Gladwyne, PA

Waverly Heights

5-star overall rating with 5-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

1400 Waverly Road, Gladwyne, PA

(610) 645-8600

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

31

Certified beds

Average residents

29

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1986-08-25

CMS approved date

Coverage

Medicare

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

2.28

Registered nurse staffing · state 0.78 · national 0.68

LPN hours / resident day

0.05

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

3.60

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

5.93

All reported nurse hours · state 3.89 · national 3.89

Licensed hours

2.33

RN + LPN hours · state 1.69 · national 1.54

Weekend hours

5.48

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

1.83

Weekend registered nurse coverage · state 0.55 · national 0.47

Physical therapist

0.22

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

2.34

CMS adjusted RN staffing hours

Adjusted total hours

6.06

CMS adjusted total nurse staffing hours

Case-mix index

1.34

Higher values indicate more complex resident acuity

RN turnover

19%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

23%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

412

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

70.45

Composite VBP score used to determine payment impact.

Payment multiplier

1.0226

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.73

Baseline 20.32% · Performance 18.32% · Measure score 6.73 · Achievement 6.73 · Improvement 5.60

Healthcare-associated infections

5.25

Baseline 7.84% · Performance 6.27% · Measure score 5.25 · Achievement 5.25 · Improvement 5.03

Total nurse turnover

6.21

Baseline 40.43% · Performance 38.30% · Measure score 6.21 · Achievement 6.21 · Improvement 0.87

Adjusted total nurse staffing

10

Baseline 6.16 hours · Performance 6.22 hours · Measure score 10 · Achievement 10 · Improvement 9

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.6%	10.72% 0.1 pts better	No Different than the National Rate · Eligible stays 88 · Observed rate 9.09% · Lower 95% interval 7.09%
Discharge to community	53.09%	50.57% 2.5 pts better	No Different than the National Rate · Eligible stays 84 · Observed rate 50% · Lower 95% interval 41.83%
Medicare spending per beneficiary	0.68	1.02 0.3 pts better
Drug regimen review with follow-up	0%	95.27% 95.3 pts worse	Numerator 0 · Denominator 32
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 32
Discharge self-care score	25.81%	53.69% 27.9 pts worse	Numerator 8 · Denominator 31
Discharge mobility score	35.48%	50.94% 15.5 pts worse	Numerator 11 · Denominator 31
Pressure ulcers or injuries, new or worsened	3.13%	2.29% 0.8 pts worse	Numerator 1 · Denominator 32 · Adjusted rate 3.18%
Healthcare-associated infections requiring hospitalization	6.27%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 42 · Observed rate 2.38% · Lower 95% interval 3.18%
Staff COVID-19 vaccination coverage	11.36%	8.2% 3.2 pts better	Numerator 10 · Denominator 88
Staff flu vaccination coverage	99.01%	42% 57 pts better	Numerator 100 · Denominator 101
Discharge function score	32.26%	56.45% 24.2 pts worse	Numerator 10 · Denominator 31
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.7 0.2 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.2 About the same	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	86.9% 13.1 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	93.5% 6.5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	3.2% 3.2 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	6.5% 6.5 pts better	11.4% 11.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight	1.2%	6.5% 5.3 pts better	5.4% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q4 0.0% · 4Q avg 1.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	12.0%	19.9% 7.9 pts better	19.6% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 9.5% · Q3 10.0% · Q4 14.3% · 4Q avg 12.0%
Percentage of long-stay residents who received an antipsychotic medication	26.2%	18.7% 7.5 pts worse	16.7% 9.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 26.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	6.5%	19.6% 13.1 pts better	16.3% 9.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	19.7%	18.3% 1.4 pts worse	14.9% 4.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · 4Q avg 19.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.9% 0.9 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	1.7% 1.7 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	11.4%	26.4% 15 pts better	19.8% 8.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 9.1% · Q3 10.1% · Q4 8.7% · 4Q avg 11.4%
Percentage of long-stay residents with pressure ulcers	5.2%	5.3% 0.1 pts better	5.1% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 3.8% · Q3 7.9% · Q4 2.9% · 4Q avg 5.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.5%	68.9% 21.6 pts better	81.7% 8.8 pts better	Short Stay · 2024Q4-2025Q3 · Q2 95.0% · Q3 88.5% · Q4 82.6% · 4Q avg 90.5%
Percentage of short-stay residents who had an outpatient emergency department visit	10.8%	9.8% 1 pts worse	12.0% 1.2 pts better	Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 8.8% · Expected 9.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	68.7% 31.3 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	12.8%	23.1% 10.3 pts better	23.9% 11.1 pts better	Short Stay · 20240701-20250630 · Adjusted 12.8% · Observed 8.8% · Expected 16.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-21 · Fire 2025-02-21

1 health deficiencies

Top issue: Infection Control (1 deficiency)

7 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2024-04-25 · Fire 2024-04-25

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-07-20 · Fire 2023-07-20

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

3 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-21

F · Potential for more than minimal harm 2025-02-21

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-03-21

E · Potential for more than minimal harm 2025-02-21

K133 · Construction Deficiencies

Fire Safety

Install a two-hour-resistant firewall separation.

Corrected 2025-03-21

E · Potential for more than minimal harm 2025-02-21

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-03-21

E · Potential for more than minimal harm 2025-02-21

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-03-21

E · Potential for more than minimal harm 2025-02-21

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2025-03-21

E · Potential for more than minimal harm 2025-02-21

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-03-21

E · Potential for more than minimal harm 2024-04-25

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2024-05-20

E · Potential for more than minimal harm 2024-04-25

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-05-20

E · Potential for more than minimal harm 2024-04-25

K541 · Services Deficiencies

Fire Safety

Install properly constructed and protected linen or trash chutes.

Corrected 2024-05-20

E · Potential for more than minimal harm 2024-04-25

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-05-20

E · Potential for more than minimal harm 2023-07-20

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2023-08-30

E · Potential for more than minimal harm 2023-07-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-08-30

C · Minimal harm 2023-07-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-08-30

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-02-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-12

D · Potential for more than minimal harm 2024-04-25

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-05-27

D · Potential for more than minimal harm 2024-04-25