Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waverly Heights during CMS and state inspections, most recent first.
A resident with a history of falls and deconditioning, care planned for two-person assist with toileting and transfers, was transferred by a CNA using a sit-to-stand mechanical lift without a second staff member. During the bed-to-bathroom transfer, the resident released the lift, their knees buckled, and they began slipping from the device. The CNA called the resident’s private caregiver for help, and together they lowered the resident to the floor. The DON confirmed that a two-person assist was required at the time of the transfer.
Infection control lapses were observed with tube feeding and oxygen equipment for multiple residents. A tube feeding pump and stand were stored in the nurses' station medication room with dried formula on them after use, and the ICN confirmed they had not been cleaned or disinfected. Two residents had oxygen tubing that was undated and not bagged, and one resident also had nebulizer tubing on the nightstand that was not bagged, contrary to the facility's oxygen equipment policy.
Failure to provide required QAPI training to staff. Review of employee education records showed no evidence that five nurse aides received training on the facility’s QAPI program, including its elements and goals. The deficiency was confirmed with the Administrator.
The facility failed to implement effective infection control measures related to enhanced barrier precautions for residents with indwelling devices and wounds. Observations showed inadequate signage and PPE availability, while staff interviews revealed a lack of education and awareness about the precautions. This deficiency affected three residents, including one with an indwelling catheter and another with pressure ulcers.
A resident was transferred to the hospital due to a fever, but the facility failed to provide timely written notification of the transfer and its reasons to the resident and their representative(s). The facility Administrator confirmed the absence of a system for written notice before discharge.
A resident received Morphine Sulfate, a narcotic pain medication, without a physician order due to a nurse's failure to verify the resident's identity before administration. The error was recognized only after the medication was signed out, and the Director of Nursing confirmed the lapse in protocol.
Inadequate Assistance During Mechanical Lift Transfer Resulting in Fall
Penalty
Summary
The facility failed to provide adequate assistance during a transfer for a resident who was at risk for falls. The resident had diagnoses including atherosclerotic heart disease, polymyalgia rheumatica, and a history of falls, and was care planned as being at risk for falls related to deconditioning. The resident’s care plan, dated October 10, 2023, specified that the resident required a two-person assist for toileting and transfers. On the date of the incident, a nurse aide attempted to transfer the resident using a sit-to-stand mechanical lift without the required second staff member. During this transfer from bed to bathroom, the resident let go of the lift and their knees buckled. According to the resident’s private caregiver, the nurse aide was performing the transfer and shower by herself when the resident began slipping out of the sit-to-stand lift, at which point the aide called for help and they lowered the resident to the floor. The DON later confirmed that the resident required a two-person assist at the time of the transfer.
Infection Control Lapses With Tube Feeding and Oxygen Equipment
Penalty
Summary
The facility failed to ensure an effective infection control program related to tube feeding and oxygen administration for three of 12 residents reviewed, including R1, R8, and R3. Review of the facility policy titled "OXYGEN ADMINISTRATION AND CARE OF EQUIPMENT" dated January 1, 20218, stated that cannulas should be changed bi-weekly and as needed, that the date and time should be on the bottle and cannula, and that oxygen tubing should be placed in a plastic bag attached to the concentrator when not in use. On February 4, 2026, at 12:15 p.m., the tube feeding stand for R1 was observed inside the nurses' station medication room with dried tube feeding formula stains on the stand, and the Infection Control Nurse confirmed that the stand and pump had been removed from the resident room after administration without being cleaned or disinfected. R8 was observed with an oxygen concentrator in the room, and the oxygen tubing was undated and not bagged. R3 was observed with an oxygen concentrator in the room, and the oxygen tubing was not bagged; nebulizer tubing was also found on the nightstand and was not bagged during two separate observations. The Infection Control Nurse confirmed these findings during the unit tour.
Failure to Provide Required QAPI Training to Staff
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) program was not provided for staff as part of the facility’s QAPI program. Review of employee education records showed no evidence of QAPI training for five nurse aides, identified as Employees E4, E5, E6, E7, and E8. The deficiency was confirmed with the Administrator during interview, and the report cited that the facility did not ensure staff were informed of the elements and goals of the QAPI program.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish, implement, and maintain an effective infection control program related to enhanced barrier precautions. This deficiency was identified through a review of facility policy, observations, and staff interviews. The facility's policy on Enhanced Barrier Precautions (EBP) was not effectively implemented, as there was a lack of proper signage and availability of personal protective equipment (PPE) for residents requiring such precautions. Observations revealed that signage on residents' doors only instructed individuals to see the nurse before entering, without indicating the necessary precautions or providing PPE at the point of care. Three residents were identified as requiring enhanced barrier precautions due to the presence of indwelling devices and wounds. Resident R10 had an indwelling catheter and was admitted with conditions that necessitated enhanced barrier precautions, but the order for such precautions was delayed by a month. Resident R3 had pressure ulcers, and Resident R129 had a surgical wound, yet there was no physician order for enhanced barrier precautions for Resident R129. The lack of appropriate signage and PPE availability at the point of care for these residents indicates a failure in the facility's infection control practices. Interviews with staff members revealed a lack of education and awareness regarding enhanced barrier precautions. Employee E6, the infection control preventionist, stated that PPE was not required for certain types of contact and expressed concerns about resident privacy regarding signage. Employees E10 and E11 were unaware of the enhanced barrier precautions and had not received education on the matter. This lack of staff training and awareness contributed to the facility's failure to implement effective infection control measures, as required by the CDC guidelines and facility policy.
Failure to Provide Timely Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to notify Resident R8 and their representative(s) in writing of the reasons for the transfer to the hospital in a timely manner. Resident R8 was transferred to the hospital due to a fever on September 7, 2023. However, the clinical record did not contain documentation of a written hospital transfer notice provided to the resident and their representative(s). An interview with the facility Administrator confirmed that there was no system in place for providing written notice before discharge, and that the resident and their representative were not notified in writing in a language and manner they understood.
Significant Medication Error Due to Failure in Resident Identification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the administration of Morphine Sulfate to Resident R9, who did not have a physician order for this medication. The error occurred when a charge nurse administered 0.25 milligrams of Morphine Sulfate to Resident R9 by mistake. The nurse realized the error only after signing out the medication. Resident R9 reported that she was asleep when the nurse administered the liquid medication without verifying her identity. The Director of Nursing confirmed that the nurse did not follow the appropriate practice of medication administration, which includes identifying the correct resident before administering medication. This lapse in protocol resulted in Resident R9 receiving a narcotic pain medication that was not prescribed for her, potentially causing serious side effects. The facility's investigation and interviews with staff corroborated these findings, highlighting a significant breach in medication administration procedures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gladwyne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaumont At Bryn Mawr | 2.1 mi | ★★★★★ | 0 | 0 |
| Cathedral Village | 2.2 mi | ★★★★★ | 4 | 0 |
| Meadowview Rehabilitation And Nursing Center | 2.6 mi | ★★★★★ | 11 | 0 |
| Masonic Village At Lafayette Hill | 2.6 mi | ★★★★★ | 0 | 0 |
| Rosemont Center | 2.9 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.