Tallgrass Healthcare Campus

Inspectors wroteBased on record review and interview, the facility failed to immediately implement effective measures to prevent further potential abuse or mistreatment of residents. After Resident (R) 1 made an allegation of abuse which named a facility staff member as the alleged perpetrator, the facility did not immediately suspend the staff member (AP), which allowed the AP to have further access to the alleged victim and/or other vulnerable residents.

Inspectors wroteThe facility identified a census of 66 residents, with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to protect Resident (R) 2, a cognitively impaired female, from sexual abuse. On 11/12/25 at 01:40 PM, staff found R2, who had severe cognitive impairment, was unable to consent to sexual relations, and had a history of wandering, in R1's room on his bed. R1, who had a Brief Interview for Mental Status (BIMS) score of 15 (cognitively intact) and a history of sexual behaviors, performed oral sex on R2. Staff separated the residents and placed R2 on one-to-one observation. This deficient practice placed R2 and other cognitively impaired female residents in Immediate Jeopardy.

Inspectors wroteThe facility identified a census of 62 residents. The facility had two medication rooms and three medication carts. Based on observation, record review, and interview, the facility failed to ensure staff locked and secured medications while away from the medication cart on the Sunshine Hall. This placed residents at risk for accidental ingestion of medication and adverse reactions.

Inspectors wroteThe facility had a census of 62 residents. The sample included 16 residents, with one reviewed for discharge. Based on record review and interview, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO- a public official who works to resolve resident issues in nursing facilities) of Resident (R) 1 and R67's. The facility also failed to develop a discharge summary that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay for R67's unplanned discharge. This placed the residents at risk for uninformed care choices and impaired rights.

Inspectors wroteThe facility identified a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 9's comprehensive care plan was revised with information about his dialysis (a procedure where impurities or wastes were removed from the blood). This deficient practice placed R9 at risk for missed dialysis visits and complications related to dialysis.

Inspectors wroteThe facility identified a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's physician ordered fluid restriction was followed by staff. This placed R2 at risk of fluid overload and possible complications.

Inspectors wroteThe facility identified a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 9's dialysis (a procedure where impurities or wastes were removed from the blood) physician order was in his orders of the Electronic Medical Record (EMR). This deficient practice placed R9 at risk for missed dialysis visits and complications related to dialysis.

Inspectors wroteThe facility had a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified Resident (R) 32's as-needed antianxiety (a class of medications that calm and relax people) without a stop date and R2's fluid restriction parameter monitoring with the use of a diuretic (a medication to promote the formation and excretion of urine). This placed the residents at risk for inappropriate and/or unnecessary medication.

Inspectors wroteThe facility had a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 32's as-needed (PRN) antianxiety (a class of medications that calm and relax people) lorazepam, which placed R32 at risk of receiving unnecessary medication.

Inspectors wroteThe facility had a census of 62 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to include a hospice (a program that gives special care to people who are near the end of life) plan of care that outlined visit frequency, medications, medical equipment, and the resident representative's preference for Resident (R) 4 and R32. This deficient practice placed the residents at risk of not receiving resident-directed end-of-life care.

Inspectors wroteThe facility had a census of 62 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to provide 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 Resident (R) 17. The facility staff failed to change gloves when providing incontinent care for R17. This deficient practice placed the residents at risk for possible exposure to infection.

Inspectors wroteThe facility had a census of 63 residents. Based on observation, record review, and interview, the facility failed to implement a water management program for Legionella disease (Legionella is a bacterium spread through mist, such as air-conditioning units in large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease or heavy tobacco use are most at risk of developing a pneumonia caused by Legionella). This deficient practice placed the residents at increased risk of infectious disease.

Inspectors wroteThe facility had a census of 63 residents. Based on observation, interview, and record review, the facility failed to serve food in one of two dining rooms in a sanitary manner. This deficient practice placed residents at risk for food borne illness.

Inspectors wroteThe facility had a census of 63 residents. The sample included 16 residents. Based on record review and interview, the facility failed to provide Resident (R)5 and R20, or their representative, the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055 which included the cost to continue services. This placed the resident at risk of uninformed decisions about their skilled services.

Inspectors wroteThe facility had a census of 63 residents. The sample included 16 residents with one reviewed for dental care. Based on observation, record review and interview, the facility failed to facilitate the necessary dental care services for Resident (R) 26. This placed R26 at risk for pain, weight loss, and worsening dental issues.

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents. Based on observation, record review, and interview the facility failed to distribute and serve food in accordance with professional standards for food service safety for the 61 residents who resided in the facility and received their food from the facility kitchen, when the facility failed to ensure clean and sanitary food prep areas, and failed to dispose of expired food items. This placed the 61 residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents, with five reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing services for three sampled residents, Resident (R) 38, R49, and R9 . This placed the residents at risk for complications related to poor hygiene.

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide the physician ordered interventions for bowel management for one sampled resident, Resident (R) 38. This placed the resident at risk for constipation and decline.

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents. Based on observation, record review, and interview the facility failed to ensure one of six residents reviewed during medication administration pass, remained free of medication error. This placed the resident at risk for adverse reaction from the medication.

Inspectors wroteThe facility had a census of 61 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 36's insulin (hormone which allows cells throughout the body to uptake glucose) pen with the opened and expiration date, and discard expired stock medications on one of three medication carts. This placed the residents at risk for ineffective medications.