Waverly Hills Post Acute

In the surveyor’s words

From the most serious findings on record at Waverly Hills Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 15, 2026

  Based on policy review, medical record review, facility investigation review, Emergency Medical Services, Police Department Incident Narrative, and interview, the facility failed to ensure safety interventions were implemented and failed to ensure an environment free of accident hazards for 1 of 3 (Resident #4) sampled resident reviewed for accidents, resulting in significant injury and death to Resident #4 . On 1/9/2026, Resident #4, who was moderately cognitively impaired and required staff assistance with transfers, was found unresponsive by Certified Nursing Assistant (CNA) A and lying supine (lying on back with face upward) on the floor with the bed control cord stretched across her body and neck area and pinned under her back near her left shoulder. […]

• Immediate jeopardy, isolatedF689Aug 17, 2023

  Based on policy review, fall investigation review, medical record review, observation, and interview, the facility failed to ensure a safe and secure environment for 6 of 8 residents (Resident #11, #14, #18, #52, #163, and #215) reviewed for falls and accidents. The facility failed to ensure processes were implemented to provide supervision and assistance to ensure the residents' environment was free of accident hazards. The facility failed to conduct appropriate fall investigations to identify all contributing factors (root causes) including the disabling of the courtyard door alarm on the 400 hall and failed to implement appropriate interventions to ensure resident safety. […]

• No harm, potential for more than minimal, patternF812Jul 17, 2024

  Based on policy review, observation, and interview the facility failed to ensure food was stored, prepared, and served under sanitary conditions related to unlabeled, undated, food items, expired foods, and dirty metal carts, food containers, food carts, floors, and nourishment refrigerators. The finding include: 1. Review of the facility's policy titled, Dietary: Food Storage, dated [DATE], revealed .Food shall be stored in accordance with professional standards for food service .staple items such as flour, sugar, and cornmeal should be stored in clean, closed containers .All stored items should have an expiration date or a purchase/delivery date .Open Date .ready- to-eat .food .shall be clearly marked at the time the original container is opened . […]

• No harm, potential for more than minimal, patternF921Jul 17, 2024

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 6 of 60 (Resident #6, #21, #22, #35, #36, and #45) resident shared bathrooms observed. The findings include: 1. Review of the facility's policy titled, Infection Prevention and Control Program, dated 11/20/2023, revealed, .All reusable items and equipment requiring .cleaning .or disinfection shall be cleaned in accordance with our current procedures governing the cleaning and disinfection of soiled or contaminated equipment .The reusable equipment shall be decontaminated using a germicidal detergent prior to storing for reuse . […]

• No harm, potential for more than minimal, patternF725Aug 17, 2023

  Based on facility policy review, Certified Nursing Assistant (CNA) Assignment Sheets, Nursing Home Licensing Checklist, facility time punches, the facility working schedule, and interview, the facility failed to ensure Daily Assignment Sheets were completed for 18 of 18 (1/2/2023, 1/9/2023, 1/13/2023, 2/10/2023, 2/14/2023, 2/15/2023, 3/4/2023, 3/5/2023, 3/14/2023, 3/21/2025, 3/25/2023, 3/31/2023, 4/2/2023, 4/8/2023, 4/14/2023, 5/11/2023, 7/1/2023, and 7/29/2023) days and sufficient staff were scheduled for 2 of 218 (3/23/2023 and 4/2/2023) days reviewed. The findings include: 1. […]