Health inspection·February 5, 2026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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. Oxygen tubing should be placed in a plastic bag attached to the concentrator when not in use.Observation of the facility nurses' station on February 4, 2026, at 12:15 p.m., with Employee E3, Infection Control Nurse, Employee E3, revealed that the tube feeding stand for Resident R1 was inside the nurse's station medication room. It was revealed that the stand had stains of dried tube feeding formula indicating the stand and the machine was not cleaned or disinfected prior to storing in the nurse's station. Employee E3 stated staff removed the stand and the pump after the administration and confirmed that it was not cleaned or disinfected. Employee E3 stated staff should disinfect or clean the pump and stand when removed out of resident room to prevent cross-contamination.Observation of Resident R8 on February 3, 2026, at 11:30 a.m. and on February 4, 2026, at 12:30 p.m revealed Resident R8 had an oxygen concentrator in his room, the oxygen tubing was undated and was not bagged.Observation of Resident R3 on February 3, 2026, at 11:35 a.m. revealed Resident R3 had an oxygen concentrator in his room, the oxygen tubing was undated and was not bagged. There was a nebulizer tubing on the nightstand which was not bagged.Observation of Resident R3 on February 4, 2026, at 12:35 p.m. revealed Resident R3 had an oxygen concentrator in his room, the oxygen tubing was not bagged. There was a nebulizer tubing on the nightstand which was not bagged.Employee E3 confirmed the above finding on on February 4, 2026, at 12:15 p.m., during a tour of the nursing unit.28 Pa. Code 211.12(d)(1)(2)(3)(5)Nursing service Residents Affected - Few Page 1 of 2 395718 395718 02/05/2026 Waverly Heights 1400 Waverly Road Gladwyne, PA 19035

F 0944 Level of Harm - Potential for minimal harm Residents Affected - Many Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Based on the review of facility provided documentation and interview with staff, it was determined that facility did not ensure to include as part of its Quality Assurance and Performance Improvement (QAPI) program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for four of five employees reviewed (Employees E4, E5, E6 ,E7 and E8)Findings include:Review of Employee education record for Employee E4, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.Review of Employee education record for Employee E5, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.Review of Employee education record for Employee E6, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.Review of Employee education record for Employee E7, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.Review of Employee education record for Employee E8, Nurse Aide, revealed no evidence of training provided regarding facility's QAPI program.Findings confirmed with Administrator on February 5, 2026 at 12:30 p.m 28 Pa Code 201.14(a)Responsibility of licensee28 Pa Code 201.20(a)(d) Staff development 395718 Page 2 of 2