Tallmadge Health & Rehab Center

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to maintain accurate and timely medication records of controlled substances and other medications according to acceptable standards of practice. This affected three residents (#1, #17 and #20) of eight residents reviewed for medication administration. The facility census was 86.

Inspectors wroteBased on interview, photograph review, and facility policy, the facility failed to ensure medications were stored, prepared, and administrated properly. This had the potential to affect all 47 residents residing on the 100 and 200 hall in the facility.

Inspectors wroteBased on interview, record review, and Employee Handbook review, the facility failed to ensure staff were awake at all times to effectively meet the needs of all residents. This had the potential to affect all 81 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #2's gastric tube was properly assessed, monitored, and cared for. This affected one resident (Resident #2) out three residents reviewed for feeding tubes. Review of medical record for Resident #2 revealed an admission date of 08/28/25 with diagnosis included but not limited to, chronic respiratory failure, other artificial openings of gastrointestinal tract status, type 2 diabetes mellitus with diabetic neuropathy, severe protein-calorie malnutrition, gastrostomy infection, end stage renal disease, dependence on renal dialysis, dependence on respirator, and tracheostomy status. [...]

Inspectors wroteBased 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. The resident was subsequently assessed by hospital staff to have an unstageable sacral wound with a significant amount of purulence in the tissue consistent with a necrotizing soft tissue infection. [...]

Inspectors wroteBased on observation, interview, record review, hospital record review, and interview, the facility failed to ensure Resident #39 received proper care and assistance in managing his ostomy and tube feed needs. This affected one resident (Resident #39) of three residents reviewed for dependent resident care.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, medical record review, observation of resident council, review of resident rights, and review of the formal complaint from residents at the facility, the facility failed to ensure residents were treated with dignity and respect. This affected four residents (#3, #69, #285, #28) of four residents reviewed for dignity. The facility census was 85.

Inspectors wroteBased on interview, record review, and review of email correspondence, the facility failed to ensure resident concerns were addressed in manner that provided a resolution to their concerns. This affected two residents (#10 and #21) of four residents reviewed for concerns. The facility census was 85.

Inspectors wroteBased on interviews, medical record review, personnel file review, and policy review, the facility failed to implement their abuse policy by failing to immediately remove a staff member accused of emotional abuse during the investigation. This affected one resident (#3) of four residents reviewed for abuse and neglect. A second example of no actual harm with the potential for minimal harm occurred when the facility failed to ensure reference checks were completed on new employees upon hire. This had the potential to affect all residents residing in the facility. The facility census was 85.

Inspectors wroteBased on interview and record review the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) for Resident #56 was accurately completed upon the resident's admission to the facility. This affected one resident (#56) of one resident reviewed for PASARR. The facility census was 85.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to ensure Resident #23's Thrombo-Embolic Deterrent (TED) hose (compression stockings) were in place as ordered and failed to ensure monitoring was completed for Resident #63's biliary drain. This affected two residents (#23 and #63) out of six residents reviewed for skin conditions. The facility census was 85.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure Resident #7 was safely transferred using a mechanical lift. This affected one resident (#7) of three residents reviewed for accidents. The facility census was 85.

Inspectors wroteBased on interview, medical record review, and policy review, the facility failed to establish a baseline weight for Resident #73. This affected one resident (#73) of four residents reviewed for nutrition. The facility census was 85.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure Resident #287's midline intravenous access site dressing changes were completed per physician order. This affected one resident (#287) out of one residents reviewed for intravenous therapy. The facility identified four residents receiving intravenous therapy. The facility census was 85.

Inspectors wroteBased on interview and record review the facility failed to ensure dialysis communication forms had been completed before and after dialysis treatments. This affected one resident (#10) of two residents reviewed for dialysis communication. The facility census was 85.

Inspectors wroteBased on interviews, observation, record review, facility policy review, review of pharmacy destruction logs, review of facility policy, and review of Ohio Revised Code, the facility failed to ensure medications were returned to the pharmacy timely following discharge and narcotics were destroyed in a timely manner. In addition, the facility failed to ensure Resident #21 received routine medications per physician orders. This affected Resident #21 and had the potential to affect all residents residing in the facility. The facility census was 85.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure pharmacy recommendations were timely reviewed and addressed by the provider. This affected two residents (#30 and #67) of five residents reviewed for unnecessary medications. The facility census was 85.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure appropriate follow up with a specialty physician related to an antibiotic medication. This affected one resident (#296) out of two residents reviewed for death. The facility census was 85.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate documentation was recorded regarding Resident #287's midline intravenous (IV) dressing changes. This affected one resident (#287) of four residents reviewed for documentation. The facility census was 85.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure effective infection control measures were maintained during wound dressing changes. This affected one resident (#287) of six residents reviewed for skin conditions. The facility census was 85.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure Resident #56 received appropriate treatment following an Urinary Tract Infection (UTI). This affected one resident (#56) of two residents reviewed for treatment of UTIs. The facility census was 85.

Inspectors wroteBased 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 re-admitted due to abdominal pain. This affected one resident (#90) of three residents reviewed for pain management. The facility census was 75.

Inspectors wroteBased on medical record review, resident representative interview, review of video footage,staff interview, observation, and review of the facility policy, the facility failed to ensure staff performed proper hand hygiene and follow appropriate infection control practices for discarding soiled items when providing incontinence care. This affected two (Residents #51 and #81) of three residents reviewed for incontinence care. The facility census was 85 residents.

Inspectors wroteBased on medical record review, resident and staff interview, and review of a facility policy, the facility failed to timely refer a resident for dental services when dentures went missing. This affected one (#51) of 16 residents identified by the facility who wore dentures. The census was 82.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a self-reported incident (SRI) investigation and staff interviews, the facility failed to ensure Resident #81 was appropriately secured during a wheelchair transport resulting an unsafe transfer of the resident. This finding affected one (Resident #81) of three residents reviewed for falls.

Inspectors wroteBased 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). This affected one resident (#83) of three residents reviewed for pain management. The facility census was 85.

Inspectors wroteBased on closed medical record review and interview the facility failed to timely treat a urinary tract infection (UTI). This affected one resident (Resident #86) of three residents reviewed for timely care and treatment. The facility census was 85.

Inspectors wroteBased on observation, medical record review, hospital record review and interview the facility failed to ensure Resident #74 was provided transportation services to attend a follow-up urology consultation appointment as necessary to meet the resident's total care needs and as scheduled. This affected one resident (#74) of three residents reviewed for medical appointments. The facility census was 84.

Inspectors wroteBased on observation, record review, facility policy review and interview the facility failed to maintain adequate infection control practices to prevent the spread of infection during incontinence care for Resident #30. This affected one resident (#30) of one resident observed for incontinence care. The facility census was 84.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #27's and Resident #9's wound treatments were maintained for Resident #27's perineal pressure ulcer and Resident #9's unstageable coccyx pressure ulcer. This affected one out of three residents reviewed for pressure ulcers. The facility census was 82.

Inspectors wroteBased on medical record review, review of audit forms, and interview, the facility failed to ensure medications were available for administration in accordance with physician orders. This affected two (Residents #54 and #83) of three residents reviewed for pharmaceutical services.

Inspectors wroteBased on observation, review of the facility Hand Hygiene/Handwashing policy and interview the facility failed to ensure staff performed hand hygiene during Resident #27's incontinence care and Resident #9's wound treatment procedure to prevent cross contamination of germs and failed to ensure staff sanitized/disinfected scissors before use during the wound treatment for Resident #9. This affected one out of three residents reviewed for incontinence care and two out of three residents reviewed for wounds. The facility census was 82.

Inspectors wroteBased on interviews and review of manufacturer instructions the facility failed to ensure staff were educated on proper use of the Sani-Cloth Bleach wipes used to sanitize multi use items including the pulse oximeter. This had the potential to affect all 86 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to provide scheduled showers for three of three residents reviewed, Resident #397, #395, and #392, failed to provide shaving for two of two residents reviewed, Resident #397 and #392, and failed to provide nail care for two of two resident reviewed, Residents #395 and #392. The facility census was 86.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address and treat a wound timely. This affected one resident (Resident #392) of three residents reviewed for wounds. The facility census was 86.