Inspection Reports for
Center at Waterfront LLC
1541 NORTH LINDBERG CIRCLE, WICHITA, KS, 67206
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
68% occupied
Based on a January 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 19, 2026
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2026-01-15.
Findings
All previously cited deficiencies have been corrected as of 2026-02-18 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Jan 22, 2026
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a regulatory survey.
Findings
The facility identified multiple deficiencies including issues with transfer and discharge documentation, baseline care plans, assistance with ADLs, fall prevention, CNA education compliance, medication administration timeliness, food storage and safety, trash disposal, and infection prevention and control practices. Corrective actions, systemic changes, staff education, and ongoing monitoring plans were implemented to address these deficiencies.
Deficiencies (9)
F628 – Transfer & Discharge Requirements: Bed-hold notices lacked patient signatures and discharge summaries were unsigned.
F655 – Baseline care plans were incomplete or non-individualized, not reflecting patient-specific needs and preferences.
F677 – Delayed response to grooming requests; care plans and CNA documentation did not clearly identify grooming needs or response times.
F689 – Falls prevention measures were inadequate; patients at risk did not have appropriate assessments or interventions.
F730 – The facility failed to ensure all CNAs completed the required 12 hours of annual continuing education, including infection prevention.
F759 – Medication administration was late during the cited shift, with contributing factors and potential patient impact identified.
F812 – Improper food storage practices including raw meats stored above ready-to-eat foods and improper glove use were identified.
F814 – Trash receptacles were not properly closed, and garbage was left on the ground near the dumpster, posing environmental risks.
F880 – Infection prevention and control failures related to PPE use, wound care, line care, and shared equipment were identified and corrected.
Report Facts
Annual continuing education hours required: 12
Audit frequency: 100
Audit duration: 4
Audit duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Smith | Administrator | Submitted the Plan of Correction to KDADS. |
| Shirley Boltz | Contact for Plan of Correction assistance. | |
| C Patterson | Added and modified the Plan of Correction. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 9
Date: Jan 15, 2026
Visit Reason
The inspection was conducted as a Health Recertification Survey and complaint survey regarding allegations in complaint number 2693970.
Complaint Details
The inspection included a complaint survey regarding allegations in complaint number 2693970.
Findings
The facility was found deficient in multiple areas including failure to provide written bed hold notices and discharge summaries, incomplete baseline care plans, inadequate assistance with activities of daily living, insufficient fall investigations, lack of annual CNA performance reviews, high medication error rates, unsanitary food preparation practices, improper garbage disposal, and inadequate infection prevention and control practices related to Enhanced Barrier Precautions.
Deficiencies (9)
The facility failed to provide written bed hold notices and timely written notification for hospital transfers for residents R64, R7, and R97. The facility also failed to complete a discharge summary recapitulation for resident R66.
The facility failed to complete thorough baseline care plans for residents R97 and R70, omitting contact isolation for C-diff and fall interventions respectively.
The facility failed to provide necessary assistance with facial hair removal for resident R38 despite documented need and resident request.
The facility failed to thoroughly investigate falls for residents R64 and R75 to identify causative factors and implement appropriate interventions.
The facility failed to complete annual performance reviews for five Certified Nurse Aides employed more than 12 months.
The facility failed to maintain a medication error rate below 5 percent, with 30 errors observed out of 39 medication administrations, resulting in a 79.62 percent error rate.
The facility failed to prepare and serve food under sanitary conditions, including handling food with soiled gloves and leaving food packages open in refrigeration.
The facility failed to properly maintain and dispose of kitchen garbage and refuse, with outside bins left open during observation.
The facility failed to ensure adequate infection control related to Enhanced Barrier Precautions for residents with indwelling devices and wounds, including lack of signage and PPE use by staff.
Report Facts
Census: 54
Medication administrations observed: 39
Medication errors identified: 30
Medication error rate: 79.62
Certified Nurse Aides without annual performance review: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Reported uncertainty about bed hold form completion |
| Licensed Nurse J | Licensed Nurse | Reported discharge medication review process |
| Administrative Nurse F | Administrative Nurse | Reported incomplete discharge summary and baseline care plan issues |
| Administrative Staff C | Admission Coordinator | Reported documentation practices for bed hold notices |
| Administrative Nurse D | Administrative Nurse | Reported expectations for discharge summary and bed hold compliance |
| Certified Nurse Aide M | Certified Nurse Aide | Reported education on isolation precautions |
| Consultant Staff JJ | Consultant Staff | Reported therapy staff role in ADL care |
| Licensed Nurse L | Licensed Nurse | Observed late medication administration |
| Licensed Nurse G | Licensed Nurse | Observed late medication administration |
| Dietary Staff CC | Dietary Staff | Observed unsanitary food handling practices |
| Dietary Manager BB | Dietary Manager | Reported expectations for handwashing and glove use |
| Certified Nurse Aide V | Certified Nurse Aide | Observed failure to use gown with Enhanced Barrier Precautions |
| Licensed Nurse K | Licensed Nurse | Observed failure to use gown with Enhanced Barrier Precautions |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Apr 2, 2025
Visit Reason
The inspection was conducted as a result of an abbreviated survey and complaint investigation triggered by an elopement incident involving Resident 1 (R1).
Complaint Details
The complaint investigation was triggered by an elopement incident on 03/13/25 when Resident 1 left the second floor, exited the building, and was found outside by staff after a community member alerted the resident's representative. The facility was informed of immediate jeopardy due to failure to provide adequate supervision and interventions.
Findings
The facility failed to provide adequate supervision and interventions to prevent an elopement of a cognitively impaired resident at moderate risk, resulting in immediate jeopardy. Corrective actions were completed prior to the surveyor's entrance and the deficiency was cited as past noncompliance.
Deficiencies (1)
F 689: The facility failed to ensure adequate supervision and interventions to prevent an elopement for a cognitively impaired resident at moderate risk, who left the facility unsupervised and was found outside uninjured.
Report Facts
Resident census: 53
Wandering Risk Assessment score: 5
Wandering Risk Assessment score: 6
Wandering Risk Assessment score: 11
Temperature: 78
Time of elopement: 1140
Time resident found: 1202
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 9, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-03-18.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2024-04-24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 9, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-03-18.
Findings
All deficiencies cited in the prior inspection have been corrected as of 2024-04-24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Mar 18, 2024
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during a regulatory inspection.
Findings
The facility outlined corrective actions to address multiple deficiencies including resident access to mirrors, notification of discharges to the Ombudsman, bed hold notices, development of Care Area Assessments, baseline care plans, assistance with shaving, treatment of skin injuries, wound care, dialysis communication, medication administration parameters, antipsychotic medication monitoring, and food sanitation.
Deficiencies (14)
F558-D: The facility will provide reasonable accommodations for residents to access mirrors, including alternative mirrors or assistance as needed.
F582-D: The facility will ensure all residents discharged from skilled stays receive a Notice of Medicare Non-Coverage within 2 days of discharge.
F623-E: The facility will notify the Ombudsman monthly of resident discharges or transfers as required.
F625-D: The facility will provide a notice of bed hold upon discharge to hospital or within 24 hours if emergent, specifying bed hold costs.
F636-E: The facility will develop Care Area Assessments for triggered care plan areas and educate MDS Coordinators on this requirement.
F655-D: The facility will ensure baseline care plans are developed within 48 hours of admission and kept updated until comprehensive care plans are developed.
F676-D: The facility will ensure residents receive assistance with shaving and access to mirrors as needed or requested.
F684-D: The facility will ensure appropriate treatment for skin injuries and sanitary dressing changes with staff education and audits.
F686-D: The facility will ensure proper cleaning of pressure ulcers during treatments per standards of care with staff education and audits.
F698-D: The facility will ensure ongoing communication with dialysis facilities regarding dialysis care and services with staff education and audits.
F757-D: The facility will ensure staff follow physician ordered parameters for medication administration with education and audits.
F758-D: The facility will monitor all residents on antipsychotic medication and complete AIMS assessments as indicated with staff education and audits.
F812-F: The facility will prepare and store food under sanitary conditions and implement cleaning schedules with staff education and audits.
F921-F: The facility will provide a safe, functional, sanitary, and comfortable environment with enhanced cleaning schedules and staff education.
Inspection Report
Annual Inspection
Census: 60
Deficiencies: 14
Date: Mar 18, 2024
Visit Reason
Annual health resurvey inspection of Center at Waterfront LLC to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide reasonable accommodations, failure to notify residents and Ombudsman of transfers and Medicare non-coverage, incomplete resident assessments and care plans, inadequate assistance with activities of daily living, improper medication administration, failure to monitor psychotropic medication use, unsanitary food preparation conditions, and unsafe environmental conditions.
Deficiencies (14)
F558 Reasonable Accommodations Needs/Preferences: Facility failed to provide Resident R29 assistance with shaving due to inaccessible mirror, despite resident preference to be clean shaven.
F582 Medicaid/Medicare Coverage/Liability Notice: Facility failed to notify Resident R167 of Medicare Non-Coverage at least two days before Medicare Part A stay ended.
F623 Notice Requirements Before Transfer/Discharge: Facility failed to notify State Ombudsman of four discharged/transferred residents and lacked a policy for such notification.
F625 Notice of Bed Hold Policy Before/Upon Transfer: Facility failed to provide Residents R18 and R44 written notice specifying duration and cost of bed hold policy at time of hospital transfer.
F636 Comprehensive Assessments & Timing: Facility failed to complete Care Area Assessments (CAAs) for seven residents, including R18, R22, R29, R3, R35, R40, and R43, resulting in incomplete comprehensive care plans.
F655 Baseline Care Plan: Facility failed to develop baseline care plans for Residents R20, R214, and R221, missing key elements such as dialysis and antipsychotic medication instructions.
F676 Activities Daily Living (ADLs)/Mntn Abilities: Facility failed to provide Resident R29 assistance with facial shaving as needed, impacting personal hygiene.
F684 Quality of Care: Facility failed to provide appropriate treatment and sanitary dressing changes for Resident R3's skin injuries and failed to maintain sanitary bed linens.
F686 Treatment/Services to Prevent/Heal Pressure Ulcer: Facility failed to cleanse pressure ulcer wound of Resident R5 before applying new dressing, contrary to professional standards.
F698 Dialysis: Facility failed to ensure ongoing communication with dialysis center for Resident R214, including incomplete dialysis communication forms.
F757 Drug Regimen is Free from Unnecessary Drugs: Facility failed to follow physician ordered parameters for Midodrine administration for Resident R29 and failed to administer sliding scale insulin as ordered for Resident R18.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: Facility failed to monitor Resident R35 for antipsychotic medication use, including lack of required AIMS assessment.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility failed to maintain sanitary food preparation areas including dirty shelves, stained surfaces, and deeply grooved cutting boards.
F921 Safe/Functional/Sanitary/Comfortable Environment: Facility failed to maintain a safe, sanitary, and comfortable environment including kitchen floors with food debris and dirty drains.
Report Facts
Resident census: 60
Residents reviewed: 17
Midodrine doses administered outside parameters: 7
Sliding scale insulin doses missed: 11
Stage III pressure ulcer size: 5.5
Stage III pressure ulcer size: 4.5
Stage III pressure ulcer size: 0.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including failure to notify Ombudsman, medication administration, and dialysis communication |
| Licensed Nurse I | Licensed Nurse | Named in findings related to dialysis communication and wound care |
| Licensed Nurse K | Licensed Nurse | Named in findings related to insulin administration and wound care |
| Administrative Staff A | Administrative Staff | Named in findings related to Ombudsman notification and MDS completion |
| Certified Nurse Aide Q | Certified Nurse Aide | Named in finding related to assistance with shaving for Resident R29 |
| Certified Nurse Aide N | Certified Nurse Aide | Named in finding related to assistance with shaving for Resident R29 |
| Consultant GG | Consultant | Named in wound care and pressure ulcer treatment findings |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 23, 2022
Visit Reason
Resurvey to verify correction of previous deficiencies at the long term care facility.
Findings
The health survey resulted in a finding of no deficiency citations under 42 CFR Part 483, Subpart B requirements for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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, for long term care facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 1, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific findings are detailed in this document; it serves as a corrective action plan linked to a prior deficiency report.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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
Date: Oct 1, 2020
Visit Reason
The plan of correction document addresses the results of a health survey and complaint investigation for the facility.
Findings
The health survey and complaint #KS00150737 resulted in no deficiency citations related to applicable regulations under 42 CFR Part 483, Subpart B for long term care facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 1, 2020
Visit Reason
The health survey was conducted in response to complaint #KS00150737 to assess compliance with applicable regulations for long term care facilities.
Complaint Details
Complaint #KS00150737 was investigated and found to have no substantiated deficiencies.
Findings
The survey resulted in a finding of no deficiency citations with respect to applicable regulations under 42 CFR Part 483, Subpart B.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087086 POC LX6F11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection.
Findings
No specific findings or deficiencies are detailed in this document. It serves solely as a record of the Plan of Correction submission.
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