Inspection Reports for Center at Waterfront LLC
1541 NORTH LINDBERG CIRCLE, KS, 67206
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
53 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 53
Deficiencies: 1
Apr 2, 2025
Visit Reason
The inspection was conducted as a result of an abbreviated survey combined with a complaint investigation related to an elopement incident involving Resident 1 (R1).
Findings
The facility failed to provide adequate supervision and interventions to prevent elopement of a cognitively impaired resident at moderate risk, resulting in an immediate jeopardy situation. Corrective actions were completed prior to the surveyor's entrance and verified on-site.
Complaint Details
The complaint investigation involved Resident 1 who eloped from the facility on 03/13/25. The facility was alerted by a community member and the resident's representative. The resident was found outside uninjured. The investigation confirmed the facility's failure to implement adequate supervision and care plan interventions prior to the elopement.
Severity Breakdown
J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision and interventions to prevent elopement of a cognitively impaired resident at moderate risk. | J |
Report Facts
Census: 53
Elopement risk score: 5
Elopement risk score: 6
Elopement risk score: 11
Temperature: 78
Time of elopement: 1140
Time resident found: 1202
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Provided statements about elopement risk evaluations and observation rooms. |
| Certified Nurse Aide M | Certified Nurse Aide | Reported last seeing Resident 1 and blood sugar check timing related to elopement. |
| Certified Medication Aide R | Certified Medication Aide | Described staff knowledge of residents at risk for elopement and prevention methods. |
| Social Services X | Social Services | Reported on communication from a stranger using Resident 1's phone and notification process. |
| Administrative Nurse D | Administrative Nurse | Verified elopement risk status and investigation details. |
| Administrative Staff A | Administrative Staff | Reported on notification from Resident 1's representative and locating Resident 1 after elopement. |
Inspection Report
Re-Inspection
Deficiencies: 0
May 9, 2024
Visit Reason
An offsite revisit survey was conducted on 05/09/24 to verify correction of all previous deficiencies cited on 03/18/24.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 04/24/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 14
Mar 18, 2024
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on 3/18/24.
Findings
The Plan of Correction addresses multiple deficiencies related to resident care, including access to mirrors, notification of discharges, bed hold notices, care area assessments, baseline care plans, assistance with shaving, treatment of skin injuries, wound care, dialysis communication, medication administration, antipsychotic medication monitoring, and sanitation in food preparation and dining areas. The facility outlines corrective actions, staff education, audits, and monitoring to achieve substantial compliance by late April 2024.
Severity Breakdown
D: 11
E: 2
F: 2
Deficiencies (14)
| Description | Severity |
|---|---|
| Failure to provide reasonable accommodations to residents’ physical environment to have access to a mirror when needed. | D |
| Failure to ensure all residents who discharge from a skilled stay receive a Notice of Medicare Non-Coverage (NOMNC) within 2 days of discharge. | D |
| Failure to notify the Ombudsman when residents discharge or transfer from the facility as required. | E |
| Failure to provide a notice of bed hold upon discharge to hospital or within 24 hours if emergent discharge. | D |
| Failure to develop Care Area Assessments for further investigation and development of the comprehensive care plan. | E |
| Failure to ensure baseline care plans are developed within 48 hours of admission as required. | D |
| Failure to ensure residents receive assistance with shaving as needed. | D |
| Failure to ensure residents receive appropriate treatment for skin injuries and sanitary dressing changes. | D |
| Failure to appropriately clean pressure ulcers during treatments as per standards of care. | D |
| Failure to ensure an appropriate system for ongoing communication with the dialysis facility regarding dialysis care and services. | D |
| Failure to ensure staff follows physician ordered parameters for administration of medications. | D |
| Failure to monitor all residents on an antipsychotic medication appropriately. | D |
| Failure to prepare and store food under sanitary conditions to prevent potential for food borne illness. | F |
| Failure to provide a safe, functional, sanitary, and comfortable environment for residents and staff, including cleaning of floors and drains. | F |
Report Facts
Deficiency tags: 15
Dates for substantial compliance: Apr 24, 2024
Education completion dates: Apr 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Larry Nanny | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Added Plan of Correction entry | |
| Teresa Edwards | Modified Plan of Correction entry |
Inspection Report
Re-Inspection
Census: 60
Deficiencies: 15
Mar 18, 2024
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements including resident care, medication management, and facility environment.
Findings
The facility was cited for multiple deficiencies including failure to provide reasonable accommodations, failure to notify residents and Ombudsman of transfers and discharges, incomplete resident assessments and care plans, failure to provide assistance with activities of daily living, inadequate wound care, failure to follow medication orders, inadequate dialysis communication, unsanitary food preparation areas, and unsafe kitchen environment.
Severity Breakdown
SS=D: 12
SS=E: 2
SS=F: 2
Deficiencies (15)
| Description | Severity |
|---|---|
| Failure to provide reasonable accommodations to Resident 29 who could not access the mirror for shaving. | SS=D |
| Failure to notify Resident 167 of Medicare Non-Coverage at least two days before end of Medicare Part A stay. | SS=D |
| Failure to notify State Ombudsman of resident discharges/transfers for four residents (R62, R60, R18, R44). | SS=E |
| Failure to provide written notice specifying bed hold policy duration and cost to residents R18 and R44 at hospital transfer. | SS=D |
| Failure to complete comprehensive assessments (CAAs) for seven residents including R18, R22, R29, R3, R35, R40, and R43. | SS=E |
| Failure to develop baseline care plans including dialysis and psychotropic medication for residents R20, R214, and R221. | SS=D |
| Failure to provide assistance with shaving for Resident 29 who could not see the mirror. | SS=D |
| Failure to provide appropriate treatment and sanitary dressing changes for Resident 3's skin injuries and wounds. | SS=D |
| Failure to cleanse pressure ulcer wound before applying new dressing for Resident 5. | SS=D |
| Failure to ensure ongoing communication with dialysis facility regarding care for Resident 214. | SS=D |
| Failure to follow physician ordered parameters for administration of Midodrine medication for Resident 29. | SS=D |
| Failure to administer sliding scale insulin as ordered for Resident 18. | SS=D |
| Failure to monitor Resident 35 for use of antipsychotic medication including lack of AIMS assessment. | SS=D |
| Failure to prepare and serve food under sanitary conditions in the kitchen including food debris on shelves, refrigerator, floor, and cutting boards. | SS=F |
| Failure to provide a safe, functional, sanitary, and comfortable environment including unsanitary kitchen floors with food debris and trash in drains. | SS=F |
Report Facts
Census: 60
Residents selected for review: 17
Stage III pressure ulcer size: 5.5
Stage III pressure ulcer size: 4.5
Stage III pressure ulcer size: 0.2
Blood pressure readings: 166
Blood pressure readings: 150
Blood glucose readings: 340
Blood glucose readings: 259
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Interviewed regarding multiple deficiencies including care plans, medication administration, dialysis communication, and wound care |
| Licensed Nurse I | Licensed Nurse | Interviewed regarding wound care and dialysis communication |
| Administrative Staff A | Administrative Staff | Interviewed regarding care plan completion and Ombudsman notification |
| Administrative Nurse F | Administrative Nurse | Observed providing wound care and interviewed regarding wound treatment |
| Consultant GG | Consultant | Interviewed regarding wound care expectations |
| Licensed Nurse K | Licensed Nurse | Interviewed regarding insulin administration and wound care |
| Certified Nurse Aide Q | Certified Nurse Aide | Interviewed regarding assistance with shaving for Resident 29 |
| Certified Nurse Aide N | Certified Nurse Aide | Interviewed regarding assistance with shaving for Resident 29 |
| Certified Nurse Aide M | Certified Nurse Aide | Interviewed regarding resident mobility and pain |
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 23, 2022
Visit Reason
The document is a Plan of Correction submitted in response to a health survey of the facility.
Findings
The health survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, requirements for long term care facilities.
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 23, 2022
Visit Reason
Resurvey conducted to verify correction of previous deficiencies at the facility.
Findings
The health survey resulted in no deficiency citations, indicating compliance with applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Inspection Report
Routine
Deficiencies: 0
Nov 19, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 1, 2020
Visit Reason
The plan of correction document addresses the Health Survey and complaint #KS00150737 for the facility.
Findings
The Health Survey and complaint resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B, requirements for long term care facilities.
Complaint Details
Complaint #KS00150737 was investigated and resulted in no deficiency citations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 1, 2020
Visit Reason
The health survey was conducted in response to complaint #KS00150737 to assess compliance with applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The survey resulted in a finding of no deficiency citations with respect to the applicable regulations.
Complaint Details
Complaint #KS00150737 was investigated and found to have no deficiencies.
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