Pennsylvania Department of Health
WAVERLY HEIGHTS
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WAVERLY HEIGHTS - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on February 11, 2026, at Waverly Heights, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BLDG (EAST,WEST,SOUTH, 2 NEW PATIENT ROOMS) - Component: 01 - Tag: 0000
Facility ID# 233402

Component 01

East, West, South Wings and Two New Patient Rooms

Based on a Medicare/Medicaid Recertification Survey completed on February 11, 2026, it was determined that Waverly Heights - East, West, South Wings and Two New Patient Rooms were not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type III (211), protected ordinary building, with a lower level, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Multiple Occupancies:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Multiple Occupancies - Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of the following:

o They are not intended to serve four or more inpatients for purposes of housing, treatment, or customary access.
o They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
o The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.
19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

Observations:
Name: MAIN BLDG (EAST,WEST,SOUTH, 2 NEW PATIENT ROOMS) - Component: 01 - Tag: 0131 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of fire barrier walls, affecting one of two levels in the component. Findings include: Observation on February 11, 2026, at 9:40 am, revealed, on the lower level, an open penetration by data wires above the fire barrier doors near Residential Laundry.Exit interview with the Maintenance Director on February 11, 2026, at 11:00 am, confirmed the open penetration.

Plan of Correction - To be completed: 02/20/2026

Penetration around data wires above the fire barrier doors near residential laundry was repaired with a through penetration firestop system W-L-3030.

Building services staff will monitor on monthly rounds.

Results of these audits will be reported at the quarterly QAPI meeting.

Initial comments:Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0000
Facility ID# 233402

Component 02

North Building

Based on a Medicare/Medicaid Recertification Survey completed on February 11, 2026, it was determined that Waverly Heights - North Building was not in compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (111), protected noncombustible building, with a lower level, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Rubbish Chutes, Incinerators, and Laundry Chu:

Rubbish Chutes, Incinerators, and Laundry Chutes
2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82

Observations:
Name: BUILDING 02 (NORTH BUILDING) - Component: 02 - Tag: 0541 Based on observation and interview, it was determined the facility failed to maintain the fire resistance of trash chutes, affecting one of two levels in the component. Findings include: Observation on February 11, 2026, at 9:55 am, revealed, on the first floor near Resident Room 130, the trash chute door failed to latch.Exit interview with the Maintenance Director on February 11, 2026, at 11:00 am, confirmed the door failed to latch.

Plan of Correction - To be completed: 02/20/2026

First floor trash chute door near resident room 130 was repaired.

Trash chute doors will be checked for proper latching by Building services staff on daily rounds.

Results of these audits will be reported at the quarterly QAPI meeting.

Initial comments:Name: EAST ADDITION - Component: 04 - Tag: 0000
Facility ID# 233402

Component 04

East Addition

Based on a Medicare/Medicaid Recertification Survey completed on February 11, 2026, at Waverly Heights - East Addition, it was determined there were no deficiencies identified under the requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type II (111), protected noncombustible building, with a lower level and partial basement, that is fully sprinklered.

Plan of Correction:

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