Inspection Reports for
Waverly Heights
P.O.BOX 179, 1400 WAVERLY ROAD,, GLADWYNE, PA, 19035
Back to Facility Profile19 Reports
Inspection Report — Nov 26, 2025
Monitoring
Date: Nov 26, 2025
Visit Reason
The visit was an unannounced partial inspection conducted as a monitoring review of the facility's compliance with licensing regulations.
Findings
The inspection identified multiple deficiencies related to fire drill documentation, medication records, medication storage, and medication administration procedures. The facility submitted plans of correction which were accepted and implemented.
Citations (6)
132c Fire Drill Records: Fire drill records did not include the number of residents in the home or evacuated during drills on specified dates.
181f Record of Medication: A resident's medication list included a medication they had stopped taking, and the resident no longer met requirements to self-administer medications.
183b Meds and Syringes Locked: A resident's medications were found unlocked and unattended in a shared room with a resident not capable of self-administration.
183d Prescription Current: A discontinued medication was found in the home's medication cart.
183e Storing Medications: Expired medications were present in the medication cart and resident did not follow manufacturer's instructions for medication expiration.
185a Implement Storage Procedures: A narcotic log showed a discrepancy where a pill was signed out but not actually administered at the recorded time.
Report Facts
Residents Served: 57
Current Residents: 2
Residents Age 60 or Older: 58
Residents with Mobility Need: 10
Total Daily Staff: 67
Waking Staff: 50
Inspection Report — Oct 9, 2024
Renewal
Date: 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.
Citations (8)
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
Total daily staff: 67
Waking staff: 50
Residents with mobility need: 10
Residents with physical disability: 10
Current hospice residents: 2
Inspection Report — Jul 10, 2024
Follow-Up
Date: 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.
Citations (3)
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
Residents Served: 60
Current Hospice Residents: 3
Residents with Mobility Need: 10
Total Daily Staff: 70
Waking Staff: 53
Notice — Mar 5, 2024
Date: Mar 5, 2024
Visit Reason
This document serves to notify Waverly Heights that their request to waive certain Pennsylvania Code requirements for preadmission screening and medical evaluation forms is granted, allowing use of MatrixCare forms instead of Department forms.
Findings
The waiver is granted with the condition that Waverly Heights uses the specified MatrixCare forms in lieu of the Department's forms. The Department will review compliance with this waiver during the annual inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Theresa Hartman | Bureau Director, Human Services Licensing | Signed the waiver approval letter |
Inspection Report — Feb 15, 2024
Complaint Investigation
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection on 02/15/2024.
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.
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.
Citations (2)
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
Residents Served: 62
Current Hospice Residents: 4
Residents with Mobility Need: 11
Total Daily Staff: 73
Waking Staff: 55
Inspection Report — May 1, 2023
Renewal
Date: 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
Current Hospice Residents: 2
Residents Age 60 or Older: 51
Residents with Mobility Need: 10
Inspection Report — Apr 11, 2022
Renewal
Date: 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.
Citations (4)
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
Residents Served: 48
Staffing Hours: 57
Waking Staff: 43
Outdated Boiler Certificates: 2
Outdated Food Items: 6
Loose Pills: 4
Inspection Report — Jan 19, 2022
Date: Jan 19, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit for a new licensing-related reason involving adjustment of physical space use with no change in licensed capacity.
Findings
No deficiencies were found during the inspection.
Report Facts
Residents Served: 39
Staffing: 46
Waking Staff: 35
Residents with Mobility Need: 7
Residents 60 Years or Older: 39
Notice — Jun 8, 2021
Date: 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
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 — Apr 8, 2021
Renewal
Date: 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.
Citations (7)
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
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
Notice — Feb 26, 2020
Date: Feb 26, 2020
Visit Reason
This document serves as a renewal notification and license issuance for Waverly Heights Personal Care Home. It informs the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal approval letter with instructions regarding future inspections.
Report Facts
Inspection Report — Oct 9, 2019
Renewal
Date: Oct 9, 2019
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at Waverly Heights.
Findings
The facility submitted a plan of correction which was found to be fully implemented and in compliance. Violations were identified related to annual training hours, sanitary conditions, and medication storage procedures, all of which had corrective actions approved and fully implemented.
Citations (3)
Regulation 2600.65(e): Direct care staff person A received only 5.5 hours of annual training in 2018 instead of the required 12 hours.
Regulation 2600.85(a): A box used to store Resident #1's glucometer had dried red-brown smears on the exterior, indicating unsanitary conditions.
Regulation 2600.185(a): The facility failed to properly document glucose readings and medication administration for Resident #1, with discrepancies noted in MAR and glucometer readings.
Report Facts
Residents Served: 47
Total Daily Staff: 54
Waking Staff: 41
Direct Care Staff Person A Annual Training Hours: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicole Stroman | Administrator | Named as administrator and legal entity representative signing plan of correction |
| Shawn Parker | Human Services Licensing Supervisor | Signed letter confirming plan of correction compliance |
Notice — Feb 22, 2019
Date: Feb 22, 2019
Visit Reason
This document serves as a renewal notification and license issuance for Waverly Heights Personal Care Home following the renewal application submitted on February 19, 2019.
Findings
The Department of Human Services approved the renewal application and issued a regular license. The letter also informs that an onsite annual inspection will be conducted within the next twelve months as required by regulation.
Report Facts
Inspection Report — Oct 22, 2018
Renewal
Date: Oct 22, 2018
Visit Reason
The inspection was a renewal visit conducted by the Department's Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 for Personal Care Homes.
Findings
Multiple violations related to food storage temperature, medication administration records, and medication administration documentation were found. Plans of correction were submitted and partially implemented with adequate progress noted.
Citations (3)
55 Pa.Code §2600.103(f) Food requiring refrigeration shall be stored at or below 40°F. The ice cream freezer temperature was 15°F on 10/22/18, exceeding the required maximum.
55 Pa.Code §2600.187(a) Medication records must include specific details. The medication administration record for resident #1 did not include Tums as observed on 10/22/18.
55 Pa.Code §2600.187(d) The home shall follow prescriber directions. Resident #1 was prescribed Azithromycin three times weekly, but no documentation of administration was found for 6/1/18.
Report Facts
Number of Residents Served: 43
Number of Current Hospice Residents: 3
Number of Hospice Residents in Past Year: 5
Waking Staff: 38
Total Daily Staff: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Meredith Feher | Administrator | Named as administrator on page 2 and in letter on page 1. |
| Nicole J. Strouan | PC Admin | Signed plan of correction documents on pages 3, 4, and 5. |
| Sabrina Freeman | Inspector conducting the violation report on pages 3-5. |
Inspection Report — Feb 21, 2018
Renewal
Date: Feb 21, 2018
Visit Reason
This document is a renewal application and license issuance for Waverly Heights Personal Care Home, confirming the facility's authorization to operate and noting the requirement for an annual inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It serves as a license renewal confirmation and notification of upcoming annual inspection requirements.
Inspection Report — Mar 22, 2017
Renewal
Date: Mar 22, 2017
Visit Reason
The inspection was an annual licensing inspection conducted on March 22, 2017, for renewal of the facility license.
Findings
The inspection found violations related to fire drill exit routes not being specific. A plan of correction was submitted to update fire drill documentation and ensure alternative exit routes are properly identified.
Citations (1)
Regulation 55 Pa.Code §2600.132(f) requires alternate exit routes during fire drills. The exit routes listed on the fire drill log were not specific and stated only "smoke doors" or "smoke area."
Report Facts
Number of Residents Served: 44
Total Daily Staff: 51
Walking Staff: 36
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 7
Number of Residents Age 60 or Older: 44
Number of Residents with Mental Illness: 2
Number of Residents with Mobility Need: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicole J. Stroman | Personal Care Administrator | Named in relation to the violation and plan of correction |
Inspection Report — Mar 1, 2017
Renewal
Date: Mar 1, 2017
Visit Reason
The document is a renewal application response and license issuance for Waverly Heights Personal Care Home. It states the Department will conduct an onsite inspection within the next twelve months as required by law.
Findings
No inspection findings are reported in this document. It primarily communicates the license renewal approval and the requirement for a future annual inspection.
Inspection Report — Mar 17, 2016
Renewal
Date: Mar 17, 2016
Visit Reason
The inspection was an annual licensing inspection conducted on March 17, 2016, for renewal of the facility license.
Findings
Several violations of 55 Pa.Code Chapter 2600 were found, including failure to request timely criminal background checks, lack of operable bedside lighting, incomplete medication administration records, and missing medication administration documentation. Plans of correction were submitted for all violations.
Citations (4)
Regulation 2600.51: A criminal background check was not requested until 7/28/15 for a staff member hired earlier.
Regulation 2600.101(1)(7): The bed in room #251 lacked a source of light that could be turned on/off from bedside.
Regulation 2600.182(c): Resident #1's glucometer readings were not recorded on the medication administration record as required.
Regulation 2600.187(a): Medication administration record for resident #2 did not include documentation for Acetaminophen 325mg as needed for temperature.
Report Facts
Number of Residents Served: 44
Total Daily Staff: 52
Waking Staff: 30
Number of Current Hospice Residents: 1
Number of Hospice Residents in Past Year: 4
Residents Age 60 or Older: 44
Residents with Mental Illness: 2
Residents with Intellectual Disability: 1
Residents with Mobility Needs: 8
Residents with Physical Disability: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Aurora Crew | Administrator | Named as facility administrator on page 2. |
| Nicole Stroman | PC admin | Signed as legal entity representative and plan of correction approver on multiple pages. |
| Autumn Keppel | Department representative present on-site during inspection on 3/17/2016. | |
| Christine McHale | Department representative present on-site during inspection on 3/17/2016. |
Notice — Feb 23, 2016
Date: Feb 23, 2016
Visit Reason
The document is a renewal notification and license certificate issued in response to the facility's renewal application to operate a Personal Care Home.
Findings
No inspection findings are reported. The letter advises that an annual onsite inspection will be conducted within the next twelve months as required by regulation.
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