Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tallgrass Creek, Inc during CMS and state inspections, most recent first.
Failure to use EBP during high-contact care for a resident with a Foley catheter. A CNA began catheter care without a gown, then wore an unsecured gown that repeatedly fell off during peri-care, dressing, and transfer-related care. The CNA stated she thought the gown was only needed during catheter care, while the facility’s EBP procedure required gown and glove use for high-contact activities such as toileting, hygiene, dressing, and catheter care.
Unclear indication for continued antipsychotic use: A resident with dementia, mood disturbance, anxiety, and severely impaired cognition received Seroquel for a mood disorder, but the record did not show an appropriate indication or documented physician rationale for continued antipsychotic use. The EMR listed excessive aggression during cares as the indication and noted non-pharm approaches such as retrying care later or using a different caregiver; staff observed the resident receiving the AM dose, and an admin nurse confirmed the antipsychotic was being given.
The facility failed to ensure the Consult Pharmacist identified and reported the lack of appropriate indication or required physician documentation for a resident’s Seroquel use. The resident had dementia, mood disturbance, anxiety, and severely impaired cognition, and the EMR listed Seroquel for excessive aggression during cares. Monthly pharmacist reviews did not request an approved diagnosis or indication, and an RN later verified the resident was receiving Seroquel for mood disorder.
The facility failed to ensure a safe environment free from hazardous materials for nine cognitively impaired residents and did not follow proper transfer practices, resulting in an injury to a resident during a Hoyer lift transfer.
The facility failed to ensure an accurate reconciliation of controlled medications was completed consistently, as the daily controlled medication record log lacked evidence of two nurse signatures on 10 of 72 opportunities. This placed residents at risk of medication misappropriation, diversion, and ineffective medication regimens.
The facility failed to ensure proper food storage, preparation, and service, placing residents at risk of foodborne illness and cross-contamination. Observations included improperly stored chicken strips, a leaking freezer unit, and inadequate sanitization of food processing equipment.
The facility failed to follow infection control standards during the use of shared equipment, transport of clean linens, and storage of a resident's oxygen therapy equipment. Staff did not sanitize shared equipment between uses, and clean linens were transported uncovered, placing residents at risk for infectious diseases.
A resident with severe cognitive impairments was left uncovered and exposed for an extended period, despite the facility's policy requiring regular checks. This failure to monitor and cover the resident appropriately compromised her dignity and quality of life.
The facility failed to ensure proper preparation of pureed foods, resulting in runny and unattractive food items. Dietary staff used an unmeasured amount of water and did not follow recipes, compromising the appearance and palatability of the food. This placed residents at risk of decreased palatability and impaired nutritional status.
A resident with dementia and Alzheimer's disease was not provided with the prescribed nectar thick liquids, receiving thin liquids instead on multiple occasions. Staff acknowledged the error, and the facility's policy on thickened liquids was not consistently followed, placing the resident at risk for complications.
Failure to Use Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions were used for a resident with a Foley catheter during high-contact care. During observation, a CNA donned clean gloves, placed a chuck on the floor, and emptied the catheter bag while another CNA handed her a yellow disposable gown after she had already begun the task. Both CNAs put on yellow gowns, but one CNA did not tie hers in the back, and the gown repeatedly fell from her shoulders during catheter care, peri-care, and other personal care activities. The CNA removed and replaced gloves multiple times, sanitized her hands, and continued resident care while the gown remained unsecured or fell off. The resident involved had a Foley catheter and was being assisted with catheter care, peri-care, dressing, transfer to a wheelchair using a full mechanical lift, and other personal care. The CNA stated she was unaware she had to keep the gown on and thought it was only needed during catheter care. Administrative Nurse E stated she had provided education to staff regarding EBP use and would provide further education. The facility’s EBP procedure stated that gown and glove use was required during high-contact care activities, including dressing, bathing, transferring, hygiene, changing linens, changing briefs, assisting with toileting, urinary catheter care, and wound care.
Unclear indication for continued antipsychotic use
Penalty
Summary
The facility failed to ensure an appropriate indication, or a documented physician rationale, for the continued use of a resident’s antipsychotic medication. Resident 13 had diagnoses of dementia, mood disturbance, and anxiety, and the Quarterly MDS recorded severely impaired cognition, dependence on staff for most ADLs, and receipt of an antipsychotic during the observation period. The Psychotropic Drug Use CAA also recorded antipsychotic use along with diagnoses of depression and dementia with behaviors. The physician’s order directed staff to administer Seroquel 12.5 mg once daily and 25 mg at hour of sleep for a diagnosis of mood disorder. The EMR listed the indication for Seroquel as excessive aggression during cares and noted non-pharmacological interventions such as trying again at a different time or using a different caregiver. During observation, the resident received the morning dose of Seroquel, and an Administrative Nurse verified the resident was receiving the antipsychotic with a diagnosis of mood disorder. The nurse also verified the facility would contact the physician for appropriate diagnoses for residents on antipsychotic medications.
Pharmacist Review Did Not Identify Missing Documentation for Antipsychotic Use
Penalty
Summary
The facility failed to ensure the Consult Pharmacist identified and reported the lack of an appropriate indication or required physician documentation for a resident’s use of Seroquel, an antipsychotic medication. The resident had diagnoses of dementia, mood disturbance, and anxiety, and the Quarterly MDS recorded severely impaired cognition, dependence with most ADLs, and use of an antipsychotic during the observation period. The Psychotropic Drug Use CAA also documented antipsychotic use along with diagnoses of depression and dementia with behaviors. The physician’s order directed staff to administer Seroquel 12.5 mg once daily and 25 mg at hour of sleep for a diagnosis of mood disorder, and the EMR listed the indication as excessive aggression during cares with non-pharmacological interventions to retry later or use a different caregiver. However, the monthly Pharmacist Consultant Reviews did not request an approved diagnosis or indication for the resident’s Seroquel use. During observation, the resident received the morning dose of Seroquel, and an Administrative Nurse verified the resident was receiving Seroquel with a diagnosis of mood disorder.
Failure to Ensure Safe Environment and Proper Transfer Practices
Penalty
Summary
The facility failed to ensure a safe environment free from hazardous materials for nine cognitively impaired independently mobile residents. During an initial walkthrough, it was observed that the west hall's laundry room door was unlocked, and a bottle of Oxivir-TB spray was left on top of the washing machine. Additionally, the west hall's spa room was found unlocked with an unlocked cabinet containing disposable ice packs and alcohol cleaning wipes. In the east hallway's activity area, an unsupervised supplemental oxygen storage rack with 10 oxygen cylinders was found, three of which were pressured above 1000 PSI. These hazardous materials were accessible to residents, posing a risk for preventable accidents and injuries. Staff interviews confirmed that hazardous materials should be locked and inaccessible to residents, and the facility's policy required staff to ensure the environment remains free from potential risks of accidents and falls. However, these protocols were not followed, leading to the deficiency observed during the survey. The facility also failed to ensure an environment free from avoidable accidents for a resident (R15) who was injured during a lift-assisted transfer. R15, who had severe cognitive impairment and required extensive assistance for transfers, suffered a quarter-size skin tear on his left hand when it got caught between two moving levers of a Hoyer lift. The incident report indicated that R15 often became agitated or anxious during care, which contributed to the accident. Staff interviews revealed that R15's hands should be securely placed on his chest during transfers, and one of the assisting staff should monitor his hand placement. However, these safety measures were not adequately followed, resulting in the injury. The facility's policies on incident reporting and investigation, as well as lift, transfers, and bed mobility, were not adhered to, leading to the deficiencies observed. The failure to lock hazardous materials and ensure safe transfer practices placed residents at risk for preventable accidents and injuries. The facility's staff acknowledged the lapses in following protocols, which contributed to the unsafe environment and the injury sustained by R15.
Failure to Ensure Accurate Reconciliation of Controlled Medications
Penalty
Summary
The facility failed to ensure an accurate reconciliation of controlled medications was completed consistently. Observations revealed that the daily controlled medication record log from 04/20/24 to 05/06/24 lacked evidence of two nurse signatures indicating a reconciliation was completed on 10 of 72 opportunities. This was confirmed by a Licensed Nurse who stated that the count sheet should be signed by the off-going nurse and the on-coming nurse at the beginning and the end of each shift after the narcotic count had been completed and the medication room keys exchanged. An Administrative Nurse confirmed that the two nursing staff were expected to sign the narcotic count shift sheet at the beginning and the end of each shift to indicate the count was completed as required. The facility's policy dated May 2021 documented that narcotic/controlled substances were to be counted on a regular basis by the off-going and on-coming nurse/care associate. Despite these policies and reminders posted in the medication rooms, the facility failed to ensure an accurate reconciliation of controlled medications, placing residents at risk of medication misappropriation, diversion, and ineffective medication regimens.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to ensure proper food storage, preparation, and service in accordance with professional standards, placing residents at risk of foodborne illness and cross-contamination. During an initial tour of the kitchen, surveyors observed an opened box and bag of breaded chicken strips in the walk-in freezer that were not sealed and lacked an open date. Additionally, frozen water icicles were found to have dropped onto an opened box of food below in the freezer unit. These observations indicate a failure to maintain the freezer unit properly and to store food items safely. Further deficiencies were noted during food preparation. Dietary Staff CC did not properly wash and sanitize the Robo coupe container and lid between each food item that was pureed. Dietary Staff EE admitted to not being aware of the leaking freezer unit and stated that food containers should be either run through the dishwasher or washed and sanitized in the three-bin wash sinks. The facility's Standard Operating Procedure (SOP) for Food Preparation and Service, dated February 2024, mandates strict food preparation procedures, including cleaning and sanitizing sinks, slicing machines, and cutting boards after each use. The facility's failure to adhere to these procedures compromised food safety and increased the risk of cross-contamination and foodborne illness among residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure infection control standards were followed during the use of shared equipment, transport of clean linens, and storage of a resident's oxygen therapy equipment. Specifically, an inspection revealed that a resident's supplemental oxygen face mask and two oxygen connector ports were stored on a paper towel on a shared sink. Additionally, a nurse failed to sanitize shared blood pressure equipment between taking the vitals of two residents. Staff also did not sanitize a Hoyer lift before or after transferring a resident, and a large, uncovered cart carrying brown towels was transported through the facility's east hall. Interviews with staff confirmed that all laundry should be covered during transport, and shared equipment should be sanitized between uses. Oxygen tubing and masks should be stored in clean bags when not in use. The facility's Infection Prevention and Control Surveillance and Monitoring policy indicated that safe infection control practices should be implemented to prevent contamination and infections. However, the facility did not adhere to these standards, placing residents at risk for infectious diseases.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide a dignified care environment for Resident 23, who had severe cognitive impairments due to dementia and aphasia. The resident required maximal assistance with daily activities and was at risk for falls and injuries. On the morning of May 6, 2023, Resident 23 was observed sleeping in her bed with her lower body exposed and only an incontinence brief covering her. Her room door was open, making her visible from the hallway. This situation persisted for approximately 1.5 hours, during which multiple residents and staff walked by her room without addressing her exposed state. Staff interviews revealed that the facility's policy required residents to be checked at least every two hours, but some staff preferred to check every 30 minutes. Despite this, Resident 23 was left uncovered and exposed for an extended period. The facility's Resident Rights policy emphasized the importance of treating residents with respect and ensuring their dignity, which was not upheld in this instance. The failure to monitor and cover Resident 23 appropriately placed her at risk for impaired dignity and quality of life.
Failure to Ensure Proper Preparation of Pureed Foods
Penalty
Summary
The facility failed to ensure that dietary staff prepared pureed food that conserved the nutritive value, flavor, and appearance. Observations revealed that the dietary staff used an unmeasured amount of water to puree baked tilapia, lima beans, and barbecued pulled pork, resulting in runny and unattractive food items. The dietary staff did not follow any recipes, as the facility had recently implemented a new policy that did not require recipes for pureed foods. This new policy aimed to achieve a pudding-thick consistency by adding water to the original cooked foods, but it compromised the appearance and palatability of the pureed items. Interviews with dietary staff and a consultant confirmed that the new standard operating procedure did not require recipes and involved adding water to achieve the desired consistency. The consultant claimed that the nutritive value and flavor would not be compromised, but observations indicated otherwise. Additionally, the dietary staff had difficulty distinguishing between different pureed food items due to a lack of labeling. The facility's failure to follow proper procedures for preparing pureed foods placed residents at risk of decreased palatability and impaired nutritional status.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a resident's therapeutic diet as ordered by his physician, placing the resident at risk for complications including choking. The resident, who had diagnoses of dementia and Alzheimer's disease, required a pureed diet with nectar thick liquids due to difficulty or pain with swallowing. Despite this, observations on multiple occasions revealed that the resident was provided with thin liquids instead of the prescribed nectar thick liquids. Staff interviews confirmed that the resident's care plan, which included the dietary order, was accessible in the resident's room and the dining room, and that staff had been educated on the importance of adhering to these dietary orders. On several occasions, thin liquids were observed in the resident's room, contrary to the prescribed nectar thick liquids. Staff members, including a CNA and a licensed nurse, acknowledged the presence of incorrect fluid consistency and indicated that it might have been placed by the night shift. The facility's policy on thickened liquids, revised in March 2020, stated that thickened liquids should be provided as ordered to promote ease of swallowing and prevent choking and aspiration. Despite this policy and staff education, the facility did not consistently adhere to the resident's dietary orders, resulting in a deficiency that placed the resident at risk for serious health complications.
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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 Overland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Healthcare Resort Of Leawood - Iron Horse Hlth | 1.3 mi | ★★★★★ | 5 | 1 |
| Ignite Medical Resort Overland Park Llc | 1.4 mi | ★★★★★ | 1 | 0 |
| Village Shalom Inc | 2.1 mi | ★★★★★ | 0 | 0 |
| Brookdale Overland Park | 2.2 mi | ★★★★★ | 11 | 0 |
| Stratford Commons Rehab & Health Care Center | 3.5 mi | ★★★★★ | 21 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.