Tonganoxie Terrace
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 30 Google reviews
Watch Tonganoxie Terrace
Get an email when new inspections, ratings, or penalties are published for this facility.
We’ll only email you about this — no spam, unsubscribe anytime.
Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (2/5 stars)
- Above-median deficiencies (19 vs median 9.0)
- High staff turnover (57%)
Below average in KS · Meets national RN staffing standard · $13,397 in fines
What this means for your family
Tonganoxie Terrace shows a pattern of inconsistent care quality. While many residents report positive experiences with rehab and nursing staff, the recurring reports of poor sanitation and hygiene are concerning. We strongly recommend conducting multiple unannounced visits at different times of the day to verify the cleanliness and staffing levels before making a decision.
Google Reviews
Google Reviews
30 reviews on Google“Tonganoxie Terrace receives highly polarized feedback, with some families praising the attentive rehab staff and admissions process, while others report severe concerns regarding cleanliness and neglect. Recurring complaints highlight issues with sanitation, including reports of urine-stained bedding and poor room maintenance. Prospective families should be aware of these significant inconsistencies in care quality and perform frequent, unannounced visits.”
Quality Themes
Tap a score for detailsStrengths
- Attentive and caring nursing staff
- Helpful admissions and administrative support
- Effective rehabilitation therapy programs
- Proactive communication during health crises
Concerns
- Poor sanitation and cleanliness (urine odors, unwashed bedding) (mentioned by 4 reviewers)
- Understaffing leading to neglect or slow response times (mentioned by 3 reviewers)
- Inadequate communication between staff and family members (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 30 analyzed
How They Respond to Reviews
This facility responds to some reviews.
Questions for Your Tour
- 1I noticed some feedback regarding the facility's overall cleanliness; what specific protocols do you have in place to ensure resident rooms and linens are maintained to a high standard?
- 2With the current staffing levels, how do you ensure that residents receive timely assistance when they press their call lights or need immediate help?
- 3Given the recent health inspection results, what steps is the leadership team taking to address the identified deficiencies and improve the overall quality of care?
- 4I see that you sometimes engage with families online; how do you typically handle communication with families when there is a change in a resident's health status or a concern that needs to be addressed?
- 5What does a typical daily activity schedule look like for residents here, and how do you encourage participation for those who might be more reserved?
- 6Since medication management is a critical part of daily life, could you walk me through your process for ensuring that medications are administered accurately and on time?
Personalized based on this facility's data
Key Review Excerpts
“The staff were so sweet to her and she loved all of the activities. Ashley in admissions really helped us understand how Medicare pays and what services are covered.”
“I seen urine on a bed in the same room of a family member for three or four days unchanged. I think the place needs to be torn down and rebuilt and updated.”
“I recently stayed at Tonganoxie nursing center after a hospital stay for pneumonia and needed OT and PT as well as skilled nursing care. All staff were very caring, friendly, and attentive to my needs.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
6
measures
6
measures
5
measures
Residents on antipsychotic medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents vaccinated for pneumonia
Residents needing more daily help over time
Residents who lost too much weight
Residents whose bladder or bowel control got worse
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
Tonganoxie Terrace shows concerning patterns with 100 deficiencies across 6 surveys, including families filing complaints that triggered additional inspections. The facility has persistent problems with medication management, fire safety systems, and care planning that appear repeatedly across multiple years. While deficiencies are reported as corrected, the recurring nature of issues in critical areas like medication errors, safety hazards, and resident care suggests ongoing operational challenges that families should carefully evaluate.
Jan 29, 2026Routine31
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Resident Rights Deficiencies
The resident has the right to receive notices in a format and a language he or she understands.
Resident Rights Deficiencies
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Pharmacy Service Deficiencies
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Aug 6, 2025Complaint3
Resident Rights Deficiencies
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Mar 20, 2024Routine38
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Emergency Preparedness Deficiencies
Establish policies and procedures for volunteers.
Emergency Preparedness Deficiencies
List the names and contact information of those in the facility.
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Construction Deficiencies
Use approved construction type or materials.
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies
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.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Miscellaneous Deficiencies
Have restrictions on the use of highly flammable decorations.
Aug 31, 2023Complaint1
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Sep 7, 2022Routine42
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Emergency Preparedness Deficiencies
Establish roles under a Waiver declared by secretary.
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Construction Deficiencies
Meet other general requirements.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Electrical Deficiencies
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Pharmacy Service Deficiencies
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.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Construction Deficiencies
Use approved construction type or materials.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Smoke Deficiencies
Have properly installed hallway dispensers for alcohol-based hand rub.
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Federal Penalties
Fine
Jan 29, 2026
$33,920
Payment Denial
Jan 29, 2026
1-day denial
Fine
Aug 31, 2023
$13,397
Ownership & Operations
Who Operates This Facility
Tonganoxie Terrace
for profit
Ownership & Management
Owners
Goldberg, Nathan
Owner
Insel, David
Owner
Navas-Migueloa, Luis
Owner
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
30 reviews from families & visitors
Official Website
Visit tongieterrace.com
Medicare data downloads
Original nursing home datasets
EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
Safer Alternatives Nearby
Based on current clinical data, we identified 1 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.