
Worse
Percentage of long-stay residents who were physically restrained (qm409) 0.0% 0.2%
Better
Percentage of long-stay residents experiencing one or more falls with major injury (qm410) 2.8% 4.7%
Better
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) 88.1% 91.3%
Worse
Percentage of long-stay residents who received an antipsychotic medication (qm419) 16.8% 18.7%
Better
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) 80.7% 78.2%
Better
Percentage of short-stay residents who newly received an antipsychotic medication (qm434) 0.0% 1.9%
Better
Percentage of long-stay residents whose ability to move independently worsened (qm451) 17.4% 15.9%
Worse
Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) 25.0% 19.6%
Worse
Percentage of high risk long-stay residents with pressure ulcers (qm453) 4.9% 6.3%
Better
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm454) 100.0% 95.8%
Better
Percentage of short-stay residents who made improvements in function (qm471) Not Available
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm472) 62.5% 72.5%
Worse

Azria Health Waverly Violations, Complaints and Fines

These are complaints and fines that are reported by CMS. Some of the data is not very recent, but we have decided to include it here so that you have as much information as possible.

Amount fined in recent period: $26,000.00, Complaints filed: 0

Deficiency Deficiency Date / Date Corrected
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
(Health)
07-18-2018 / 08-31-2018
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
(Health)
07-18-2018 / 08-31-2018
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
(Health)
07-18-2018 / 08-31-2018
Provide and implement an infection prevention and control program.
(Health)
07-18-2018 / 08-31-2018
Implement emergency and standby power systems.
(Fire Safety)
07-26-2018 / 08-31-2018
Provide properly protected cooking facilities.
(Fire Safety)
07-26-2018 / 08-31-2018
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
(Fire Safety)
07-26-2018 / 08-31-2018
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
(Fire Safety)
07-26-2018 / 08-31-2018
Provide a written emergency evacuation plan.
(Fire Safety)
07-26-2018 / 08-31-2018
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
(Fire Safety)
07-26-2018 / 08-31-2018
Have generator or other power source capable of supplying service within 10 seconds.
(Fire Safety)
07-26-2018 / 08-31-2018
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
(Health)
10-31-2019 / 12-15-2019
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
(Health)
10-31-2019 / 12-15-2019
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
(Health)
10-31-2019 / 12-15-2019
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
(Health)
10-31-2019 / 12-15-2019
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
(Health)
10-31-2019 / 12-15-2019
Provide safe and appropriate respiratory care for a resident when needed.
(Health)
10-31-2019 / 12-15-2019
Provide and implement an infection prevention and control program.
(Health)
10-31-2019 / 12-15-2019
Implement emergency and standby power systems.
(Fire Safety)
11-01-2019 / 12-13-2019
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
(Fire Safety)
11-01-2019 / 12-13-2019
Install a fire alarm system that can be heard throughout the facility.
(Fire Safety)
11-01-2019 / 12-13-2019
Install corridor and hallway doors that block smoke.
(Fire Safety)
11-01-2019 / 12-13-2019
Have simulated fire drills held at unexpected times.
(Fire Safety)
11-01-2019 / 12-13-2019
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
(Fire Safety)
11-01-2019 / 12-13-2019
Have generator or other power source capable of supplying service within 10 seconds.
(Fire Safety)
11-01-2019 / 12-13-2019
Meet requirements for the use of electrical equipment.
(Fire Safety)
11-01-2019 / 12-13-2019
Provide and implement an infection prevention and control program.
(Health)
06-24-2020 / 08-05-2020
Implement emergency and standby power systems.
(Fire Safety)
11-15-2021 / 01-01-2022
Keep aisles, corridors, and exits free of obstruction in case of emergency.
(Fire Safety)
11-15-2021 / 01-01-2022
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
(Fire Safety)
11-15-2021 / 01-01-2022
Install emergency lighting that can last at least 1 1/2 hours.
(Fire Safety)
11-15-2021 / 01-01-2022
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
(Fire Safety)
11-15-2021 / 01-01-2022
Construct fire resistant interior walls.
(Fire Safety)
11-15-2021 / 01-01-2022
Inspect, test, and maintain automatic sprinkler systems.
(Fire Safety)
11-15-2021 / 01-01-2022
Properly select, install, inspect, or maintain portable fire extinguishes.
(Fire Safety)
11-15-2021 / 01-01-2022
Provide a written emergency evacuation plan.
(Fire Safety)
11-15-2021 / 01-01-2022
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
(Fire Safety)
11-15-2021 / 01-01-2022
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
(Fire Safety)
11-15-2021 / 01-01-2022
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
(Fire Safety)
11-15-2021 / 01-01-2022
Have generator or other power source capable of supplying service within 10 seconds.
(Fire Safety)
11-15-2021 / 01-01-2022
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.
(Health)
11-17-2021 / 01-01-2022
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
(Health)
11-17-2021 / 01-01-2022
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
(Health)
11-17-2021 / 01-01-2022
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.
(Health)
11-17-2021 / 01-01-2022
PASARR screening for Mental disorders or Intellectual Disabilities
(Health)
11-17-2021 / 01-01-2022
Provide appropriate treatment and care according to orders, resident?s preferences and goals.
(Health)
11-17-2021 / 01-01-2022
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
(Health)
11-17-2021 / 01-01-2022
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
(Health)
11-17-2021 / 01-01-2022
Ensure that residents are free from significant medication errors.
(Health)
11-17-2021 / 01-01-2022
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.
(Health)
11-17-2021 / 01-01-2022
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
(Health)
11-17-2021 / 01-01-2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
(Health)
11-17-2021 / 01-01-2022
Provide and implement an infection prevention and control program.
(Health)
11-17-2021 / 01-01-2022
Have enough outside ventilation via a window or mechanical ventilation, or both.
(Health)
11-17-2021 / 01-01-2022

Hospitals Near Azria Health Waverly

Quite often skilled nursing facilities and hospitals work closely together to help patients recover or manage a terminal illness. Hospitals deals with acute care while nursing homes treat patients for a longer period of time. New residents at skilled nursing homes typically come from a hospital and nursing home residents may be readmitted to a hospital if their recovery does not proceed well. (Hospital readmission rates are closely monitored by CMS.) Consequently it is important that you consider which hospitals are near a nursing home which choosing one. Below is a list of hospitals near Azria Health Waverly.

This information is based on the most recent Hospital data. Historical data is not available.

Hospital 5-Star Overall Rating
CHI HEALTH ST. ELIZABETH
555 SOUTH 70TH ST
LINCOLN, NE 68510
3
CHI HEALTH NEBRASKA HEART
7500 SOUTH 91ST ST
LINCOLN, NE 68526
3
BRYAN MEDICAL CENTER
1600 SOUTH 48TH ST
LINCOLN, NE 68506
5
CHI HEALTH LAKESIDE
16901 LAKESIDE HILLS CT
OMAHA, NE 68130
5
LINCOLN SURGICAL HOSPITAL
1710 SOUTH 70TH STREET
LINCOLN, NE 68506
Not Available
NEBRASKA ORTHOPAEDIC HOSPITAL
2808 SOUTH 143RD PLAZA
OMAHA, NE 68144
Not Available
SAUNDERS MEDICAL CENTER
1760 COUNTY RD J
WAHOO, NE 68066
Not Available
SYRACUSE AREA HEALTH
2731 HEALTHCARE DR
SYRACUSE, NE 68446
Not Available
CRETE AREA MEDICAL CENTER
P O BOX 220, 2910 BETTEN DR
CRETE, NE 68333
Not Available
LINCOLN REGIONAL CENTER
801 W PROSPECTOR PLACE
LINCOLN, NE 68522
Not Available

Medical Professionals Associated with Azria Health Waverly

These are the doctors who are affiliated with Azria Health Waverly. The data is from the most recent period. Historical data is not available.

  • APRIL SMITH ( INTERNAL MEDICINE - CHEYENNE COUNTY HOSPITAL ASSOCIATION INC )
  • JAMIE STAAB PETERS ( NURSE PRACTITIONER - HEALTH AT HOME CONSULTANTS LLC )

Detailed Analysis Pages:

Depending on the nursing home, this page can get really long. So, we have also broken up the data onto separate pages to allow you to find what you want more easily. We will keep adding to these pages as we continue to analyze the nursing home database.

CMS Five Star Ratings and Quality Measures for Azria Health Waverly

Five different rating results plus detailed inspection numbers and quality measures for Azria Health Waverly.

Covid Infections at Azria Health Waverly

This report is updated weekly and shows new and historical infection levels.

Nursing Hours Analysis for Azria Health Waverly

How long a nurse spends with a resident can be an important factor in their recovery. This page shows the average nursing hours spent per resident for RNs, LPNs, CNAs, PTs and all licensed staff.

Ownership Details for Azria Health Waverly

A list of all of the registered owners for Azria Health Waverly. This includes direct and indirect owners and managers.

Noted Deficiencies for Azria Health Waverly

A list of all of the deficiencies for the facility. This includes a description, type of deficiency, incident date and when the facility reports that the incident was corrected.

Comparison Ranking of Nearby Skilled Nursing Facilities

How does Azria Health Waverly compare to other skilled nursing facilities? This list shows the competitive set within a 25 mile radius.

Best Nursing Homes in WAVERLY, NE

Homes that you should consider. A list ranking the best skilled nursing facilities in WAVERLY based on their weighted inspection score as of April 01, 2023.

Worst Nursing Homes in WAVERLY, NE

Homes that you avoid if possible. A list ranking the worst skilled nursing facilities in WAVERLY based on their weighted inspection score as of April 01, 2023.