Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Center At Waterfront Llc during CMS and state inspections, most recent first.
A cognitively impaired resident with moderate elopement risk left the facility unsupervised after staff failed to implement care plan interventions addressing elopement, and the incident was only discovered when the resident's representative was alerted by a community member. Staff interviews and records confirmed that the resident's risk was known but not addressed in the care plan prior to the event.
The facility failed to maintain sanitary conditions in food preparation areas, with issues such as food debris in the refrigerator, stained shelf covers, and deeply grooved cutting boards. Dietary staff confirmed these concerns needed attention, and the cleaning schedule was not being adequately followed.
The facility failed to maintain a sanitary kitchen environment, with food debris and dirt observed around the kitchen floor perimeter, beneath equipment, and in floor drains. Dietary staff acknowledged the need for cleaning, but the facility lacked a specific policy for kitchen floor cleaning.
The facility failed to notify the State Ombudsman of the transfer or discharge of four residents, including those with acute kidney failure, pancytopenia, peripheral vascular disease, and metabolic encephalopathy. Administrative staff were unaware of the requirement, and the facility lacked a policy for such notifications.
The facility failed to develop comprehensive assessments by not completing the Care Area Assessments (CAAs) for further investigation and development of the comprehensive care plan for seven residents. These residents had various medical conditions and required specific care plans that were not adequately addressed, leaving them without proper care plans to address their complex medical needs.
A resident with Parkinson's disease could not access the mirror in his bathroom to shave, leading to unshaven facial hair despite his preference to be clean-shaven. Staff interviews and observations confirmed that the resident required assistance with shaving, but the facility failed to provide reasonable accommodations to his physical environment, resulting in inadequate grooming care.
The facility failed to notify a resident with a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered Part A stay. The Social Service Designee responsible for completing the NOMNCs had quit six weeks prior, leading to the deficiency.
The facility failed to provide two residents and/or their representatives with a written notice specifying the duration and cost of the bed hold policy at the time of the residents' transfer to the hospital. Staff interviews revealed that bed holds were not completed for residents when they transferred to the hospital, and administrative staff were unaware of the need for such documentation.
The facility failed to develop baseline care plans within 48 hours of admission for three residents, including one with multiple diagnoses, one on antipsychotic medication, and one requiring dialysis. This led to deficiencies in their care, as confirmed by staff interviews and record reviews.
The facility failed to assist a resident with Parkinson's disease in shaving, despite his need for supervision and expressed preference to be clean-shaven. Observations and staff interviews confirmed that the resident had several days' growth of facial hair and had difficulty seeing the mirror to shave while seated in his wheelchair.
The facility failed to provide appropriate treatment for a resident with skin injuries and did not follow sanitary procedures during dressing changes. The resident, who had multiple diagnoses and was at risk for pressure ulcers, did not receive proper wound care, and the facility did not adhere to its policy for pressure ulcers. Observations revealed undated dressings, improper hand hygiene, and unsanitary bed linens, indicating significant deficiencies in treatment protocols and infection control.
A resident with a stage III pressure ulcer on the coccyx did not have the wound cleansed before a new dressing was applied. The resident was at high risk for pressure ulcers due to obesity, decreased mobility, and incontinence. Despite facility policies and staff expectations to cleanse wounds before dressing changes, the nurse did not follow this procedure, leading to a deficiency in care.
The facility failed to ensure proper communication with the dialysis facility for a resident with end-stage renal disease (ESRD). The baseline care plan lacked dialysis instructions, and the Dialysis Communication Form was incomplete, missing critical information. Staff confirmed that the form should be filled out and sent with the resident, but this protocol was not followed.
The facility failed to follow physician-ordered parameters for administering medications to two residents. One resident received Midodrine Hydrochloride outside the prescribed blood pressure parameters, and another resident did not receive the ordered sliding scale insulin for elevated blood glucose levels. These deficiencies were confirmed through interviews and record reviews.
The facility failed to monitor a resident for the use of antipsychotic medications. Despite the resident's diagnosis of dementia with psychotic disturbance and a policy requiring an AIMS assessment, no such assessment was completed when the medication was ordered. This oversight was confirmed by staff interviews and a review of the resident's medical record.
Failure to Provide Adequate Supervision and Elopement Interventions for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a history of weakness, insomnia, diabetes mellitus, and moderate cognitive impairment was admitted to the facility and identified as being at moderate risk for elopement based on multiple wandering risk assessments. The resident's care plan, however, did not include any interventions or instructions related to elopement risk prior to the incident, despite documentation of decreased safety awareness, impaired cognition, and a recent non-injury fall. The resident required staff supervision or assistance for ambulation and used a wheelchair for mobility. On the day of the incident, the resident left the second floor, traveled to the first floor, and exited the facility without staff knowledge. The facility became aware of the elopement only after the resident's representative, who had been contacted by a community member, called to alert staff that the resident was seen outside. Staff then conducted a search and located the resident outside the facility. The resident was found uninjured and returned to the building. At the time of the incident, the facility's care plan for the resident lacked any interventions addressing the known elopement risk, and staff had not provided adequate supervision to prevent the resident from leaving the premises. Interviews with facility staff confirmed that the resident was known to be at risk for elopement, and that observation rooms were used for residents requiring close monitoring. However, the care plan was not updated to reflect the resident's elopement risk until after the incident occurred. The facility's policy required individualized care plans for residents at risk of elopement and immediate response to door alarms, but these measures were not effectively implemented for this resident prior to the event.
Failure to Maintain Sanitary Conditions in Food Preparation Areas
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions, as observed during an initial tour of the kitchen. Specific issues included food debris on the bottom shelf of the reach-in refrigerator next to the coffee machine, a dark brown stain on a plastic shelf cover underneath the coffee and tea machine, and a build-up of food debris on shelves underneath the tray line and a worktable storing cereal boxes. Additionally, there was a large build-up of crumbs underneath the toaster, and four cutting boards were found to be deeply grooved. Dietary Staff BB confirmed these areas of concern needed attention. The Dietary Aide Daily Cleaning Schedule, which was undated, indicated that dietary aides were responsible for cleaning and sanitizing these areas every shift, but this was not being adequately performed.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff. During an initial tour and a follow-up visit to the kitchen, surveyors observed a large amount of food debris and ground-in dirt around the perimeter of the kitchen floor. Additionally, the floor beneath the steam table, cooks' line, and tray lines contained significant food debris. Three floor drains in the kitchen were also found to contain food debris and trash. Dietary staff confirmed these areas of concern needed attention. The facility's cleaning schedules indicated that floor drains should be cleaned on specific days and that cooks were responsible for sweeping and mopping the floors every shift. However, the facility lacked a policy related to the cleaning of kitchen floors.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to notify the State Ombudsman of the transfer or discharge of four residents, as required by regulations. Resident 60, who had acute kidney failure, diabetes, and heart disease, was discharged to acute care without notification to the Ombudsman. Similarly, Resident 62, who had pancytopenia, fibromyalgia, and a malignant neoplasm of the breast, left the facility against medical advice without the required notification. Administrative Staff A confirmed the lack of notification and the absence of a policy for such notifications. Resident 18, who had peripheral vascular disease, osteomyelitis, and diabetes with a foot ulcer, was transferred to the hospital and returned without the Ombudsman being informed. Resident 44, diagnosed with metabolic encephalopathy and sepsis, was also transferred to an acute hospital without notification. Both Administrative Nurse D and Administrative Staff A were unaware of the requirement to inform the Ombudsman of hospital admissions. The facility lacked a policy for Ombudsman notification for resident discharges, leading to these deficiencies.
Failure to Complete Comprehensive Assessments and Care Plans
Penalty
Summary
The facility failed to develop comprehensive assessments by not completing the Care Area Assessments (CAAs) for further investigation and development of the comprehensive care plan for seven residents. These residents had various medical conditions and required specific care plans that were not adequately addressed. For instance, one resident with peripheral vascular disease, osteomyelitis, and diabetes mellitus with a foot ulcer did not have CAAs triggered for further investigation, despite requiring substantial assistance with daily activities and receiving multiple medications, including pain management and antibiotics. Observations confirmed the resident's need for a comprehensive care plan, which was not developed due to incomplete CAAs. Another resident with cellulitis and a skin tear, who was dependent on a wheelchair and required oxygen and CPAP at night, also did not have CAAs completed for further investigation. This resident had frequent pain and required specific wound care, which was documented but not followed up with a comprehensive care plan. The facility's failure to complete the CAAs left the resident without a proper care plan to address their complex medical needs. Additionally, a resident with acute and chronic respiratory failure and COPD, who required continuous oxygen therapy, did not have CAAs completed for further investigation. This resident exhibited shortness of breath and was on multiple medications, including antibiotics and antiplatelets. Despite these needs, the CAAs were not developed, leaving the resident without a comprehensive care plan. The facility's lack of a written policy for the completion of MDS or CAAs and reliance on the Resident Assessment Instrument (RAI) manual contributed to these deficiencies, as acknowledged by the administrative staff.
Failure to Provide Reasonable Accommodations for Resident's Grooming Needs
Penalty
Summary
The facility failed to provide reasonable accommodations to a resident with Parkinson's disease, who could not access the mirror in his bathroom to shave. The resident, who had normal cognitive function and required supervision or touching assistance for personal hygiene, was observed with unshaven facial hair on multiple occasions. Despite the resident's preference to be clean-shaven and his difficulty seeing the mirror due to its location, staff did not adequately assist him with shaving. Interviews with various staff members, including a licensed nurse and certified nurse aides, confirmed that the resident required assistance with shaving and had requested help, but the assistance provided was insufficient to meet his needs. The resident's care plan instructed staff to provide assistance with grooming, bathing, and personal hygiene, but the facility's failure to accommodate his physical environment prevented him from accessing the mirror. The facility's policy on ADL services required staff to provide assistance with ADLs every shift, including shaving, but this was not effectively implemented for the resident. The administrative nurse acknowledged that staff should provide grooming assistance per resident preferences, yet the resident continued to have several days' growth of facial hair, indicating a lapse in care and accommodation for his needs.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to notify one resident, R167, with a Notice of Medicare Non-Coverage (NOMNC) at least two days before the end of a Medicare covered Part A stay. The deficiency was identified during a review of discharged Medicare A residents, where it was found that R167 did not receive the required NOMNC. Administrative Nurse D reported that the Social Service Designee (SSD), who was responsible for completing the NOMNCs, had quit about six weeks prior to the survey. The facility's policy, dated 06/20/23, mandates that the NOMNC must be delivered at least two calendar days before Medicare covered services end, and the beneficiary or their representative must sign and date the notice to acknowledge receipt and understanding of the termination decision. The failure to provide the NOMNC as required was a direct result of the SSD's departure and the facility's lack of a replacement to fulfill this responsibility.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide two residents and/or their representatives with a written notice specifying the duration and cost of the bed hold policy at the time of the residents' transfer to the hospital. Resident 44, who had a diagnosis of metabolic encephalopathy and was dependent on staff for assistance with ADLs, was transferred to an acute hospital with a diagnosis of sepsis. The resident's electronic medical record lacked a signed bed hold for this hospital admission. Interviews with Licensed Nurse I and Administrative Nurse D revealed that bed holds were not completed for residents when they transferred to the hospital. Administrative Staff A was unaware of the need for residents and/or their representatives to sign a bed hold when transferred to the hospital. The facility's policy, revised on 03/15/24, stated that notice of bed holds should be provided upon admission and at the time of transfer to the hospital, but this was not followed in the case of Resident 44. Similarly, Resident 18, who had an amputation on his left leg below the knee, was discharged to the hospital and returned four days later. The resident's electronic medical record also lacked evidence of written notification of the bed hold policy. Administrative Staff B reported that she should fill out a short online report about the bed hold and might talk to the family if available, but she did not get signatures for any bed holds. Administrative Nurse D confirmed that nurses did not complete bed holds for residents. Administrative Staff A was unaware of the bed holds not being completed and assumed that the facility would always have a bed available for returning residents. The facility's policy for bed holds was not adhered to in the case of Resident 18 as well.
Failure to Develop Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans for three residents within 48 hours of their admission, as required by their policy. Resident 20, who had diagnoses including aftercare for knee joint prosthesis extraction, diabetes, chronic kidney disease, and atrial fibrillation, was admitted to the facility but did not have a baseline care plan in place. This was confirmed by an interview with Administrative Nurse D. Similarly, Resident 221, who had Alzheimer's disease and was prescribed antipsychotic medication, did not have the use of this medication included in their care plan. Interviews with staff confirmed that antipsychotic medications should be included in care plans, but this was not done for Resident 221. Additionally, Resident 214, who had end-stage renal disease and required dialysis, did not have dialysis care instructions included in their baseline care plan. The resident's electronic medical record showed a physician's order for dialysis, but the baseline care plan lacked necessary details. A Dialysis Communication Form was also incomplete, missing critical information such as the resident's physician's name, contact person, and medication details. Interviews with staff confirmed that dialysis care should be included in care plans, but this was not done for Resident 214. The facility's failure to develop and implement baseline care plans within 48 hours of admission for these residents led to deficiencies in their care.
Failure to Assist Resident with Shaving
Penalty
Summary
The facility failed to provide necessary assistance with facial shaving to Resident 29, who has Parkinson's disease and requires supervision or touching assistance for personal hygiene. Despite the resident's normal cognitive function and expressed preference to be clean-shaven, observations revealed that he had several days' growth of facial hair. The resident stated he had difficulty seeing the mirror to shave due to its location in the bathroom, which he could not access while seated in his wheelchair. Interviews with staff, including a licensed nurse and certified nurse aides, confirmed that Resident 29 required assistance with shaving and had requested help. However, the facility did not ensure that this assistance was consistently provided, as evidenced by the resident's unshaven appearance over multiple days. The facility's policy on ADL services, which mandates assistance with grooming every shift as appropriate, was not followed in this case, leading to the deficiency in care for Resident 29.
Failure to Provide Appropriate and Sanitary Wound Care
Penalty
Summary
The facility failed to ensure that Resident 3 received appropriate treatment for an unidentified skin injury and sanitary dressing change. The resident, who had diagnoses including atrial fibrillation, lymphedema, and muscle weakness, was assessed with normal cognitive function and was dependent on staff for bed mobility. The resident had a skin tear, moisture-associated skin damage (MASD), and was at risk for pressure ulcers. Despite these conditions, the facility did not develop a Pressure Ulcer Care Area Assessment (CAA) and failed to follow the care plan instructions to monitor and assist the resident with turning and repositioning. Observations revealed that the resident's coccyx wound was not properly dressed, and the bed linens were not sanitary, which could contribute to the spread of infection. Additionally, the dressing on the resident's right posterior thigh was undated and contained serosanguineous drainage, indicating a lack of proper wound care documentation and treatment. On multiple occasions, the facility staff did not follow sanitary procedures during dressing changes. For instance, an administrative nurse did not sanitize her hands between glove changes while providing wound care. The resident's right thigh wound with drainage and an open area to the buttock were not properly assessed or treated until observed by surveyors. The facility's policy for pressure ulcers, which mandates treatment and care in accordance with professional standards, was not adhered to. Interviews with staff confirmed that the posterior thigh wound had not been assessed until the day of the survey, and the dressing should have been dated and documented. This failure to provide appropriate and sanitary wound care highlights significant deficiencies in the facility's treatment protocols and infection control practices.
Failure to Clean Pressure Ulcer Before Dressing Application
Penalty
Summary
The facility failed to appropriately clean the pressure ulcer (PU) of Resident 5 before applying a new dressing. Resident 5 had a stage III PU on his coccyx, which was documented to have yellow adherent slough over approximately 90% of the wound bed and a small amount of serosanguineous exudate. On 03/14/24, Administrative Nurse F changed the dressing without cleansing the wound, as the physician's order dated 02/06/24 did not include instructions for wound cleansing. This oversight was confirmed by Administrative Nurse F, who admitted to not seeking clarification of the order. The resident's medical record indicated that he was at high risk for PUs due to obesity, decreased mobility, and bowel and bladder incontinence. He was dependent on staff for all activities of daily living and had a pressure-relieving mattress and cushion. Despite these measures, the wound deteriorated, which Consultant GG attributed to the resident's overall decline in health rather than the lack of wound cleansing. However, the facility policy and other staff members, including Licensed Nurse H and Administrative Nurse D, stated that wounds should be cleansed with normal saline or wound cleanser before applying a new dressing, highlighting a failure to follow professional standards of practice.
Failure to Ensure Proper Communication for Dialysis Care
Penalty
Summary
The facility failed to ensure an appropriate system for ongoing communication with the dialysis facility regarding dialysis care and services for Resident 214, who had a diagnosis of end-stage renal disease (ESRD). The baseline care plan for the resident, dated 03/06/24, lacked staff instructions regarding dialysis. Additionally, a physician's order indicated that the resident would receive dialysis at a local dialysis center on Tuesdays and Saturdays, but the Dialysis Communication Form dated 03/12/24 was incomplete. The form lacked critical information such as the name of the resident's physician, the contact person at the facility, the facility phone number, face sheet, medication list, vital signs, medications received before dialysis, and medications sent with the resident to the dialysis center. No other Dialysis Communication Form was made available for review. Licensed Nurse I confirmed that a dialysis communication form needed to be sent with the resident each time he went to dialysis, with the appropriate sections filled out. Administrative Nurse D stated that it was the expectation for the staff to complete the pre-dialysis information on the form and send it with the resident to the dialysis center. The facility policy for Dialysis Protocol, dated 04/28/20, also required that the dialysis communication sheet be given to the dialysis center with the facility and resident information. The facility failed to adhere to these protocols, resulting in a lack of proper communication with the dialysis facility regarding the resident's care and services.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to ensure staff followed physician-ordered parameters for administering medications to two residents, R29 and R18. For R29, who has Parkinson's disease and is at risk for fluid imbalance, the physician ordered Midodrine Hydrochloride to be administered three times a day for hypotension, with instructions to hold the medication if the standing systolic blood pressure exceeded 120 mmHg. However, staff administered the medication outside of these parameters on seven occasions, with blood pressure readings ranging from 122/87 to 166/88. This failure was confirmed by Administrative Nurse D during an interview on 03/18/24, who acknowledged that the staff did not adhere to the physician's instructions for holding the medication based on blood pressure readings. For R18, who has diagnoses including peripheral vascular disease, osteomyelitis, and insulin-dependent diabetes mellitus, the physician ordered a sliding scale insulin regimen to manage blood glucose levels. Despite this, staff failed to administer the ordered sliding scale insulin on multiple occasions when the resident's blood glucose levels were elevated, with readings ranging from 257 to 340. This was verified by Licensed Nurse K and Administrative Nurse D, who confirmed that the insulin was not administered as ordered and that there were no entries on the Treatment Administration Record (TAR) or nurse progress notes to indicate that the insulin had been given. The facility's failure to follow physician-ordered parameters for medication administration for both residents resulted in deficiencies in care. The facility's policy on physician orders, revised on 08/20/22, instructed staff to administer medications as per the written orders of licensed and authorized prescribers. However, the staff's non-compliance with these orders led to the identified deficiencies, as confirmed by the interviews and record reviews conducted during the survey.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to monitor Resident 35 for the use of antipsychotic medications. The resident, diagnosed with dementia with psychotic disturbance, had a BIMS score indicating moderately impaired cognition and was receiving Seroquel for forgetfulness and possible dementia. Despite the facility's policy requiring an AIMS assessment for residents on antipsychotic medications, no such assessment was completed for Resident 35 when the medication was ordered. This oversight was confirmed by both a Licensed Nurse and an Administrative Nurse during interviews. The facility's policy, revised recently, mandates that residents on antipsychotic medications be evaluated for tardive dyskinesia at least every three months and upon starting the medication in-house. However, the resident's electronic medical record lacked any documentation of an AIMS assessment. This failure to adhere to the policy resulted in inadequate monitoring of the resident's condition and the potential side effects of the antipsychotic medication.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wichita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regent Park Rehabilitation And Healthcare | 0.2 mi | — | 21 | 0 |
| Avita Health And Rehab At Reeds Cove | 1.9 mi | — | 0 | 0 |
| Great Plains Post Acute | 2.1 mi | — | 11 | 0 |
| Larksfield Place | 2.5 mi | — | 0 | 0 |
| Life Care Center Of Wichita | 3 mi | — | 0 | 0 |
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