Pennsylvania Department of Health
 WATERFRONT SURGERY CENTER, LLC
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
WATERFRONT SURGERY CENTER, LLC
Inspection Results For:

There are  45 surveys for this facility. Please select a date to view the survey results.

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WATERFRONT SURGERY CENTER, LLC - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

This report is the result of a full Medicare recertification survey initiated on February 19, 2026 and concluded on February 20, 2026 at Waterfront Surgery Center, LLC. It was determined the facility was in compliance with the requirements of 42 CFR, Title 42, Part 416 - Conditions of Participation for Ambulatory Surgical Centers.



 Plan of Correction:


Initial comments:

This report is the result of a full State Licensure survey initiated on February 19, 2026 and concluded on February 20, 2026 at Waterfront Surgery Center, LLC. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.



 Plan of Correction:


416.44(a)(1) STANDARD PHYSICAL ENVIRONMENT:Not Assigned
The ASC must provide a functional and sanitary environment for the provision of surgical services.
Each operating room must be designed and equipped so that the types of surgery conducted can be performed in a manner that protects the lives and assures the physical safety of all individuals in the area.

Observations:

Based on a review of facility policy, documentation and interview with staff (EMP), it was determined that the facility failed to consistently maintain the required humidity levels in Operating Room two (OR), and temperature in the OR Clean Workroom and take corrective actions when out of acceptable range.

Findings include:

On February 20, 2026, a review of facility policy "Departmental Checks, Policy Number: 20.13", last revised January 18, 2021, revealed: "RN will perform a daily check of all equipment located in his/her unit and document on departmental log sheet." ... "OR daily checks are to include proper functioning of the following: 1. Humidity (MUST BE BETWEEN 35-60%) 2. Temperature (MUST BE BETWEEN 68-73February 20, 2026, a review of the OR two temperature and humidity log for January 2026 revealed that out of 17 operational days, the humidity in OR 2 was below 35 % for 16 days without intervention.

On February 20, 2026, a review of the OR Clean Workroom temperature and humidity log revealed that 24 of the previous 25 months the temperature in the OR Clean Room exceeded 73without adjustment.

An interview on February 20, 2026, at 1:00 PM, with EMP2 confirmed the above findings.




 Plan of Correction - To be completed: 03/11/2026

On March 2nd, 2026, The Departmental checks policy was revised to reflect the ASHRAE standards for humidity which specifies between 20-60% and temperature of 68 -75 degrees, the paperwork must have an action taken reflecting a written statement on what was done to rectify the out-of-range temperature or humidity. The policy now reflects that the director of nursing must be made aware of any deviations from the ranges. The director of nursing will follow up to monitor the temperature and humidity for the day.
On Monday March 16th, 2026, the board of managers will meet and vote on the proposed policy revisions.
Beginning March 2nd, 2026, the Director of nursing will monitor for a period of 30 days to ensure adherence to policy revisions. Compliance goal will be set at 100%. Once compliance goal is met, periodic monitoring will be conducted to confirm continued compliance. Results of all audits will be reported to the patient safety committee, quality assurance committee, and the Board of managers.

553.3 (1) LICENSURE Governing Body Responsibilities:State only Deficiency.
553.3
Governing Body responsibilities include:

(1) Conforming to all applicable Federal, State, and local laws.

Observations:

Based on a review of facility documents and staff interview (EMP), it was determined the facility failed to conform to an applicable State law.

The Waterfront Surgery Center was not in compliance with the following state law: The Medical Care Availability and Reduction of Error Act, 40 P.S.Patient Safety Officer: Section 309(2) A patient safety officer of a medical facility shall do all of the following: ... Ensure the investigation of all reports of serious events and incidents "


This was not met as evidenced by:

Based on a review of facility documents and staff interview (EMP), it was determined the facility failed to document an investigation in nine of eleven reported serious events (MR21; MR22; MR23; MR24; MR26; MR27; MR28; MR29; and MR30).

Findings include:

On February 20, 2026, a review of the facility, "Patient Safety Plan" (Last Revised: 1/12/2026) was completed and revealed the following: "Authority and Responsibility: Governing Body: The overall authority for direction of the Patient Safety Plan rests with the Surgery Center's Governing Body. The Governing Body has delegated its authority to implement and maintain the various components of the Patient Safety Plan to the Medical Director ... Patient Safety Officer... Overseeing and ensuring the reasonable investigations of Reportable Patient Events and Infrastructure Failures ... Analyzing investigations of Reportable Patient Events and taking such action as is immediately necessary to ensure patient safety."

On February 20, 2026, a review of MR21 revealed that MR21 underwent colonoscopy on 4/14/2025. MR21 developed " heavy rectal bleeding " and was admitted to a local hospital for "observation." This incident was reported as a serious event; however, there was no investigation documented.

On February 20, 2026, a review of MR22 revealed that MR22 underwent a colonoscopy with multiple polypectomies and biopsy on 4/22/2025. On 4/23/20205, MR22 was advised to seek care at the emergency room for rectal bleeding. This incident was reported as a serious event; however, there was no investigation documented.

On February 20, 2026, a review of MR23 revealed that MR23 underwent colonoscopy on 4/28/2025. MR23 developed dysphasia, slurred speech and a loss of taste after discharge and was referred to a local emergency room. This incident was reported as a serious event; however, there was no investigation documented.

On February 20, 2026, a review of MR24 revealed that MR24 underwent a colonoscopy on 5/2/2025 and was sent to the emergency room on 5/2/2025 at 5:00 PM for left sided abdominal pain. This incident was reported as a serious event; however, there was no investigation documented.

On February 20, 2026, a review of MR26 revealed that MR26 underwent an esophagogastroduodenoscopy (EGD) on 6/12/2025 and was sent to the emergency room directly from the facility on 6/12/2025 with blurred vision in the left eye. This incident was reported as a serious event; however, there was no investigation documented.

On February 20, 2026, a review of MR27 revealed that MR27 underwent colonoscopy on 7/11/2025. MR27 vomited during the procedure, developed " crackles at the left base " and was emergently transferred via EMS to a local hospital. This incident was reported as a serious event; however, there was no investigation documented.

On February 20, 2026, a review of MR28 revealed that MR28 underwent colonoscopy on 7/22/2025. MR28 developed "rectal bleeding." MR28 was advised to seek treatment in the emergency room. A CT scan confirmed bleeding at the polypectomy site. This incident was reported as a serious event; however, there was no investigation documented.

On February 20, 2026, a review of MR29 revealed that MR29 underwent an EGD on 9/8/2025. During the evening of 9/8/2025, MR29 was unable to void post procedure. The physician advised MR29 to seek care in the emergency room. This incident was reported as a serious event; however, there was no investigation documented.

On February 20, 2026, a review of MR30 revealed that MR30 was to undergo a right excision of a cataract on 10/14/2025. The procedure was aborted secondary to zonular dehiscence. This incident was reported as a serious event; however, there was no investigation documented.

On February 20, 2026, between 11:15 AM and 11:42 AM, EMP1, EMP2, and EMP3 confirmed that no investigation was completed on the above events.














 Plan of Correction - To be completed: 03/11/2026

On Monday March 16th,2026 All serious reports and incidents will have a root cause analysis investigation attached to the incident report requiring the root cause analysis of the event. The patient safety officer will monitor the root cause analysis and the final investigation follow up on the events. The Director of nursing will monitor for a period of 6 months to ensure adherence. Compliance goal will be set for 100%. Once compliance goal is met, periodic monitoring will be conducted to confirm continued compliance. Results of all audits will be reported to the patient safety committee, quality assurance committee, and the Board of managers.
553.3 (8)(iii) LICENSURE Governing Body Responsibilities:State only Deficiency.
553.3 Governing Body responsibilities include:
(8) Establishing personnel policies and practices which adequately support
sound patient care to include, the following:
(iii) Personnel records shall include current information relative to periodic work performance evaluations.


Observations:


Based on review facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed to review performance annually for five of ten personnel files reviewed (PF6, PF7, PF8, PF9 and PF10).

Findings Include:

Review on February 20, 2026, of the facility's personnel policy, revealed, ""... Waterfront Surgery Center personnel shall be provided with written performance evaluations after orientation and annually therafter at the calender year end. A copy of the performance evaluation will be kept in the personnel file for each employee. The employee, his or her immediate supervisor, or Executive Director shall sign all performance evaluations. ..."

Review on February 20, 2026, of the facility's policy "WSC Employee Orientation", revealed "... The knowledge/skills requirements of the orientation will be the successful completion of the orientation course and the completion of the performance checklist specific to the position . ...Also required is the understanding of the annual competency review, performance appraisal, mandatory in-services, and maintenance of current nursing practice and knowledge base. ..."

The following PF's were reviewed on February 20, 2026:

A review of PF6 revealed that a performance evaluation existed in the file and was completed on November 26, 2025 by EMP2 but was never signed by the employee.

A review of PF7 revealed that a performance evaluation existed in the file and was completed on November 26, 2025 by EMP2 but was never signed by the employee.

A review of PF8 revealed that a performance evaluation existed in the file and was completed on November 26, 2025 by EMP2 but was never signed by the employee.

A review of PF9 revealed that a performance evaluation existed in the file and was completed on November 26, 2025 by EMP2 but was never signed by the employee.

A review of PF10 revealed that a performance evaluation existed in the file and was completed on November 26, 2025 by EMP2 but was never signed by the employee.

Interview on February 20, 2026, at approximately 11:00 AM with EMP2 confirmed the performance evalutions were completed and placed in the files but not given to the employees for signatures for PF6, PF7, PF8, PF9, and PF10.










 Plan of Correction - To be completed: 03/11/2026

On Monday March 2nd, 2026. All yearly performance evaluations for the previous year must be written by the end of January. Evaluations will then be delivered, reviewed with employees, and signed by the end of February.
The performance evaluation form has been updated to include an Executive Director signature line. Once all annual evaluations are completed, they will be reviewed by the Executive Director to ensure that all required signatures and dates are accurate and compliant. The previous year evaluations will be completed by 4/6/26. If evaluations are not completed the remediation plan is to have a yearly evaluation check sheet.
567.43 LICENSURE Ventilation System:State only Deficiency.
The ventilation system shall be inspected and maintained in accordance with the written maintenance schedule to ensure that a properly conditioned air supply meeting minimum filtration, humidity and temperature requirements is provided in critical areas such as the surgical and recovery suites under
Chapter 571 (relating to construction standards).

Observations:

Based on a review of facility policy, documentation, and interview with staff (EMP), it was determined that the facility failed to consistently maintain the required humidity levels in Operating Room two (OR), and temperature in the OR Clean Workroom and take corrective actions when out of acceptable range.

Findings include:

On February 20, 2026, a review of facility policy "Departmental Checks, Policy Number: 20.13", last revised January 18, 2021, revealed: "RN will perform a daily check of all equipment located in his/her unit and document on departmental log sheet." ... "OR daily checks are to include proper functioning of the following: 1. Humidity (MUST BE BETWEEN 35-60%) 2. Temperature (MUST BE BETWEEN 68-73February 20, 2026, a review of the OR two temperature and humidity log for January 2026 revealed that out of 17 operational days, the humidity in OR 2 was below 35 % for 16 days without intervention.

On February 20, 2026, a review of the OR Clean Workroom temperature and humidity log revealed that 24 of the previous 25 months the temperature in the OR Clean Room exceeded 73without adjustment.

An interview on February 20, 2026, at 1:00 PM, with EMP2 confirmed the above findings.




 Plan of Correction - To be completed: 03/11/2026

On March 2nd, 2026, The Departmental checks policy was revised to reflect the ASHRAE standards for humidity which specifies between 20-60% and temperature of 68 -75 degrees, the paperwork must have an action taken reflecting a written statement on what was done to rectify the out-of-range temperature or humidity. The policy now reflects that the director of nursing must be made aware of any deviations from the ranges. The director of nursing will follow up to monitor the temperature and humidity for the day.
On Monday March 16th, 2026, the board of managers will meet and vote on the proposed policy revisions.
Beginning March 2nd, 2026, the Director of nursing will monitor for a period of 30 days to ensure adherence to policy revisions. Compliance goal will be set at 100%. Once compliance goal is met, periodic monitoring will be conducted to confirm continued compliance. Results of all audits will be reported to the patient safety committee, quality assurance committee, and the Board of managers.


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