Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Waverly Hills Post Acute
WAVERLY, TN · 100 certified beds · Last Life Safety survey June 18, 2025
CMS Certification Number 445251 · first certified April 1990
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TN
7 citations — more than 45% of the 303 certified nursing homes in TN. Compared within TN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: September 2026 to February 2029. This facility’s last Life Safety survey was June 2025. Facilities in TN are typically surveyed 15–44 months after the last one (median 33), measured over 279 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
Get an email about Waverly Hills Post Acute
One email when it happens. No account; stop it any time with one click.
Emergency preparedness
3 of the 7 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 7 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0584 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.
How that compares
Compared with the median facility in TN, and nationally. Surveyors differ markedly between states, so the TN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 7 |
| Median facility in TN | 8 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 17, 2023 | 1 |
| July 17, 2024 | 4 |
| June 18, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-06-18 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-07-17 |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | 1 | 2023-08-17 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 1 | 2024-07-17 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2025-06-18 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2024-07-17 |
What the citations cover
- Emergency Preparedness Deficiencies 3
- Miscellaneous Deficiencies 1
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Egress Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Egress Deficiencies | 1 |
| Smoke Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 18, 2025 — 2 citations
July 17, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (August 13, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 13, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 13, 2024) |
August 17, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (August 25, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.