Tanglewood Nursing & Rehabilitation
On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 45 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Special Focus Facility (under heightened CMS scrutiny)
- Low overall rating (1/5 stars)
- Low staffing rating (1/5 stars)
- Above-median deficiencies (25 vs median 9.0)
- High staff turnover (93%)
Bottom 25% in KS · Below recommended RN staffing · Very high staff turnover · Worst in HMG HEALTHCARE chain · $243,033 in fines · Special Focus Facility (CMS)
What this means for your family
While the therapy department receives praise for helping residents recover, the facility has a history of serious concerns regarding hygiene and nursing responsiveness. If you choose this facility, ensure you have a plan for frequent, in-person visits to monitor your loved one's care and hygiene, as communication via phone is frequently reported as unreliable.
Google Reviews
Google Reviews
45 reviews on Google“Tanglewood Nursing & Rehabilitation receives highly polarized feedback, with some families praising the therapy team and facility cleanliness, while others report severe neglect and unsanitary conditions. Recurring complaints highlight significant issues with nursing staff responsiveness, communication, and basic hygiene standards. Families considering this facility should be aware of the stark contrast between positive experiences and reports of substandard care.”
Quality Themes
Tap a score for detailsStrengths
- Effective physical and occupational therapy
- Clean and well-decorated lobby area
- Staff willingness to coordinate with insurance
Concerns
- Unsanitary facility conditions and poor hygiene (mentioned by 7 reviewers)
- Inattentive, rude, or unqualified nursing staff (mentioned by 6 reviewers)
- Poor communication and failure to answer phones (mentioned by 4 reviewers)
- Neglect of basic patient needs (bathing, sheets, call lights) (mentioned by 4 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 50 analyzed
How They Respond to Reviews
This facility responds to some reviews.
Questions for Your Tour
- 1Given the recent focus on facility maintenance, could you walk me through your current daily cleaning protocols and how you ensure high hygiene standards in resident rooms?
- 2I noticed that communication is a top priority for families; what is the best way for us to stay in touch with the nursing team, and how quickly can we expect a response regarding my loved one's care?
- 3Could you explain the process for how staff members are trained and supervised to ensure they are providing attentive, compassionate care for residents' daily needs like bathing and bedding changes?
- 4I see that the physical and occupational therapy programs are highly regarded here; how do you integrate these services into a resident's daily routine to keep them active and engaged?
- 5How does your nursing team manage medication administration and ensure that any changes in a resident's health status are communicated promptly to the family?
- 6I appreciate that you actively engage with feedback online; how do you use input from families to improve the quality of care and the overall experience at Tanglewood?
Personalized based on this facility's data
Key Review Excerpts
“The PT, OT, and ST folks were great. Some of the professional nursing staff are also great. Unfortunately, the majority of the nursing staff, especially on night shift, were inattentive, disrespectful, and rude.”
“The facility was filthy and his room was only cleaned after my mother threatened to call the state with complaints.”
“I was there for rehab, but my medications were wrong, the food was lousy, call lights were ignored, I never saw a doctor!”
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
11
measures
2
measures
4
measures
Residents on antipsychotic medication
Residents vaccinated for pneumonia
Residents on anti-anxiety or sleep medication
Residents needing more daily help over time
Residents vaccinated for the flu
Residents who lost too much weight
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
Families filed numerous complaints triggering 26 deficiencies, indicating serious concerns about care quality. The facility struggles persistently with nursing staffing, medication management, and safety hazards across all surveys from 2021-2024. Recent complaints cite inadequate nursing care, unsafe conditions, and poor dietary services, though all deficiencies show correction dates.
Oct 17, 2024Complaint25
Resident Rights Deficiencies
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nursing and Physician Services Deficiencies
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.
Nutrition and Dietary Deficiencies
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.
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
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
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
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
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.
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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
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.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
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 safe, appropriate dialysis care/services 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 mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
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 each resident’s drug regimen must be free from unnecessary drugs.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Environmental Deficiencies
Keep all essential equipment working safely.
Oct 17, 2024Routine15
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Emergency Preparedness Deficiencies
Establish policies and procedures for volunteers.
Emergency Preparedness Deficiencies
Establish roles under a Waiver declared by secretary.
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
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.
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
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 large enough exits.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Jun 17, 2024Complaint1
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Apr 18, 2023Routine37
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
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Nursing and Physician Services Deficiencies
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Emergency Preparedness Deficiencies
Establish policies and procedures for volunteers.
Emergency Preparedness Deficiencies
Provide emergency officials' contact information.
Emergency Preparedness Deficiencies
Provide primary/alternate means for communication.
Emergency Preparedness Deficiencies
Provide a means of sharing information on occupancy/needs.
Emergency Preparedness Deficiencies
Provide family notifications of emergency plan.
Emergency Preparedness Deficiencies
Establish staff and initial training requirements.
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
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
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
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
Ensure proper usage of power strips and extension cords.
Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
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 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 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
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Dec 8, 2021Routine17
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.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
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
Ensure proper usage of power strips and extension cords.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
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 safe, appropriate dialysis care/services for a resident who requires such services.
Construction Deficiencies
Use approved construction type or materials.
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Federal Penalties
Fine
Oct 17, 2024
$86,141
Payment Denial
Oct 17, 2024
20-day denial
Fine
Jun 17, 2024
$141,299
Ownership & Operations
Who Operates This Facility
Tanglewood Nursing & Rehabilitation
for profit
Chain Affiliation
Hmg Healthcare
33 facilities nationwide
Chain avg rating: 3.2/5 · Rank 32 of 33 (Worst)
Ownership & Management
Owners
Prince, Derek
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
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
45 reviews from families & visitors
Official Website
Visit tanglewoodhealthandrehabilitation.com
Medicare data downloads
Original nursing home datasets
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