Tanglewood Health and Rehabilitation

    5015 SW 28th St, Topeka, KS, 66614
    2.8 · 47 reviews
    • Assisted living
    • Memory care
    • Skilled nursing
    AnonymousLoved one of resident
    1.0

    Neglectful nursing home; avoid placement

    I placed my loved one here and deeply regret it. The room reeked of urine, bedside drawers had bugs, and there was poop under the bedside toilet lid; call lights were ignored, meds missed, bathroom access denied, and dehydration sent them to the hospital. Nursing was largely inattentive and rude and the place is clearly understaffed, though a few nurses and the therapy team were compassionate and helpful. Management was defensive and misleading about policies and care; tours looked fine but reality was filthy and unsafe. The facility has nice decor, activities and outdoor time, but that doesn't excuse neglect, poor hygiene, and loss of dignity. I'm filing complaints and strongly recommend you move your loved one elsewhere.

    Pricing

    Schedule a Tour

    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    2.81 · 47 reviews

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      2.7
    • Staff

      3.0
    • Meals

      1.4
    • Amenities

      2.6
    • Value

      1.0

    Pros

    • Skilled and effective therapy/rehab staff
    • Successful rehab-to-home transitions with support services
    • Some compassionate and dedicated nursing/CNA staff
    • Helpful and responsive administrative team (in some reports)
    • Robust activities program with outings, patio time, and events
    • Friendly, welcoming front-desk and lobby environment
    • Some residents and families report significant functional improvement
    • 24-hour care available (reported by some reviewers)
    • Facility participates in continuous quality improvement program
    • Four-star CMS rating cited by at least one review
    • Staff who go above and beyond to arrange insurance/approvals
    • Family-oriented teamwork reported by some reviewers

    Cons

    • Widespread reports of inattentive, rude, or disrespectful nursing staff
    • Chronic understaffing (reports of one nurse for 55 patients)
    • Slow or non-responsive call-light response
    • Serious sanitation issues: urine/feces odors and dirty rooms
    • Allegations of unsanitary bedding, bedsores, and poor diaper use
    • Pest problems reported (bugs in drawers)
    • Dehydration and denied basic needs (water, bathroom access)
    • Denial of appropriate diets (no diabetic or heart-healthy options)
    • Medication errors and wrong medications given
    • Allegations of neglect leading to hospital readmissions and falls
    • Inconsistent cleanliness: some areas clean, others filthy
    • Kitchen/food quality criticized; allegations of unsanitary kitchen
    • Staff unqualified or unskilled according to several reviews
    • Staff dishonesty, policy misrepresentation, and lack of accountability
    • Defensive or evasive management behavior reported
    • Poor communication: unanswered phones and ignored complaints
    • COVID-19 visiting restrictions and related concerns
    • Polarized care quality—experiences vary widely between residents
    • Serious allegations of abuse, exploitation, and report/complaint filings
    • High emotional distress among families; some call for facility closure

    Summary review

    The reviews of Tanglewood Health and Rehabilitation are highly polarized, with strong praise from some families and residents alongside severe criticism from others. The most consistent positive thread is the rehabilitation program: multiple reviewers credit therapy staff with helping residents regain mobility and return home, sometimes noting that staff went out of their way to secure insurance approvals and prevent additional transfers. Several reviews describe compassionate, dedicated employees—both nursing and support staff—who provide attentive, family-style care. The facility is also reported to offer a lively activities program (patio time, monthly outings, bingo, shopping trips) and, in some accounts, a clean and welcoming lobby and décor. A few reviewers specifically praise an administrative team and cite a four-star CMS rating and a continuous quality improvement program, which suggests that the facility has formal structures in place to monitor quality.

    Counterbalancing the praise are numerous, detailed complaints about basic care, staffing, sanitation, and safety. A large portion of reviews allege inadequate nursing care: slow or unanswered call lights, inattentive or rude staff, medication mistakes, and instances where basic needs (water, feeding, bathing, bathroom access) were not met. Several reviews describe emergency-level consequences, such as dehydration requiring hospital readmission, untreated injuries after falls, and medication errors. Understaffing is a recurrent theme—reports of one nurse covering dozens of patients and CNAs missing or taking long lunches—leading reviewers to attribute neglect and delayed responses to insufficient staffing and poor backup coverage.

    Sanitation and infection-control concerns appear frequently and are among the most alarming themes. Multiple reviewers report persistent urine and fecal odors, dirty floors and bedding, pests in furniture, and meals or kitchen conditions they consider unsanitary. Some accounts say rooms were never cleaned, bedside tables contained soiled items, and patients were exposed to unsanitary conditions without appropriate protective measures (gloves/masks). These descriptions, combined with reports of unclean bed/diaper use and complaints about the kitchen, contribute to allegations that the facility fails to meet basic hygiene and dignity standards.

    Management and organizational issues are reported inconsistently but significantly. While some reviews praise administration for responsiveness and family-centered teamwork, others describe defensive administrators, policy misrepresentation, and staff dishonesty. Several reviewers mention filing state complaints or planning to file complaints with medical boards. There are also adamant, emotionally charged allegations—ranging from descriptions of the facility as a "death trap" or "nursing concentration camp" to calls for shutdown—which indicate severe distrust among some families. At the same time, other reviewers explicitly counter that narrative, saying management was amazing and staff saved their loved one from further transitions.

    Dining, activities, and environment produce mixed impressions. Activities and outings are frequently described positively and viewed as meaningful to resident quality of life. Food is generally described as "OK" or criticized (lousy food, denied diets). A notable and specific complaint is denial of diet alternatives for patients with diabetes or cardiac diets. The physical environment is described variably—some report a clean, pleasant decoration and organized lobby, while others report filthy rooms and strong odors. This inconsistency suggests significant variability in conditions across units, shifts, or over time.

    Overall sentiment is sharply divided: some families describe exceptional rehabilitation outcomes, attentive therapy, and caring staff, while others describe systemic neglect, hygiene failures, under-staffing, and safety incidents. The recurring patterns indicate that quality likely fluctuates—possibly due to staffing levels, shift-to-shift differences, site management, or turnover. Reviews also reference institutional indicators (a four-star CMS rating, a continuous improvement program) that contrast with multiple complaint narratives, highlighting a gap between official metrics and some families' lived experiences.

    Recommendations for prospective residents and families based on these themes: arrange an unannounced visit and observe multiple shifts (including evening/night) to assess cleanliness, call-response times, and staff interactions; ask for recent inspection/complaint histories and any corrective-action plans; confirm staffing ratios, nurse availability, and backup coverage; inquire specifically about diet accommodations, hydration protocols, incontinence management, and fall-prevention procedures; speak directly with therapy staff about expected outcomes and readmission prevention; and request references from recent families who have completed rehab-to-home transitions. Given the intensity and severity of some allegations, verify current conditions rather than relying solely on older reviews or a single tour.

    In summary, Tanglewood Health and Rehabilitation elicits strong praise for rehabilitation and for some exemplary staff and administrative practices, but the facility also receives numerous and serious complaints about sanitation, neglect, understaffing, medication and diet issues, and inconsistent management. The pattern suggests highly variable resident experiences; due diligence—focused observation, up-to-date regulatory records, and direct questions about staffing and clinical protocols—is essential for anyone considering placement there.

    Location

    Map showing location of Tanglewood Health and Rehabilitation

    About Tanglewood Health and Rehabilitation

    Tanglewood Health and Rehabilitation sits at 5015 SW 28th Street in Topeka, Kansas, and folks know it for skilled nursing, short-term rehab, and long-term care, plus assisted living, independent living, and care for memory issues, so they really do cover a lot. The facility has 54 beds and stays open all day, every day, so help's around when you need it, and there's always a nurse or caregiver on hand. People there can get therapy for physical needs, speech, or help with living skills-even IV therapy and nutritional counseling are available. The leadership includes clinically trained department directors, which you don't see everywhere, and the staff offers personalized care for each resident, including medication help and special diets-meals come three times a day, with dietary needs handled. They have Wi-Fi, housekeeping, an emergency voice alert system in case someone gets hurt, therapy whirlpool baths, safe transportation, and 24/7 security.

    There's a home-like feel, especially for those in long-term care, and the building's got a big living room, a dining room, library, and a recreation room for things like games or reading. Programs for memory care get special attention, and those who need palliative or hospice care find support there too. The staff supports recovery and well-being with wellness and therapy programs, and folks can expect their medical, social, and emotional needs to get noticed-there's even a community newsletter and an ombudsman to help with any problems that come up. Family and residents can follow updates on Facebook, and the facility's won some honors, like being called a Top Nursing Home in Kansas and holding a 4-star rating. Tanglewood aims for individualized, quality care, with a focus on safety and comfort right alongside medical support.

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