Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Healthcare Campus during CMS and state inspections, most recent first.
A cognitively impaired female resident, unable to consent, was subjected to sexual abuse by another resident with a known history of inappropriate sexual behaviors. Despite prior incidents and staff awareness, interventions were insufficient, leading to an incident where staff found both residents unclothed and engaged in sexual activity.
A medication cart was left unattended and unlocked in a hallway while the responsible nurse was away, contrary to facility policy requiring all medication carts to remain locked when not in direct use or supervision. Administrative staff intervened to secure the cart until the nurse returned.
The facility did not notify the LTCO when two residents were transferred or discharged, including one resident who was hospitalized and another who left against medical advice. In both cases, required notifications were missed, and for one resident, the discharge summary lacked a comprehensive recapitulation of the stay. Staff interviews confirmed gaps in understanding and adherence to notification and documentation policies.
A resident with end-stage renal disease who required regular dialysis had a care plan that did not include the dialysis center's location, contact information, or the specific days of treatment. While some dialysis-related instructions were present, key scheduling and provider details were missing, and the physician's order for dialysis was not documented in the EMR. Staff interviews indicated that dialysis information was often communicated verbally rather than through the care plan, and the omission was acknowledged as an oversight.
A resident with CHF, respiratory failure, and hypertension was not consistently kept within a physician-ordered 2000 ml fluid restriction. Despite clear orders and facility policy, staff allowed the resident to exceed her fluid limit on multiple days, with staff interviews confirming both the resident's noncompliance and the staff's lack of enforcement.
A resident with ESRD who required regular dialysis did not have a physician's order for dialysis documented in the EMR, and the care plan lacked key details such as the dialysis center's location, contact information, and treatment schedule. Staff relied on verbal communication to track dialysis days, and the omission of the order was acknowledged as an oversight after the resident's hospital discharge.
A consultant pharmacist did not identify that a PRN lorazepam order for a resident with multiple complex conditions lacked a required stop date, as mandated by facility policy. The pharmacist's monthly review did not document any recommendations regarding this omission, and staff confirmed the order was indefinite. The facility's policy requires reporting and acting on such irregularities, but this was not done.
A resident with multiple complex medical conditions was prescribed PRN lorazepam without a stop date, despite facility policy and CMS regulations requiring such orders to have defined durations. Staff confirmed the omission, and documentation showed the resident experienced episodes of minimal responsiveness, with medications held due to inability to safely swallow. This resulted in a failure to ensure the resident's drug regimen was free from unnecessary drugs.
Two residents receiving hospice services had care plans that lacked essential details such as hospice contact information, visit frequency, medications, and supplies, with staff relying on separate notebooks at the nurses' station for this information instead of including it in the care plans as required by facility policy.
Staff did not implement enhanced barrier precautions or follow proper glove-changing protocols while providing wound and perineal care to a resident with an open, draining heel wound. EBP signage and PPE were absent, and staff failed to change gloves between dirty and clean tasks, contrary to facility policy, resulting in a lapse in infection prevention and control.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
A cognitively impaired female resident with severe cognitive impairment, a history of wandering, and inability to consent to sexual relations was not protected from sexual abuse by another resident. The male resident involved was cognitively intact, had a history of inappropriate sexual behaviors, and was known to make sexually explicit comments, gestures, and attempts at contact. Despite being aware of his inappropriate behaviors and receiving counseling and medication for hypersexuality, he continued to pursue and interact with the cognitively impaired resident. Multiple documented incidents occurred prior to the abuse event, including the male resident making inappropriate gestures, blowing kisses, and inviting the female resident to his room. Staff and social services were aware of these behaviors and had taken steps such as moving the male resident to a different room and providing education about consent and legal implications. However, the female resident continued to access the male resident's room, and staff interventions were insufficient to prevent further contact between the two residents. The deficiency culminated when staff found both residents in the male resident's room, both unclothed from the waist down, with the male resident performing oral sex on the cognitively impaired female resident. Interviews with staff and the male resident confirmed the incident and the ongoing pattern of inappropriate sexual behavior. The facility's failure to adequately supervise and prevent contact between the residents resulted in the female resident being subjected to sexual abuse.
Removal Plan
- Staff immediately separated R1 and R2, and placed R2 under one-on-one supervision, pending assessment
- R1 was placed on continuous monitoring, and R2 was restricted from unsupervised access to rooms
- Administrative Staff A and Administrative Nurse D initiated an internal investigation per the abuse policy upon knowledge of the incident, and after R1 and R2 were separated
- Staff re-education on abuse prevention, reporting, and sexual consent with cognitively impaired residents training initiated and continued for all staff to be re-educated prior to working the next scheduled shift until all staff had been re-educated
Unattended and Unlocked Medication Cart
Penalty
Summary
A deficiency occurred when a medication cart on Sunshine Hall was found unattended and unlocked beside the nurse's desk while the responsible licensed nurse was away. Administrative nursing staff observed the unlocked cart and secured it until the nurse returned. Interviews with administrative and licensed nursing staff confirmed that facility policy requires all medication carts and rooms to remain locked when not in use or when staff are not in direct sight of the cart. The facility's policy also specifies that medications and biologicals must be stored safely, securely, and only accessible to authorized personnel.
Failure to Notify Ombudsman and Complete Discharge Recapitulation
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO) regarding the transfer and discharge of two residents, as required by both facility policy and regulatory standards. In the case of one resident with diagnoses including sepsis, Parkinson's disease, and aspiration pneumonia, the electronic medical record documented a hospital transfer, but there was no evidence that the LTCO was notified. Administrative staff confirmed that the notification was missed, despite being responsible for this task and the facility's policy requiring prompt notification to the LTCO after issuing a transfer notice. For another resident with chronic iron deficiency, low back pain, Barrett’s esophagus, and a cognitive communication deficit, the facility did not notify the LTCO upon the resident's unplanned discharge against medical advice. The resident, who had a history of homelessness and expressed a desire to return to living on the street, left the facility after staff and social worker consultations. Although Adult Protective Services and the local police department were notified, there was no documentation of LTCO notification. Administrative staff acknowledged that the ombudsman was not notified for this type of discharge. Additionally, the facility failed to develop a discharge summary that included a recapitulation of the resident's stay for the unplanned discharge. The discharge documentation lacked a thorough summary of the resident’s course of treatment, diagnoses, and other required information. Staff interviews revealed a lack of understanding regarding what constitutes a recapitulation, and the completed discharge summary did not meet the facility’s policy requirements for a comprehensive recapitulation of the resident’s stay.
Care Plan Lacked Dialysis Details for Resident with ESRD
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised to include essential information regarding his dialysis treatment. The resident, who had end-stage renal disease and was dependent on renal dialysis, had a care plan that documented his diagnosis, the presence of a shunt in his left arm, and instructions for monitoring the access site and avoiding blood pressure measurements in the affected arm. However, the care plan did not include the location and contact information for the dialysis center or specify the days on which the resident received dialysis. Additionally, the electronic medical record lacked a physician's order for dialysis, although a scanned communication form documented pre- and post-dialysis vital signs and related information. Interviews with staff revealed that information about the resident's dialysis schedule was typically communicated verbally rather than being documented in the care plan. A CNA stated that nurses would inform staff about which residents had dialysis, but was not aware of specific care plan details. A licensed nurse confirmed that the care plan should include dialysis information, and an administrative nurse acknowledged that the omission of dialysis days in the care plan was an oversight following the resident's return from the hospital. The facility's policy required that changes in a resident's condition be reflected in the care plan, but this was not followed in this case.
Failure to Enforce Physician-Ordered Fluid Restriction
Penalty
Summary
Staff failed to follow a physician-ordered fluid restriction for a resident with a history of congestive heart failure, respiratory failure, and hypertension. The resident was on a 2000 ml per 24-hour fluid restriction, with specific allocations for dietary and nursing staff, and was not to have a bedside water pitcher. Despite these orders, review of the Treatment Administration Records showed that the fluid restriction was exceeded on multiple days across three consecutive months. The facility's policy required nursing and dietary departments to collaborate and document fluid intake, but this was not consistently adhered to. Interviews with staff revealed that the resident, a former director of nursing at the facility, was aware of her fluid restriction but did not always comply, and staff acknowledged that she would often drink more than allowed. Staff statements indicated that the resident's prior professional role influenced her behavior and the staff's response, with several staff members noting her tendency to disregard the restriction. The facility's policy outlined the process for managing fluid restrictions, but the failure to enforce and document compliance led to the deficiency.
Failure to Document Dialysis Orders and Care Details in EMR
Penalty
Summary
The facility failed to ensure that a resident with end-stage renal disease (ESRD) who was dependent on dialysis had a physician's order for dialysis documented in the Electronic Medical Record (EMR). The resident's care plan noted the presence of a shunt for dialysis, instructions to monitor for infection and bleeding, and restrictions on blood pressure measurement in the affected arm. However, the care plan did not include the dialysis center's location, contact information, or the specific days of dialysis treatment. Additionally, the physician's order for dialysis was missing from the resident's EMR orders tab, although pre- and post-dialysis vital signs and communication forms were present in a separate section of the EMR. Staff interviews revealed that information about which residents were on dialysis was typically communicated verbally, and there was no dedicated dialysis book for the resident. A licensed nurse confirmed that the dialysis order should have been present on the Medication Administration Record (MAR) or Treatment Administration Record (TAR), but it was not. The administrative nurse acknowledged that the omission of the dialysis order was an oversight following the resident's return from the hospital. The facility's policy required coordination and documentation of dialysis care, but these requirements were not fully met in this case.
Consultant Pharmacist Failed to Identify Medication Order Irregularities
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and addressed medication regimen irregularities for two residents. For one resident with multiple complex diagnoses, including severe protein-calorie malnutrition, chronic kidney disease, major depressive disorder, and paraplegia, the CP did not identify that a PRN (as-needed) lorazepam order lacked a required stop or discontinue date. The resident's care plan noted high-risk medication use, and the physician's order allowed lorazepam administration every four hours as needed, but without a stop date. The CP's monthly review did not document any recommendations regarding this omission. Facility staff confirmed that the PRN lorazepam order was indefinite and acknowledged that the CP should have identified the missing stop date, as per facility policy. Additionally, the report notes that the facility's Drug Regimen Review Report Distribution policy requires the CP to report any recommendations of apparent irregularities resulting from the medication regimen review to the attending physician and/or the director of nursing, and that each recommendation must be acted upon. However, the CP failed to identify and report the irregularity in the medication order, and there was no documentation of recommendations or follow-up. This failure was observed through record review, staff interviews, and direct observation of the resident.
Failure to Obtain Stop Date for PRN Antianxiety Medication
Penalty
Summary
The facility failed to obtain a stop date for an as-needed (PRN) antianxiety medication, lorazepam, prescribed to a resident with multiple complex medical conditions, including severe protein-calorie malnutrition, chronic kidney disease, major depressive disorder, chronic ulcer, paralytic syndrome, anemia, peripheral vascular disease, diabetes mellitus, and paraplegia. The resident's care plan noted high-risk use of lorazepam and opioids, with warnings about potential for profound sedation, respiratory depression, coma, and death. The physician's order for lorazepam directed administration every four hours as needed for agitation, anxiety, or shortness of air, but did not include a stop or discontinue date. Review of the resident's electronic medical record and interviews with facility staff confirmed that the PRN lorazepam order was indefinite and lacked a required stop date. Facility policy and CMS regulations require that each resident's drug regimen be free from unnecessary drugs, including those used for excessive duration. Staff acknowledged the omission, and documentation showed that the resident had experienced episodes of minimal responsiveness, leading to medications being held due to inability to safely swallow. The absence of a stop date for the PRN lorazepam order constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs.
Failure to Integrate Hospice Plan of Care into Resident Care Plans
Penalty
Summary
The facility failed to include comprehensive hospice plans of care for two residents who were receiving hospice services. For one resident with diagnoses including hemiplegia, cerebral infarction, diabetes, chronic kidney disease, and hypertension, the care plan only indicated that the resident was on hospice and directed staff to refer to a notebook at the nurses' station for hospice information. The care plan did not provide staff with hospice contact information, details about supplies and medications provided by hospice, or the frequency of hospice staff visits. Interviews with staff confirmed that this information was not included in the care plan and was only available in the hospice notebook, which staff did not routinely reference for daily care tasks. Another resident, with conditions such as severe protein-calorie malnutrition, chronic kidney disease, major depressive disorder, chronic ulcer, anemia, peripheral vascular disease, diabetes, and paraplegia, also had a care plan that lacked specifics regarding hospice services. The care plan noted the resident's terminal prognosis and directed staff to work with the hospice team, but did not specify delegation of hospice staff services, visit frequency, medications, or medical equipment and supplies provided. Staff interviews revealed that while the hospice provider's name was included, other critical details were missing from the care plan and were instead kept in a separate hospice notebook at the nurses' station. The facility's policy required coordination of care planning with the hospice provider, including all services and supplies provided by hospice. However, the care plans for both residents did not integrate this information, and staff relied on separate notebooks for hospice details rather than having this information readily available in the residents' care plans. This practice resulted in incomplete care plans that did not fully outline the hospice services being provided to the residents.
Failure to Implement Enhanced Barrier Precautions and Proper Glove Use During Resident Care
Penalty
Summary
Facility staff failed to implement enhanced barrier precautions (EBP) and proper glove-changing protocols during care for a resident with a left heel wound exhibiting serous drainage. Observations revealed that there was no EBP signage or personal protective equipment (PPE) available outside or inside the resident's room. During wound care, a licensed nurse did not use EBP, and a certified nurse aide provided perineal care without changing gloves between dirty and clean tasks, contrary to facility policy. The administrative nurse confirmed that the resident should have been placed on EBP once the wound became open and draining, but this was not done. The facility's policies required EBP for residents with open wounds and specified glove changes between dirty and clean procedures during perineal care. However, staff did not follow these protocols, as evidenced by the lack of EBP implementation and improper glove use during care activities. These actions resulted in a failure to maintain a sanitary environment and to prevent the potential transmission of communicable diseases and infections among residents.
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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 Junction City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chapman Valley Manor | 9.2 mi | ★★★★★ | 0 | 0 |
| Enterprise Estates Nuring Center | 16.1 mi | ★★★★★ | 20 | 0 |
| Wakefield Care And Rehab | 16.3 mi | ★★★★★ | 13 | 0 |
| Stoneybrook Retirement Community | 17.8 mi | ★★★★★ | 9 | 0 |
| Via Christi Village Manhattan, Inc | 19 mi | ★★★★★ | 8 | 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.