Tallmadge Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Tallmadge Health & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF686Oct 9, 2025

  Based on closed record review, policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer program to ensure necessary and timely interventions were initiated for Resident #96 who was identified to have skin breakdown in the hospital just prior to admission. The facility also failed to timely identify changes in skin integrity and implement necessary wound care to promote wound healing and prevent infection.Actual harm occurred on 07/31/25 when Resident #96, who was dependent on staff for activities of daily living, was transferred to the hospital due to a change in condition. […]

• Actual harm, isolatedF697Dec 19, 2024

  Based on record review, review of hospital documentation, review of staff schedules, staff interview and policy review, the facility failed to develop and implement a comprehensive and effective pain management program for Resident #90, at the time of admission including adequate and accurate assessment and administration of physician ordered pain medication resulting in a re-hospitalization for the resident due to unrelieved pain. Actual harm occurred on 08/16/24 following Resident #90's admission to the facility for post-operative care when the resident experienced excruciating pain, was yelling out in pain and requesting pain medication that was not timely addressed. The resident was subsequently transferred to the hospital and readmitted due to abdominal pain. […]

• Actual harm, isolatedF697Apr 16, 2024

  Based on observation, interview, medical record review and policy review the facility failed to provide Resident #83 requested pain medication prior to pressure ulcer/injury wound care. Actual harm occurred on 04/12/24 at 10:11 A.M. when Registered Nurse #100 was observed to provide Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer/injury wound care to Resident #83, who had a physician order for narcotic pain medication as needed, despite the resident reporting pain and inquiring if she received pain medication prior to the wound care. Resident #83 voiced multiple complaints of pain during the procedure, rated her pain a level eight on a scale of one to 10, and was observed to have facial grimacing (due to the increased pain). […]

• No harm, potential for more than minimal, widespreadF804Apr 1, 2025

  Based on observation, interview, tasting of meal test tray, and facility policy review, the facility failed to ensure meals provided were palatable and served at an appetizing temperature. This affected seven residents (Resident #10, #21, #26, #28, #30, #41, and #69) and had the potential to affect all 82 residents receiving meals from the facility. The facility identified three residents (#25, #65, and #281) who received nothing by mouth and did not receive food from the facility kitchen. The facility census was 85. Findings include: Interview on 03/17/25 at 10:44 A.M. with Resident #21 revealed the food is frequently cold and the coffee is cold. Interview on 03/17/25 at 1:16 P.M. […]

• No harm, potential for more than minimal, widespreadF812Apr 1, 2025

  Based on observation, interview and facility policy review, the facility failed to ensure resident refrigerators were maintained in a safe and sanitary condition, free from expired food. This affected one (Resident #10) of three resident refrigerators observed. The facility identified 29 residents with refrigerators in their rooms. The facility census was 85. Findings include: Review of the facility resident council meeting minutes dated [DATE] revealed a concern related to resident refrigerator having items that are not being labeled or dated and should only be kept for three days and then discarded. Observation and interview on [DATE] at 12:36 P.M. […]