Tonganoxie Terrace
Tonganoxie, Kansas · CCN 175215
31 surveys since 2011, 11 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 187
- Surveys
- 31
- Harm or worse
- 11
- Immediate jeopardyall corrected before survey
- 5
Findings at the most serious level CMS records. All were recorded as past non-compliance — corrected before the survey.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 90
- Ownership
- For profit - Limited Liability company
- Chain
- Independent
- County
- Leavenworth
- Medicare-certified since
- 1992
CMS ratings
- Overall
- 1
- Health inspection
- 1
- Staffing
- 1
- Quality measures
- 1
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 43 for-profit facilities of 66–99 beds in Kansas.
Last survey on record
Jun 23, 2026
139 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.00 | 3.56 |
| Registered-nurse hours per resident day | 0.42 | — |
| Annual nurse turnover | 68.6% | 52.1% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $22,048 across 1 penalty
- Payment denials
- 1
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J11.7% | K— | L— |
| Actual harm | G11.7% | H— | I— |
| No harm, potential for more than minimal | D3458.6% | E1322.4% | F915.5% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6774×
Provide care and assistance to perform activities of daily living for any resident who is unable.
- F6573×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F6843×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6893×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F7613×
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
In the surveyor’s words
From the most serious findings on record at Tonganoxie Terrace, in the surveyor’s own words.
- Immediate jeopardy, isolatedF684Aug 31, 2023
The facility identified a census of 71 residents. Based on record review, interview, and observation, the facility failed to ensure staff implemented care and treatment consistent with standards of care when staff failed to follow a physician order to assess Resident (R) 1's blood glucose levels four times daily. The facility failed to ensure staff transcribed and performed physician ordered blood glucose checks for R1. On [DATE] R1 readmitted to the facility as an emergency admission. Licensed Nurse (LN) I called the emergency room (ER) physician for order clarification and received orders for a Accu-checks (use of a handheld machine to test blood sugar levels) four times daily for seven days. LN H entered the Accu-check order into the Electronic Medical Record (EMR) incorrectly. […]
- Immediate jeopardy, isolatedF757Mar 11, 2021
The facility had a census of 55 residents. The sample included 17 residents, with eight residents reviewed for unnecessary medication. Based on interview and record review, the facility failed to adequately monitor the efficacy of [MEDICATION NAME] (blood thinning drug) for Resident (R) 40 who the hospital admitted with a critically high International Normalized Ratio (INR) (a laboratory measurement used to determine the effects of oral anticoagulants, blood thinners) which lead to the resident's hospitalization for a critically low hemoglobin (substance that allows for the transport of oxygen throughout the body), placing the resident in immediate jeopardy (IJ). […]
- Actual harm, isolatedF686Jan 29, 2026
The facility had a census of 70 residents. The sample included 18 residents, with one reviewed for pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to initiate effective interventions to prevent the development of the left lateral (pertaining to the side, away from the middle) foot and left middle toe facility acquired pressure ulcers for Resident (R) 44.Findings included: - R44's diagnoses included metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), anemia (an inadequate number of… […]
- No harm, potential for more than minimal, widespreadF574Jan 29, 2026
The facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to inform the residents of the posting of the Ombudsman (an independent, neutral official who investigates, reports on, and helps resolve complaints) and State Agency contact numbers.Findings included:- On 01/27/26 at 01:15 PM, the State Agency and Ombudsman information posters were located in the front portion of the building lobby/hallway area. […]
- No harm, potential for more than minimal, widespreadF577Jan 29, 2026
The facility had a census of 70 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to inform the resident council of the state inspection report.Findings included:- On 01/27/26 at 01:15 PM, the State Agency inspection book was located in the front lobby. The resident council minutes' review from 01/2025 through 01/2026 lacked information regarding the location of state inspection results.On 01/28/26 at 03:29 PM, the Resident Council President, Resident (R) 12, reported that the council had not been informed of the location of the state inspection results.On 01/29/26 at 11:45 AM, Activity Staff Z reported she had not included the location of the State Agency's inspection report. […]
Read 30 findings in full →The most serious and the most recent: 30 of 187 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 23, 2026Complaint1 finding
- Jun 3, 2026Complaint1 finding
- Jan 29, 2026Standard15 findings · 1 harm
- Aug 6, 2025Complaint3 findings
- Mar 20, 2024Standard16 findings
- Aug 31, 2023Complaint1 finding · 1 harm
- May 8, 2023Complaint1 finding
- Sep 7, 2022Standard and complaint21 findings
Show the 23 earlier surveys
- Mar 11, 2021Standard5 findings · 1 harm
- Apr 14, 2020Infection control1 finding
- Aug 7, 2019Complaint1 finding
- Apr 8, 2019Standard and complaint16 findings · 2 harm
- Jul 9, 2018Complaint1 finding
- Jun 18, 2018Standard8 findings
- Jun 6, 2017Complaint3 findings · 1 harm
- May 25, 2017Complaint2 findings
- Apr 13, 2017Complaint2 findings · 1 harm
- Aug 5, 2016Complaint2 findings · 2 harm
- May 9, 2016Standard and complaint15 findings
- Aug 6, 2015Complaint11 findings
- Jul 22, 2015Complaint3 findings
- May 18, 2015Complaint7 findings · 1 harm
- Mar 5, 2015Standard and complaint1 finding
- Jan 6, 2015Standard and complaint22 findings
- Nov 19, 2014Complaint3 findings
- Aug 6, 2014Complaint5 findings
- Mar 4, 2014Complaint1 finding
- Sep 13, 2013—7 findings
- Aug 22, 2013—1 finding · 1 harm
- Jun 4, 2012—9 findings
- Feb 23, 2011—2 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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