Tanglewood Nursing & Rehabilitation, Topeka, Kansas

45
Citations from health inspectionsKansas average: 28 a home: 3
Residents harmed or put in dangerKansas average: 1.6 a home: $227,440
Fines from the federal governmentKansas average: $20,430 a home: 1 out of 5
Overall rating in starsKansas average: 3.1

The figures come from Medicare Care Compare files released October 8, 2026 by CMS, the federal Medicare agency. The citations span each home's three most recent inspection cycles plus their complaint visits, going back to March 2017 at the earliest; the fines span about three years, beginning September 2023. Browse the CMS files

Four inspection visits produced 45 citations. Residents were in immediate danger in two findings. Residents were found hurt in one case. Federal fines came to $227,440 (two fines). Once, Medicare stopped paying for new admissions.

A candidate for Special Focus. For its list of nursing homes with past poor inspection results, CMS has named this home a candidate.

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Quick Look at the Record

The home's overall star rating: 1 out of 5
Rating for health inspections: 1 out of 5
Rating for staffing: 1 out of 5
Rating for quality of care: 4 out of 5
Nurse time for each resident: 2.78 hours each dayThe Kansas average is 4.07 hours
Time from registered nurses: 0.39 hours each dayThe Kansas average is 0.71 hours
Nursing staff who left during one year: 71.2%against the Kansas average of 48.1%
Beds that are certified: 54
Ownership: Corporation (for profit)
Chain: Hmg Healthcare, with 31 homes
Street address: 5015 Sw 28th Street, Topeka, Kansas 66614
County: Shawnee

Each inspection's citations

Every citation marks a federal rule inspectors found broken, along with its seriousness and the number of residents affected.

25 citations dated Oct. 17, 2024

F908 Keep Essential Equipment Working Safely: minimal risk to residents, widespread, found on a complaint visit.
F880 Infection Prevention and Control: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F851 Submit Accurate Staffing Data to Federal Government: risk of harm, no one found hurt, widespread, found on a complaint visit.
F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, widespread, found on a complaint visit.
F805 Food Prepared to Meet Individual Needs: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F804 Food Taste and Temperature: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F801 Qualified Kitchen and Dietitian Staff: risk of harm, no one found hurt, widespread, found on a complaint visit.
F757 Unnecessary Drugs: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F756 Monthly Drug Regimen Review: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F755 Pharmacy Services: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F742 Mental Health and Trauma Treatment: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F727 Required Registered Nurse and Nursing Director: risk of harm, no one found hurt, widespread, found on a complaint visit.
F698 Dialysis Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F697 Pain Management: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F695 Breathing and Oxygen Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F693 Feeding Tube Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F690 Bladder, Bowel and Catheter Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F689 Accident Hazards and Supervision: residents were harmed, one or a few residents, found on a complaint visit.
F686 Pressure Ulcer (Bedsore) Care: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F677 Help With Daily Living: risk of harm, no one found hurt, a pattern, several residents, found on a complaint visit.
F641 Accurate Resident Assessments: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F625 Written Notice of Bed Hold Policy: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F623 Notice Before Transfer or Discharge: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F622 Valid Reasons and Paperwork for Transfer or Discharge: risk of harm, no one found hurt, one or a few residents, found on a complaint visit.
F584 A Safe, Clean, Homelike Room: immediate danger to residents, a pattern, several residents, found on a complaint visit.

One citation dated June 17, 2024

F684 Quality of Care: immediate danger to residents, one or a few residents, found on a complaint visit.

14 citations dated April 18, 2023

F880 Infection Prevention and Control: risk of harm, no one found hurt, widespread.
F757 Unnecessary Drugs: risk of harm, no one found hurt, one or a few residents.
F755 Pharmacy Services: risk of harm, no one found hurt, a pattern, several residents.
F727 Required Registered Nurse and Nursing Director: risk of harm, no one found hurt, widespread.
F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents.
F684 Quality of Care: risk of harm, no one found hurt, one or a few residents.
F677 Help With Daily Living: risk of harm, no one found hurt, a pattern, several residents.
F657 Updating the Care Plan on Time: risk of harm, no one found hurt, one or a few residents.
F610 Investigating Abuse Allegations: risk of harm, no one found hurt, one or a few residents.
F609 Reporting Suspected Abuse: risk of harm, no one found hurt, one or a few residents.
F585 Right to File Complaints Without Retaliation: risk of harm, no one found hurt, a pattern, several residents.
F583 Keep Resident Records Private: risk of harm, no one found hurt, one or a few residents.
F561 Respect Resident Choices and Self Determination: risk of harm, no one found hurt, one or a few residents.
F550 Dignity and Resident Rights: risk of harm, no one found hurt, one or a few residents.

Five citations dated Dec. 8, 2021

F812 Food Storage and Kitchen Safety: risk of harm, no one found hurt, a pattern, several residents.
F698 Dialysis Care: risk of harm, no one found hurt, one or a few residents.
F689 Accident Hazards and Supervision: risk of harm, no one found hurt, one or a few residents.
F677 Help With Daily Living: risk of harm, no one found hurt, a pattern, several residents.
F661 Share Information at Planned Discharge: risk of harm, no one found hurt, one or a few residents.

Payment Denials and Fines

Date	Penalty	Amount
Oct. 17, 2024	Fine	$86,141
Oct. 17, 2024	Payment denial for new admissions	20 days
June 17, 2024	Fine	$141,299

Ownership and Management of the Home

The home is run by Cibc Bank USA (operational or managerial control).
The home is run by Forvis Mazars LLP (operational or managerial control).
The home is run by Healthmark Group Ltd (operational or managerial control).
The home is run by Zions Bancorporation (operational or managerial control).

The CMS Care Compare files, updated every month, provide provider information, health deficiencies, penalties, and ownership. The CMS certification number is 175463. Other homes in Kansas.