Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heather Knoll Retirement Village during CMS and state inspections, most recent first.
A resident with dementia, anxiety, repeated falls, and general weakness, who required partial assistance for mobility, exited the facility unnoticed and was later found by a COTA in the parking lot without a coat, hat, or gloves in very cold weather. The resident reported going out to see a car and wanting fresh air, and staff interviews showed that the CNA and unit manager were unaware the resident had left without staff or family. An LPN had given the resident medications earlier, later saw the resident being brought back by therapy, briefly counseled the resident about signing out and dressing appropriately, but did not perform or document a health assessment or determine how long the resident had been outside. Leadership staff stated no investigation was conducted because the resident had intact cognition, and the family, who had previously been told of attempts to leave, were not notified that the resident had actually been outside without staff supervision and without appropriate clothing.
A resident with intact cognition and specific activity preferences was not provided with meaningful activities of interest. Despite expressing the importance of group activities and favorite pastimes, the resident was only offered coloring pages and word searches, and watched television. Interviews confirmed the lack of one-on-one activity visits, contrary to the facility's policy requiring personalized programming for residents unable or unwilling to join group activities.
The facility failed to provide adequate incontinence care for two residents, resulting in moisture-associated skin damage (MASD) and improper use of incontinence products. A resident developed MASD due to infrequent changes of disposable undergarments, while another resident received care involving the use of two incontinence liners simultaneously, against manufacturer instructions. These actions violated the facility's incontinence care protocol, leading to non-compliance with care standards.
A resident with a history of MSSA infection did not receive the prescribed Oxacillin IV due to a delay in pharmacy delivery and a lack of timely communication with the IDP. The facility's staff were aware of the medication's unavailability but did not promptly seek alternative treatment, resulting in a significant medication error.
The facility failed to provide sanitary incontinence care for a resident, as a nursing assistant did not use protective barriers for soiled items, contaminating clean linens. Additionally, two STNAs and an LPN did not follow Enhanced Barrier Precautions for another resident with a staphylococcus infection, neglecting to wear gowns during high-contact care activities. These actions violated the facility's infection prevention protocols.
Failure to Prevent and Assess Resident Exit in Cold Weather
Penalty
Summary
The facility failed to ensure a resident area was free from accident hazards and that adequate supervision was provided when one resident exited the building without staff knowledge in very cold weather. The resident, admitted with diagnoses including unspecified dementia, anxiety disorder, repeated falls, general weakness, balance deficit, and orthostatic hypotension, had a care plan addressing fall risk but no plan of care identifying elopement risk. A comprehensive MDS showed intact cognition and a BIMS score of 15, and the resident required partial assistance for bed mobility, transfers, and ambulation. On the day of the incident, nursing documentation only noted that the resident was observed outside by a COTA, with no further detail about the circumstances of the exit. Interviews revealed that direct care staff, including a CNA and the unit manager, were unaware that the resident had left the facility without staff or family. The resident reported going to the parking lot to see his car and acknowledged it was cold and that going out without a coat was unwise. The COTA stated she found the resident approximately 20 feet from the building and 50 feet from the door in the parking lot, wearing street clothes but no hat, coat, or gloves, and that he said he wanted fresh air. An LPN reported she had given the resident medications before he left to wait for his sister, later saw him being wheeled back by the COTA, and spoke briefly with him about signing out and dressing appropriately, but did not complete or document any assessment and could not verify which door he used or how long he was outside. The Administrator, DON, and QA nurse acknowledged that no investigation was completed and no further action was taken because of the resident’s intact cognition. The resident’s family, who reported prior notifications that he had tried to leave or was looking for the door, stated they were not informed that he had actually been outside without staff and without a coat.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide meaningful activities of interest to a resident, identified as Resident #89, who was affected by this deficiency. Resident #89, who had intact cognition, expressed that keeping up with the news was somewhat important, and participating in group activities and doing favorite activities were very important. Despite these preferences, the activities log showed that from February 18 to March 5, Resident #89 was only offered coloring pages and word searches daily, and watched television. He received communion once and mail once during this period, with no other activities documented. Furthermore, the record of one-on-one activities revealed that such activities were only provided on a few days in January, with no records for February or March up to the date of the survey. Interviews with Resident #89 and several CNAs confirmed that he stayed in his room most of the time, watched television, and was not offered or did not attend group activities. The CNAs verified that Resident #89 had not received any one-on-one activity visits throughout the day. The Activities Director acknowledged the lack of documentation for one-on-one visits since January and was unaware of Resident #89's interest in the activities provided, such as coloring or word puzzles. The facility's policy stated that residents unable or unwilling to participate in group programs should receive one-on-one programming based on their interests, abilities, and likes, which was not adhered to in this case.
Inadequate Incontinence Care and Improper Use of Products
Penalty
Summary
The facility failed to provide appropriate incontinence care for two residents, leading to the development of moisture-associated skin damage (MASD) and improper use of incontinence products. Resident #108, who was admitted for a respite stay, developed MASD on his buttocks, scrotum, and penis due to inadequate incontinence care. Despite being assessed as low risk for pressure sores, Resident #108's disposable undergarments were not changed frequently enough, resulting in prolonged exposure to moisture. This lack of care was confirmed by the family member and the wound nurse, who noted that the resident was not admitted with any skin breakdown. Additionally, Resident #20, who had severe cognitive impairment and was always incontinent of urine and bowel, received improper incontinence care. During an observation, two STNAs were seen using two incontinence liners simultaneously, contrary to the manufacturer's instructions and facility policy. This practice can lead to skin damage and discomfort, as the use of multiple liners does not increase absorbency and can cause leakage. The facility's failure to adhere to its incontinence care protocol and the manufacturer's instructions for incontinence products resulted in non-compliance with care standards. The deficiency was identified during a complaint investigation, highlighting the need for proper management of incontinence to prevent skin integrity loss.
Failure to Administer Prescribed Antibiotic Timely
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Oxacillin for a MSSA infection. The resident, who had a history of osteomyelitis of the vertebra, hypertensive heart disease with heart failure, and a prosthetic joint infection, was admitted to the facility with orders for Oxacillin IV every four hours. However, the medication was not available upon the resident's readmission, and there was a delay in notifying the Infectious Disease Physician (IDP) about the unavailability of the medication. The resident's care plan required the administration of medications as ordered, but due to a delay in pharmacy delivery, the Oxacillin was not administered as scheduled. The facility's staff, including a Certified Nurse Practitioner (CNP) and Registered Nurse (RN), were aware of the delay but did not promptly contact the IDP to seek alternative treatment options. The IDP was eventually contacted the following day, and an alternative antibiotic, Keflex, was prescribed until the Oxacillin became available. Interviews with facility staff revealed that the facility did not have an Oxacillin starter kit and relied on pharmacy deliveries, which were delayed. The Director of Nursing (DON) and other staff acknowledged the communication gap and the lack of documentation regarding attempts to contact the IDP. The facility's policy on medication administration emphasized the importance of timely and accurate medication delivery, which was not adhered to in this case.
Infection Control and PPE Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide incontinence care in a sanitary manner for Resident #65, who was cognitively intact but dependent on assistance for toileting and hygiene. During an observation, a State tested Nursing Assistant (STNA) did not prepare plastic bags for soiled linens and disposable undergarments before providing care. The STNA placed feces-soiled washcloths, sheets, and disposable undergarments at the end of the bed without a protective barrier, contaminating clean bed linens. The soiled items were later moved to the resident's wheelchair, again without a barrier, and the contaminated blanket was used to cover the resident. For Resident #66, who required Enhanced Barrier Precautions (EBP) due to a methicillin-susceptible Staphylococcus aureus infection and other medical conditions, staff failed to don appropriate personal protective equipment (PPE). Despite a sign indicating the need for gloves and gowns for high-contact care activities, two STNAs and an LPN entered the resident's room and provided care without wearing gowns. Their clothing brushed against the resident's gown and bed linens, and the LPN removed a dressing without following the EBP protocol. The facility's policies for incontinence care and EBP were not adhered to, as evidenced by the actions of the staff involved. The deficiencies were identified during observations and interviews, with staff confirming their failure to follow the required procedures. The report highlights non-compliance with infection prevention and control protocols, as investigated under a specific complaint number.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tallmadge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tallmadge Health & Rehab Center | 1.1 mi | ★★★★★ | 6 | 0 |
| Falls Village Skilled Nursing & Rehabilitation | 2 mi | ★★★★★ | 0 | 0 |
| The Pinnacle Rehabilitation And Nursing Center | 2.1 mi | ★★★★★ | 8 | 0 |
| Altercare Of Cuyahoga Falls Ctr For Rehab & Nursin | 2.5 mi | ★★★★★ | 0 | 0 |
| The Colony Healthcare Center | 2.7 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.