Inspection Reports for Waverly Heights
P.O.BOX 179, 1400 WAVERLY ROAD,, PA, 19035
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 57
Capacity: 82
Deficiencies: 8
Oct 9, 2024
Visit Reason
The inspection was conducted as a renewal review of the Waverly Heights facility by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 10/09/2024.
Findings
The inspection identified multiple deficiencies including failure to timely report missed medications, breaches in record confidentiality, unsanitary conditions related to medication blister packs, lack of operable bedside lamps for residents, overdue annual medical evaluations, improper medication storage and labeling, and missing signatures on support plans. All deficiencies had plans of correction accepted and were implemented by 12/11/2024.
Deficiencies (8)
| Description |
|---|
| Failure to report missed medications to the department within 24 hours as required. |
| Controlled substance log containing confidential resident information was left unlocked and unattended. |
| Blood found on the back of medication blister packs indicating unsanitary conditions. |
| Resident did not have access to an operable lamp or source of lighting at bedside. |
| Resident's most recent annual medical evaluation was overdue. |
| Prescription medication was not labeled with an open date and had a tear/puncture on the blister pack. |
| Medication bottle label did not include an order change sticker reflecting updated instructions. |
| Individuals who participated in the development of the support plan did not sign the plan. |
Report Facts
Residents served: 57
License capacity: 82
Total daily staff: 67
Waking staff: 50
Residents with mobility need: 10
Residents with physical disability: 10
Current hospice residents: 2
Inspection Report
Follow-Up
Census: 60
Capacity: 82
Deficiencies: 3
Jul 10, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for previous deficiencies.
Findings
The submitted plan of correction was determined to be fully implemented as of the inspection dates. Deficiencies related to contract signatures, signed statements acknowledging receipt of resident rights, and resident education on the right to refuse medication were corrected and audited for compliance.
Deficiencies (3)
| Description |
|---|
| The resident-home contract, dated 6/29/24, for a resident was not signed by the resident. |
| Resident record did not contain a statement signed by the resident acknowledging receipt of a copy of the resident rights and complaint procedures. |
| Resident has not been educated to the resident's right to refuse medication if the resident believes that there may be a medication error. |
Report Facts
License Capacity: 82
Residents Served: 60
Current Hospice Residents: 3
Residents with Mobility Need: 10
Total Daily Staff: 70
Waking Staff: 53
Inspection Report
Complaint Investigation
Census: 62
Capacity: 82
Deficiencies: 2
Feb 15, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 02/15/2024.
Findings
The facility was found to have deficiencies related to missing required medical evaluations and incomplete preadmission screening forms for residents. The submitted plan of correction was accepted and later fully implemented.
Complaint Details
The inspection was complaint-related, triggered by a complaint and incident. The plan of correction was accepted and fully implemented as of 03/19/2024.
Deficiencies (2)
| Description |
|---|
| Resident did not have a medical evaluation by a physician, physician’s assistant or certified registered nurse practitioner documented on a form specified by the Department. |
| Resident’s preadmission screening form was not completed on the Department's preadmission screening form. |
Report Facts
License Capacity: 82
Residents Served: 62
Current Hospice Residents: 4
Residents with Mobility Need: 11
Total Daily Staff: 73
Waking Staff: 55
Inspection Report
Renewal
Census: 51
Capacity: 82
Deficiencies: 0
May 1, 2023
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Waverly Heights facility on 05/01/2023 and 05/02/2023.
Findings
No regulatory citations or deficiencies were identified as a result of this renewal inspection.
Report Facts
Total Daily Staff: 61
Waking Staff: 46
Residents Served: 51
License Capacity: 82
Current Hospice Residents: 2
Residents Age 60 or Older: 51
Residents with Mobility Need: 10
Inspection Report
Renewal
Census: 48
Capacity: 82
Deficiencies: 4
Apr 11, 2022
Visit Reason
The inspection was conducted as a renewal visit to review the facility's compliance with licensing requirements.
Findings
The facility was found to have several deficiencies including expired boiler certificates, missing emergency telephone numbers by a phone, outdated food items in storage, and loose pills found on medication carts. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (4)
| Description |
|---|
| Two boilers had expired boiler certificates as of 2/3/22. |
| No emergency telephone numbers posted on or by the telephone in bedroom W231. |
| Outdated food items found in dry food storage and walk-in freezer, including lentil beans, spaghetti, corn meal, yellow cake mix, and ice cream tubs. |
| Loose pills found on Windsor and Devonshire medication carts. |
Report Facts
License Capacity: 82
Residents Served: 48
Staffing Hours: 57
Waking Staff: 43
Outdated Boiler Certificates: 2
Outdated Food Items: 6
Loose Pills: 4
Notice
Capacity: 82
Deficiencies: 0
Jun 8, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Waverly Heights Personal Care Home following receipt of a renewal application. It also advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license and states that enforcement action will be taken if noncompliance is found during future inspections.
Report Facts
Maximum licensed capacity: 82
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Meredith Feher | Sr. VP of Health Care Services | Recipient of the renewal notification letter. |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signer of the renewal notification letter. |
Inspection Report
Renewal
Census: 45
Capacity: 82
Deficiencies: 7
Apr 8, 2021
Visit Reason
The inspection was conducted as a renewal review of the Waverly Heights facility on 04/08/2021 and 04/28/2021 to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to timely report medication incidents, incomplete medical evaluations, medication labeling errors, failure to follow prescriber's orders, delayed medication error reporting, illegible record entries, and missing recent resident photographs. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (7)
| Description |
|---|
| Failure to report incident of missing multivitamin medication within 24 hours to the Department. |
| Resident #2's medical evaluation did not include health status. |
| Medication change label was not placed on medication bottle as required. |
| Resident #1 was not administered prescribed multivitamin due to medication unavailability. |
| Medication error was not immediately reported to resident's designated person and prescriber. |
| Resident record entries were crossed off without proper notation. |
| Resident #2 and Resident #3 records did not include a photograph no more than 2 years old. |
Report Facts
License Capacity: 82
Residents Served: 45
Current Hospice Residents: 1
Total Daily Staff: 53
Waking Staff: 40
Residents with Mobility Need: 8
Residents Age 60 or Older: 45
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