Center at Waterfront LLC

Inspectors wroteThe facility reported a census of 54 residents. The facility identified five Certified Nurse Aides (CNA) employed for more than 12 months. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for the five CNAs reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility.

Inspectors wroteThe facility reported a census of 54 residents and one main kitchen. Based on observation, record review and interview the facility failed to prepare and serve food under sanitary conditions to prevent potential for food borne bacteria.

Inspectors wroteThe facility had a census of 54 residents. The sample included 14 residents with three residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers for Resident (R) 64, R7, and R97. Additionally, one resident reviewed for facility discharge, the facility failed to complete a recapitulation of R66's stay in the facility.

Inspectors wroteThe facility reported a census of 54 residents. Thirty-nine medication administrations were observed. Based on observation, interview and record review the facility failed to ensure a medication error rate of less than five percent when 30 errors were identified, resulting in a medication error rate of 79.62 percent.

Inspectors wroteThe facility reported a census of 54. Based on observation, interview and record review the facility failed to ensure adequate infection control related to Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for residents with indwelling medical devices including urinary catheters ( a tube inserted directly into the bladder to drain urine) and peripherally inserted central catheters (PICC-a thin, flexible tube that is inserted into a vein in the upper arm and threaded into a large vein above the heart) and residents with wounds.

Inspectors wroteThe facility identified a census of 54 residents. The sample included 14 residents with one sampled for baseline care plan. Based on observation, interview, and record review, the facility failed to complete a thorough baseline care plan for Resident (R) 97 to include contact isolation for clostridium difficile (C-diff: contagious bacteria characterized by foul-smelling frequent loose bowel movements) and for R70 to include fall interventions.

Inspectors wroteThe facility reported a census of 54 residents. The sample included 14 residents with one resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to offer and provide assistance with facial hair removal for Resident (R) 38.

Inspectors wroteThe facility reported a census of 54 residents with a sample of 14 residents which included two reviewed for accidents/falls. Based on observation, interview, record review, the facility failed to thoroughly investigate a fall to identify causative factors in order to implement appropriate immediate interventions following falls for Residents (R)64 and R75.

Inspectors wroteThe facility reported a census of 54 residents. Based on observations and interviews, the facility failed to maintain and/or dispose of kitchen garbage and refuse properly.

Inspectors wroteThe facility reported a census of 53 residents with three sampled for elopement (when a resident leaves the premises or a safe area without authorization and/or any necessary supervision). Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure a safe and secure environment and prevent an elopement for cognitively impaired Resident (R)1, who was at moderate risk for elopement. On 03/13/25 at approximately 11:40 AM, R1 left the second floor, went to the first floor, and then exited the facility. Between 11:45 AM and 12:00 PM, R1's representative called the facility to alert the facility that she had received a call from a community member who reported they saw R1 outside the facility. Upon learning this information, staff conducted a search, and staff located R1 outside the facility. R1 returned to the facility uninjured. [...]

Inspectors wroteThe facility reported a census of 60 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria.

Inspectors wroteThe resident reported a census of 60 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff.

Inspectors wroteThe facility reported a census of 60 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure staff notified the State Ombudsman of four of the four discharged /transferred residents reviewed. Resident (R)62 who left the facility against medical advice, and R 60, R18 and R 44 who transferred to acute care.

Inspectors wrote- Review of Resident (R)43's electronic medical record (EMR) included a diagnosis of osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. She received scheduled and non-medication interventions for pain. The resident reported frequent pain in the past five days of the look back period which affected her sleep, day to day activities that interfered with her therapy. She reported her worst pain in the five days was a seven out of a scale of 1-10 pain scale. She received opioid medications (a class of drugs that derive from, or mimic, natural substances found in the opium poppy plant. [...]

Inspectors wroteThe facility reported a census of 60 residents with 17 selected for review, which included two residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide one Resident (R)29, reasonable accommodations to his physical environmment, when he could not access the mirror.

Inspectors wroteThe facility reported a census of 60 residents. Based on interview and record review, the facility failed to notify one Resident (R) 167, a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered Part A stay.

Inspectors wroteThe facility reported a census of 60 residents with 17 residents sampled, including three residents reviewed for hospitalization. Based on interview and record review, the facility failed to provide the two Residents (R)18 and R 44 and/or their representative with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfer to the hospital.

Inspectors wroteThe facility reported a census of 60 residents with 17 residents selected for review. Based on observation, interview, and record review, the facility failed to develop baseline a care plans for three residents, that included one Resident (R)20 regarding not having a baseline care plan, R214, regarding failure to include dialysis (procedure where impurities or wastes were removed from the blood), and R 221, regarding failure to include psychotropic (alters mood or thought) medication.

Inspectors wroteThe facility reported a census of 60 residents with 17 selected for review, which included two residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide one Resident (R)29, assistance with facial shaving.

Inspectors wroteThe facility reported a census of 60 residents with 17 residents selected for review, which included three residents reviewed for skin issues. Based on observation, interview, and record review, the facility failed to ensure one Resident (R)3, of the three residents received appropriate treatment for an unidentified skin injury and sanitary dressing change.

Inspectors wroteThe facility reported a census of 60 residents with 17 residents sampled, including two residents reviewed for pressure ulcers (PU). Based on observation, interview and record review, the facility failed to appropriately clean the PU of one Resident (R)5, by failing to cleanse the wound before applying a new dressing to the area.

Inspectors wroteThe facility reported a census of 60 residents with 17 residents sampled, including one resident sampled for dialysis (procedure where impurities or wastes were removed from the blood). Based on observation, interview, and record review, the facility failed to ensure an appropriate system for ongoing communication with the dialysis facility regarding dialysis care and services for Resident (R)214.

Inspectors wroteThe facility reported a census of 60 residents with 17 selected for review which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure staff followed physician ordered parameters for administration of medications for two (Residents) R 29 and R 18.

Inspectors wroteThe facility reported a census of 60 residents with 17 residents sampled including five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor one Resident (R)35 for use of antipsychotic medications (drugs used to treat psychosis-related conditions and symptoms).