Tanglewood Nursing & Rehabilitation
5015 Sw 28th Street · Topeka, KS · 66614 · 7852730886
54 certified beds For profit - Corporation Chain: Hmg Healthcare
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $86,141 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
$86,141 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
82% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.14 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.32 | 0.55–0.75 |
| Weekend hours / resident-day | 3.02 | ≈ weekday level |
| Nursing turnover / year | 82% | median 45% |
| Fines (3-yr window) | 2 · $227,440 |
Inspection citations (45 in the current record)
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Immediate jeopardy · K October 17, 2024 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected December 5, 2024 · Resident Rights
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Actual harm · G October 17, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 5, 2024 · Quality of Life and Care
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Potential for harm · D October 17, 2024 · found via complaint
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected October 22, 2024 · Resident Rights
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Potential for harm · D October 17, 2024 · found via complaint
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected October 22, 2024 · Resident Rights
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Potential for harm · D October 17, 2024 · found via complaint
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected October 22, 2024 · Resident Rights
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Potential for harm · D October 17, 2024 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected October 22, 2024 · Resident Assessment and Care Planning
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Potential for harm · E October 17, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected October 22, 2024 · Quality of Life and Care
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Potential for harm · D October 17, 2024 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 22, 2024 · Quality of Life and Care
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Potential for harm · D October 17, 2024 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected October 22, 2024 · Quality of Life and Care
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Potential for harm · D October 17, 2024 · found via complaint
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected October 22, 2024 · Quality of Life and Care
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Potential for harm · D October 17, 2024 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected October 22, 2024 · Quality of Life and Care
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Potential for harm · D October 17, 2024 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected October 22, 2024 · Quality of Life and Care
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Potential for harm · D October 17, 2024 · found via complaint
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected October 22, 2024 · Quality of Life and Care
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Potential for harm · F October 17, 2024 · found via complaint
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected October 22, 2024 · Nursing and Physician Services
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Potential for harm · D October 17, 2024 · found via complaint
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected October 22, 2024 · Quality of Life and Care
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Potential for harm · E October 17, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected October 22, 2024 · Pharmacy Service
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Potential for harm · D October 17, 2024 · found via complaint
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected October 22, 2024 · Pharmacy Service
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Potential for harm · D October 17, 2024 · found via complaint
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected October 22, 2024 · Pharmacy Service
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Potential for harm · F October 17, 2024 · found via complaint
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected October 22, 2024 · Nutrition and Dietary
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Potential for harm · D October 17, 2024 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected October 22, 2024 · Nutrition and Dietary
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Potential for harm · D October 17, 2024 · found via complaint
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected October 22, 2024 · Nutrition and Dietary
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Potential for harm · F October 17, 2024 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 22, 2024 · Nutrition and Dietary
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Potential for harm · F October 17, 2024 · found via complaint
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected October 22, 2024 · Administration
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Potential for harm · E October 17, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected October 22, 2024 · Infection Control
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No harm found · C October 17, 2024 · found via complaint
Keep all essential equipment working safely.
Corrected October 22, 2024 · Environmental
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 17, 2024 | Fine | $86,141 |
| October 17, 2024 | Payment Denial | 20 days |
| June 17, 2024 | Fine | $141,299 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 175463 · certified since April 12, 2003. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.