Tallgrass Creek, Inc

In the surveyor’s words

From the most serious findings on record at Tallgrass Creek, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 16, 2023

  The facility identified a census of 43 residents. The sample included two residents reviewed for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) risk. Based on observations, record review, and interviews, the facility failed to provide adequate supervision to cognitively impaired Resident (R) 1, who was at risk for elopement and exited the facility. On 10/06/23 at 06:21 PM R1 pressed on an exit door for 30 seconds, which opened the door. The door alarm sounded, but the staff failed to promptly respond to the alarm. R1 wore a WanderGuard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on her wheelchair, which alarmed as well, but staff failed to respond. […]

• No harm, potential for more than minimal, patternF880Feb 25, 2026

  The facility had a census of 41 residents. The sample included 12 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 the facility failed to ensure Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organism which employ targeted gown and glove use during high contact care) were used for Resident (R) 18, who had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). […]

• No harm, potential for more than minimal, patternF689May 8, 2024

  The facility had a census of 42 residents. The sample included 13 residents with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from hazardous materials for nine cognitively impaired independently mobile residents. The facility additionally failed to ensure an environment free from avoidable accidents for Resident (R)15 who was injured during a lift-assisted transfer. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 05/06/24 at 07:10 AM an initial walkthrough of the facility was completed. An inspection of the west hall's laundry room revealed the door was unlocked. […]

• No harm, potential for more than minimal, patternF755May 8, 2024

  The facility identified a census of 42 residents. The facility had two medication rooms. Based on observation, record review, and interview, the facility failed to the facility failed to ensure an accurate reconciliation of controlled medications (substances that have an accepted medical use, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) was completed consistently. This placed residents at risk of medication misappropriation, diversion, and ineffective medication regimens. […]

• No harm, potential for more than minimal, patternF812May 8, 2024

  The facility identified a census of 42 residents. The facility had one main kitchen and one kitchenette and dining area. Based on observation and interview, the facility failed to ensure staff stored, prepared and served food items and maintained the freezer unit in accordance with the professional standards for food service safety. This placed residents at risk of foodborne illness and cross-contamination (the transfer of harmful substances to food). Findings included: - On 05/06/24 at 07:12 AM the initial tour of the kitchen revealed the following: in the walk-in freezer there was an opened box and bag of breaded chicken strips that was not in a sealed bag and lacked an open date. […]