Adept Nursing & Rehab of Waverly
11041 North 137th St, Waverly, NE 68462 · Lancaster County · 54 certified beds · avg 44 residents/day · certified since Jun 1, 1994
Part of chain: AVID HEALTHCARE GROUP (11 facilities, chain avg rating 1.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jun 17, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 17, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 12, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 11, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (32)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 25, 2026 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Feb 25, 2026 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Feb 25, 2026 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 25, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 24, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 8, 2025 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Apr 8, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Dec 5, 2024 | F · Potential for harm, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Dec 5, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint |
| Dec 5, 2024 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 5, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 28, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 28, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Aug 8, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Aug 8, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jun 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 12, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 12, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 10, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 10, 2024 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 10, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 10, 2024 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jan 10, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jan 10, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 10, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jan 10, 2024 | C · Minimal risk, facility-wide | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Dec 12, 2023 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | F |
| 2024 | 24 | 2 | J ▲ |
| 2025 | 3 | 0 | F |
| 2026 | 4 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $25,642, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Feb 25, 2026 | Payment Denial | 16 days from May 25, 2026 |
| Dec 5, 2024 | Payment Denial | 26 days from Feb 19, 2025 |
| Jun 17, 2024 | Fine | $9,805 |
| Dec 12, 2023 | Fine | $15,837 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Nebraska avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.62 | 4.33 | 3.95 | bottom 22% in Nebraska; bottom 43% in the U.S. |
| Registered Nurse hours | 0.76 | 0.72 | 0.69 | top 39% in Nebraska; top 31% in the U.S. |
| Weekend total nurse staffing | 3.21 | 3.79 | 3.50 | bottom 22% in Nebraska; bottom 42% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.73 | 0.47 | 0.48 | top 12% in Nebraska; top 15% in the U.S. |
| Total nursing staff turnover (%) | 78.1 | 48.7 | 45.8 | bottom 4% in Nebraska; bottom 3% in the U.S. |
| RN turnover (%) | 50.0 | 44.1 | 42.9 | bottom 43% in Nebraska; bottom 39% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.50, RN 0.74, weekend 3.11. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Brass NE Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 08/02/2023 |
| BSD Beis Health Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 08/02/2023 |
| Copper NE Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 08/02/2023 |
| Douro Valley Investment, LLC | Organization | 5% or Greater Direct Ownership Interest | — | 08/02/2023 |
| Gold NE Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 08/02/2023 |
| NE 11 Holdings Opco LLC | Organization | 5% or Greater Direct Ownership Interest | — | 08/02/2023 |
| NE SNF Holdings LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 08/02/2023 |
| SF 4140 Olde Washington Boulevard Real Property LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 08/01/2023 |
| Silver NE Trust | Organization | 5% or Greater Indirect Ownership Interest | — | 08/02/2023 |
| Tulip Investments NE LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 08/02/2023 |
| Pihlgren, Lindsey | Individual | W-2 Managing Employee | NOT APPLICABLE | 08/02/2023 |
| Silberstein, Ari | Individual | Corporate Officer | NOT APPLICABLE | 08/02/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Eastmont | 8.9 mi | Lincoln, NE | ★★☆☆☆ | 3/5 | |
| Gateway Vista | 9.2 mi | Lincoln, NE | ★★★☆☆ | 3/5 | |
| Eventide Lincoln Care Center | 10.1 mi | Lincoln, NE | ★☆☆☆☆ | 1/5 | |
| Hillcrest Firethorn | 10.3 mi | Lincoln, NE | ★★★★☆ | 3/5 | |
| Holmes Lake Rehabilitation & Care Center | 10.6 mi | Lincoln, NE | ★★☆☆☆ | 3/5 | |
| St. Jane de Chantal | 10.8 mi | Lincoln, NE | ★★★★☆ | 3/5 | |
| Ambassador Health of Lincoln | 11.1 mi | Lincoln, NE | ★★☆☆☆ | 2/5 | |
| Sumner Place | 11.9 mi | Lincoln, NE | ★★★★☆ | 4/5 | |
| Adept Nursing & Rehab of Ashland | 12.1 mi | Ashland, NE | ★★☆☆☆ | 3/5 | |
| Emerald Nursing & Rehab Brookside LLC | 12.2 mi | Lincoln, NE | ★☆☆☆☆ | 1/5 | |
| Emerald Nursing & Rehab Lancaster LLC | 12.6 mi | Lincoln, NE | ★☆☆☆☆ | 1/5 | SFF |
| Southlake Village Rehabilitation & Care Center | 13.3 mi | Lincoln, NE | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 285143.