Map showing the location of The Mulberry at Waverly in Waverly, Nebraska
11041 North 137th St, Waverly, NE, 68462

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • NebraskaLowest tier among peers178 rated homes · average 2.9★
  • Lancaster CountyLowest tier among peers14 rated homes · average 2.9★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs NE avg
  • StaffingCan add or remove a star3★−0.4 vs NE avg
  • Quality measuresCan add or remove a star2★−1.0 vs NE avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersNE avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 24% of peersNE avg3.4★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 18% of peersNE avg3.0★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.79hrsAbove only 40% of peersNE avg4.17Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.74hrsAbove 62% of peersNE avg0.71Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better84%Above only 1% of peersNE avg49%RN turnover67%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$25,642Above only 12% of peersNE avg$10,100Fines · denials2 · 2
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
41citations
10inspection dates
0actual harm (G–I)
2immediate jeopardy (J–L)
Jun 24, 2025most recent

Citations by monthMar 2023 – Jun 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Jun 24, 20251 citationCycle 1worst D · no actual harm
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Jul 24, 2025
Apr 8, 20252 citationsCycle 1worst F · no actual harm
  1. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 12, 2025
  2. F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalF · widespreadCorrected May 12, 2025
Dec 5, 20249 citationsCycle 1worst F · no actual harmpayment denial
  1. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Jan 19, 2025
  2. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Jan 19, 2025
  3. F584Honor 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.Resident RightsE · patternCorrected Jan 19, 2025
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jan 19, 2025
  5. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jan 19, 2025
  6. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jan 19, 2025
  7. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 19, 2025
  8. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Jan 19, 2025
  9. F732Post nurse staffing information every day.Nursing and Physician ServicesF · widespreadCorrected Jan 19, 2025
Aug 28, 20242 citationsCycle 2worst E · no actual harm
  1. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Sep 23, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Sep 23, 2024
Aug 8, 20242 citationsCycle 2worst D · no actual harm
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Aug 29, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Aug 29, 2024
Jun 17, 20241 citationCycle 2worst J · immediate jeopardy$9,805
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareJ · isolatedCorrected Jun 17, 2024
Feb 12, 20242 citationsCycle 2worst J · immediate jeopardy
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 11, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareJ · isolatedCorrected Mar 11, 2024
Jan 10, 20248 citationsCycle 2worst F · no actual harm
  1. F688Provide 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.Quality of Life and CareD · isolatedCorrected Feb 23, 2024
  2. 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.Resident RightsD · isolatedCorrected Feb 23, 2024
  3. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Feb 23, 2024
  4. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Feb 23, 2024
  5. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Feb 23, 2024
  6. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Feb 23, 2024
  7. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Feb 23, 2024
  8. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsC · widespreadCorrected Feb 23, 2024
Dec 12, 20231 citationCycle 3worst F · no actual harm$15,837
  1. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jan 12, 2024
Mar 9, 202313 citationsCycle 3worst F · no actual harmpayment denial
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 6, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 6, 2023
  3. F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Apr 6, 2023
  4. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Apr 6, 2023
  5. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Apr 6, 2023
  6. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Apr 6, 2023
  7. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected Apr 6, 2023
  8. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Apr 6, 2023
  9. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Apr 6, 2023
  10. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 6, 2023
  11. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Apr 6, 2023
  12. F888Ensure staff are vaccinated for COVID-19Infection ControlD · isolatedCorrected Apr 6, 2023
  13. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 6, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.79hrsAbove only 40% of peers−0.38 vs NE avg
  • Registered nursesRN hours only0.74hrsAbove 62% of peers+0.03 vs NE avg
  • Licensed practical nursesLPN hours0.53hrs
  • Nurse aidesCNA hours2.52hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.47hrs
  • Nebraska average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better84%Above only 1% of peersNE avg 49%
  • RN turnoverRegistered nurses only67%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy54 certified beds · ~44 residents a day81%Above 68% of peersNE avg 73%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $25,642In fines
  • 2Fines
  • 2Payment denials
  • $10,100NE avg in fines
Above only 12% of peersFewer fines than 12% of rated homes in Nebraska

Actions on record

  1. Dec 5, 2024Denial of payment for new admissionsfrom Feb 19, 2025
  2. Jun 17, 2024Civil money penalty$9,805
  3. Dec 12, 2023Civil money penalty$15,837
  4. Mar 9, 2023Denial of payment for new admissionsfrom Apr 7, 2023

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Avid Healthcare Group11 facilities in the chain1.5★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Douro Valley Investment, LLC
  • Ne 11 Holdings Opco LLC
Indirect owners (5%+)
  • Brass Ne Trust
  • Bsd Beis Health Trust
  • Copper Ne Trust
  • Gold Ne Trust
  • Ne SNF Holdings LLC
  • Sf 4140 Olde Washington Blvd Real Property LLC
  • Silver Ne Trust
  • Tulip Investments Ne LLC
  • +1 more
Corporate officers
  • Ari Silberstein
Managing employees
  • Lindsey Pihlgren

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 285143 · 11041 North 137th St, Waverly, NE, 68462.
  • Percentiles compare this facility with every rated nursing home in Nebraska and Lancaster County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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