Overall sentiment across the reviews is mixed and polarized: many reviewers praise the frontline caregiving staff and therapy services, while a substantial number of reviews describe serious quality and safety problems. Multiple accounts highlight compassionate, attentive CNAs and nurses, excellent rehabilitation therapy, long‑tenured employees, and a warm, home‑like atmosphere for some residents. Several families note recent positive changes under new management and ownership — physical upgrades (roof, parking, van), a certified chef and improved menus, a new medical director, and better responsiveness to concerns. Where improvements are reported, reviewers describe clean hallways and rooms, pleasant dining experiences, active programming (resident senate, outings, music), and strong communication with families.
However, a consistent and serious set of concerns appears repeatedly. Numerous reviewers report poor housekeeping in some areas, with persistent odors of urine, soiled linens, moldy or non‑disposable cups, and even claims of flies. Several accounts describe pest infestations including bed bugs and scabies. Clinical safety and quality of care concerns are prominent: missed or incorrect medications, inadequate assistance (long waits for help with ADLs), missed follow‑ups, dehydration, bowel impaction, urinary tract infections, pressure injuries/bed sores, and at least one report of a resident choking and subsequently found deceased. These reports suggest inconsistent clinical oversight and substantial risk for higher‑acuity residents. Infection control lapses (improper glove and mask use) were also reported by multiple reviewers.
Staffing and management issues are another recurring theme. Reviews cite chronic understaffing, short shifts, high turnover, and no permanent driver for the facility bus, which has led to missed appointments and canceled outings. Administrative and communication problems are described — difficult interactions with management, paperwork roadblocks when families try to transfer residents out, inconsistent handling of complaints, and occasional deception or dishonesty reported by families. Conversely, some reviewers explicitly praise specific administrative staff (admissions coordinator, housekeeping or dining managers) for being welcoming and effective, underscoring inconsistent performance between individuals and shifts.
Dining and housekeeping receive mixed ratings that appear to have changed over time for some reviewers. Several earlier reviews describe poor food quality tied to budget limitations, while later reviews highlight a certified chef, varied menus, and restaurant‑style service. Similarly, some families report daily cleaning, attentive laundry service, and no unpleasant smells after management changes, while others report urine‑soaked blankets, stained sheets, and rooms that are not swept or mopped for days. The contradictory reports suggest uneven implementation of standards and variable performance depending on time period, unit, or staff on duty.
Facilities and amenities are likewise mixed. Positive notes include inviting decor, aviary and bird feeders, TVs in rooms, a nice dining area, and meaningful activities. Negative notes describe maintenance being "jimmy‑rigged," broken or out‑of‑service transportation, personal property damage, and occasional long waits for repairs. Several reviews singled out the therapy department as exceptional, while others said physical therapy was unavailable at times.
Notable patterns and red flags: the most serious and recurrent issues are medication errors, neglect indicators (pressure injuries, dehydration, incontinence care lapses), pest sightings, and at least one reported resident death associated with choking — each of these raises regulatory and clinical safety concerns. Yet a countervailing pattern is also present: some families report clear improvements after management changes and consistently praise specific staff members and departments, especially therapy. This variability suggests that quality at Tonganoxie Terrace may be inconsistent across time, units, and shifts, with strong caregivers and pockets of good practice tempered by systemic problems in staffing, oversight, and housekeeping/maintenance.
Recommendations for someone evaluating Tonganoxie Terrace: (1) Ask for recent survey and inspection reports and evidence of remediation for cited deficiencies; (2) Tour multiple units and observe mealtime, toileting/ADL assistance, and staff‑to‑resident interactions across different shifts; (3) Ask about current staffing levels, turnover rates, medication administration protocols, infection control practices, and pest control measures; (4) Request documentation of changes made by new management (contracts for new services, chef hiring, maintenance logs, transportation availability); and (5) Speak directly with families of current residents about continuity of care, responsiveness to complaints, and discharge processes. In summary, while there are clear strengths — notably compassionate direct care staff and strong therapy services — the facility shows documented and serious concerns in clinical safety, cleanliness, pest control, and management consistency that warrant careful, specific verification before placement.
