Waverly Heights

In the surveyor’s words

From the most serious findings on record at Waverly Heights, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF689Apr 9, 2026

  Based on review of clinical records, facility documentation, and staff interview, it was determined that the facility failed to ensure adequate assistance was provided during a transfer, resulting in a fall for one of three residents reviewed for falls (Resident R1). This was identified as past non-compliance.Findings include:Clinical record review revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses including atherosclerotic heart disease, polymyalgia rheumatica, and a history of falls.Review of Resident R1's care plan, dated October 10, 2023, indicated the resident was at risk for falls related to deconditioning. […]

• No harm, potential for more than minimal, isolatedF880Feb 5, 2026

  Based on observations, Review of facility policies and clinical records. Interview with staff. It was determined that the facility failed to ensure an effective infection control program. related to tube feeding and oxygen administration. Three of 12 residents reviewed. (Resident R1, R8 and R3).Findings Include:Review of facility policy, titled OXYGEN ADMINISTRATION AND CARE OF EQUIPMENT, dated January 1, 20218, revealed, Change cannula bi-weekly and as needed. Date and time should be on bottle and cannula. […]

• No harm, potential for more than minimal, isolatedF880Feb 21, 2025

  Based on a review of facility policy, observation, and staff interviews, it was determined that the facility failed to establish, implement and maintain an effective infection control program related to enhanced barrier precaution, relating to staff education, proper signage and available personal protective equipment (PPE) for three of three reviewed. (Resident 3, Resident R10, and Resident 129) Finding includes: Review of facility policy titled Enhanced Barrier Precautions revealed that enhanced barrier is an approach to the use of personal protective equipment (PPE) to reduce transmission of Multi Drug Organisms between residents in skilled nursing facilities. Enhanced barrier precautions (EBP) expand the use of gowns and gloves beyond standard precautions. […]

• No harm, potential for more than minimal, isolatedF623Apr 25, 2024

  Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer in a timely manner for one of 12 residents reviewed (Resident R8). Findings include: Review of Resident R8's clinical record revealed that the resident was transferred to the hospital on September 7, 2023, due to fever. Further review of Resident R8's clinical record failed to reveal documentation of a written hospital transfer notice provided by the facility to Resident R8 and their representative(s). Interview with the facility Administrator, Employee E1, on April 24, 2024, at 9:43 a.m. […]

• No harm, potential for more than minimal, isolatedF760Apr 25, 2024

  Based on review of the clinical records, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that a resident was free of significant medication error related to the receiving wrong medication which was prescribed for another resident for one of 4 residents reviewed for medication administration (Resident R9). Findings include: Review of FDA (Food and Drug Administration) guidelines for Morphine sulfate revealed that Morphine sulfate is an opioid agonist indicated for the relief of moderate to severe acute and chronic pain where an opioid analgesic is appropriate. (1) Morphine sulfate 100 mg per 5 mL (20 mg/mL) solution is indicated for the relief of moderate to severe acute and chronic pain in opioid-tolerant patients. […]