Tanglewood Nursing & Rehabilitation
5015 SW 28th Street, Topeka, KS 66614 · Shawnee County · 54 certified beds · avg 47 residents/day · certified since Apr 12, 2003
SFF Candidate
Part of chain: HMG HEALTHCARE (31 facilities, chain avg rating 3.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Oct 17, 2024 · F-0584 · triggered by a complaint
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Why it matters: An unsafe or unclean environment affects residents' health, comfort, and dignity every single day.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Dec 5, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jun 17, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 18, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 17, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 5, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (45)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Oct 17, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Oct 17, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Oct 17, 2024 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint |
| Oct 17, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint |
| Oct 17, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Oct 17, 2024 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. · from a complaint |
| Oct 17, 2024 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Oct 17, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Oct 17, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint |
| Oct 17, 2024 | C · Minimal risk, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint |
| Jun 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 18, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Apr 18, 2023 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 18, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Apr 18, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Apr 18, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 18, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Apr 18, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Apr 18, 2023 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Apr 18, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Apr 18, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Apr 18, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Apr 18, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Apr 18, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 18, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Dec 8, 2021 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 8, 2021 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 8, 2021 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| Dec 8, 2021 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Dec 8, 2021 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (14 → 25).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 5 | 0 | E |
| 2023 | 14 | 0 | F |
| 2024 | 26 | 3 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $227,440, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Oct 17, 2024 | Fine | $86,141 |
| Oct 17, 2024 | Payment Denial | 20 days from Nov 15, 2024 |
| Jun 17, 2024 | Fine | $141,299 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Kansas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.01 | 4.58 | 3.95 | bottom 6% in Kansas; bottom 14% in the U.S. |
| Registered Nurse hours | 0.43 | 0.81 | 0.69 | bottom 10% in Kansas; bottom 26% in the U.S. |
| Weekend total nurse staffing | 2.71 | 4.05 | 3.50 | bottom 6% in Kansas; bottom 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.30 | 0.49 | 0.48 | bottom 17% in Kansas; bottom 31% in the U.S. |
| Total nursing staff turnover (%) | 71.2 | 48.1 | 45.8 | bottom 7% in Kansas; bottom 5% in the U.S. |
| RN turnover (%) | 60.0 | 42.0 | 42.9 | bottom 24% in Kansas; bottom 22% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.78, RN 0.39, weekend 2.50. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Balsamo, Krystal | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/29/2021 |
| Balsamo, Krystal | Individual | ADP of the SNF | NOT APPLICABLE | 09/29/2021 |
| Blome, Sheryl | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/26/2024 |
| Blome, Sheryl | Individual | ADP of the SNF | NOT APPLICABLE | 08/26/2024 |
| CCP Westwood Manor 7348 LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2014 |
| Cibc Bank USA | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/2024 |
| Cibc Bank USA | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2018 |
| Culp, Roland | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/04/2014 |
| Culp, Roland | Individual | ADP of the SNF | NOT APPLICABLE | 03/04/2014 |
| Daspit, Laurence | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/01/2014 |
| Daspit, Laurence | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2014 |
| Dohn, William | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/27/2019 |
| Dohn, William | Individual | ADP of the SNF | NOT APPLICABLE | 03/27/2016 |
| Forvis Mazars LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/24/2018 |
| Forvis Mazars LLP | Organization | ADP of the SNF | NOT APPLICABLE | 02/07/2013 |
| Gaut, Kenisha | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/06/2017 |
| Gaut, Kenisha | Individual | ADP of the SNF | NOT APPLICABLE | 09/06/2017 |
| Healthmark Group LTD | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/2014 |
| HMG Healthcare LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/19/2025 |
| HMG Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/01/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Plaza West Healthcare and Rehab | 1.9 mi | Topeka, KS | ★☆☆☆☆ | 1/5 | |
| Rolling Hills Health Center | 2.3 mi | Topeka, KS | ★★☆☆☆ | 2/5 | |
| Lexington Park Nursing & Post Acute Center | 2.3 mi | Topeka, KS | ★★★★★ | 5/5 | |
| Heritage Grove Estates | 2.6 mi | Topeka, KS | ★★★★☆ | 4/5 | |
| Brewster Health Center | 2.6 mi | Topeka, KS | ★★★★★ | 4/5 | |
| The Gardens at Aldersgate | 2.7 mi | Topeka, KS | ★☆☆☆☆ | 1/5 | abuse |
| Topeka Presbyterian Manor | 2.9 mi | Topeka, KS | ★☆☆☆☆ | 1/5 | |
| The Healthcare Resort of Topeka | 3.2 mi | Topeka, KS | ★★★★★ | 5/5 | |
| Brighton Place West | 3.5 mi | Topeka, KS | ★★☆☆☆ | 2/5 | |
| Providence Living Center | 5.1 mi | Topeka, KS | ★☆☆☆☆ | 1/5 | SFF |
| Legacy on 10th Avenue | 5.2 mi | Topeka, KS | ★☆☆☆☆ | 1/5 | |
| Brighton Place North | 5.8 mi | Topeka, KS | ★★★★☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 175463.