Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 The Colony Healthcare Center during CMS and state inspections, most recent first.
An LPN failed to follow infection control procedures by not performing hand hygiene before preparing and administering multiple medications to a resident with type 2 DM, despite facility policies requiring hand hygiene before and after each resident’s medications. The LPN later acknowledged forgetting and lacking hand sanitizer on the cart, and the DON confirmed that hand hygiene is required as part of standard precautions and medication administration practices.
Kitchen and D unit refrigerator and microwave were found dirty and unsanitary during observations. The kitchen had dried food debris, stains, grease, an open thickener container with a hair inside, and flies were seen in the area; the lowerator was also soiled. The D unit refrigerator had stained towels, stained frost, and a plastic spoon in the freezer, and the microwave was heavily soiled. The DM and ADON verified the findings.
Pest control was ineffective, with flies repeatedly observed in multiple resident rooms and the activity room. Residents reported the flies were a daily problem and had been bad for days or weeks, and staff confirmed the sightings. Pest control records showed treatment for house flies and fruit flies in specific rooms, but flies continued to be seen in resident areas.
Multiple rooms were found with unsanitary conditions, including urine and unknown liquids on bathroom floors, strong odors, running toilets, and dirty laundry left in resident areas. Staff and maintenance confirmed these issues, and cleaning or repairs were not consistently performed in a timely manner, affecting several residents.
IV Antibiotic Not Given as Ordered: A resident receiving IV Piperacillin for osteomyelitis and a stage IV pressure ulcer did not receive the antibiotic as ordered, and the TAR documented the dose as not given because the course was considered complete. An LPN documented that infectious disease said the IV could be removed and oral antibiotics started, while the DON later stated the IV had not been removed at that time and there was no documentation supporting IV removal.
Incorrect Scoop Sizes Used for Pureed Diet Meal Service: During lunch meal service, pureed chicken and pureed rice were served with the wrong scoops compared with the menu and diet guide. An observation showed the chicken and rice portions were not served using the specified scoop sizes, and the DM verified the error. Ten residents were receiving the pureed diet.
PRN Ativan orders lacked stop dates for two residents. One resident with Parkinson's disease, dementia, psychotic disorder with hallucinations, anxiety, and multiple other diagnoses received Ativan 0.5 mg PRN frequently across June, July, and August, while another resident with ESRD on dialysis, CHF, DM2, Alzheimer's disease, dementia, and anxiety disorder received Ativan 1 mg PRN on most days after the order began. The DON and Administrator verified the orders had no stop date.
Failure to provide timely nail care for a resident dependent on staff for personal hygiene. The resident had multiple serious diagnoses, including hemiplegia, ESRD, anemia, diabetes, and hypotension, and was observed with long, unclean fingernails. The resident said he wanted his nails cut, an LPN was notified, and the Administrator stated nail care was not documented and no staff member was specifically assigned to it, despite facility policy stating routine care includes nail hygiene services.
A resident with CHF, COPD, dementia, and diabetes had maggots found in a wound after staff failed to identify them, and the resident’s daughter reported the wounds had not been cared for daily as required. The same resident’s metoprolol was given by an LPN without checking BP or HR despite hold parameters in the order. In a separate case, a resident with malnutrition and Alzheimer’s had a chole site dressing in place that did not match the ordered dressing, while the TAR documented the ordered dressing had been completed.
A resident with a stage IV pressure ulcer and osteomyelitis did not receive IV Piperacillin as ordered. The TAR showed a missed dose because the course was documented as complete, while an LPN documented that infectious disease said the IV could be removed and oral antibiotics could begin. The LPN later said she received verbal orders to remove the IV, but the DON stated the IV was not removed then, the resident removed it later, and there was no documentation of IV removal.
A resident with severe cognitive impairment was treated without dignity by an STNA, who spoke loudly and repositioned the resident forcefully in a wheelchair. The incident, witnessed by family and staff, led to a complaint investigation revealing a deficiency in the facility's adherence to its policy on resident rights.
A resident experienced a significant decline in mobility and was treated for a wound infection, but the facility failed to notify the family or responsible party of these changes. Interviews with staff confirmed that the responsibility for notification was not fulfilled, despite the facility's policy requiring such communication.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration when an LPN failed to perform required hand hygiene. Resident #29, admitted on 10/27/22 with a diagnosis of type 2 diabetes mellitus and documented as having intact cognition on a quarterly MDS assessment, was observed receiving eight medications prepared and administered by LPN #215 without the LPN washing her hands or using hand sanitizer beforehand. During the observation on 1/28/26 at 8:29 A.M., the LPN placed all medications into a medicine cup and administered them to the resident without performing hand hygiene. In a subsequent interview at 8:47 A.M. the same day, LPN #215 confirmed she did not perform hand hygiene before administering the medications and stated she forgot and did not have hand sanitizer on her cart. In an interview on 1/29/26 at 7:00 A.M., the DON confirmed that facility practice requires hand hygiene to be performed before and after administering medications to each resident. Review of the facility’s undated Medication Administration policy showed it directs staff to perform appropriate hand hygiene before beginning medication administration and before and after each resident’s medications are administered. Review of the undated Standard Precautions policy indicated that practicing hand hygiene is an effective way to prevent the spread of infections and specifies when to perform hand hygiene for care between residents.
Kitchen and Unit Refrigerator and Microwave Not Kept Clean and Sanitary
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner during observations of the kitchen on 07/28/25. The reach-in cooler at the end of the steamtable had dried splatters and food debris on the bottom inside of the door. The table next to the reach-in cooler, where the juice machine and toaster were located, had dried stains around the juice machine and on the wall behind it, and the bottom shelf had dried red and brown stains where juice boxes and a black piece of machinery were stored. The wall where clean knives were hanging was dirty with dried stains, the shelf where serving utensils and scoops were stored had dried splatters and stains, the shelf with oil and other food items had grease stains, the shelf with pots and pans had food debris, the thickener container was open with a strand of hair inside, and the spice shelf had food debris and crumbs. The Dietary Manager verified these findings during interview. Additional observations on 07/30/25 found the lowerator dirty with smears and debris, and three flies were seen flying around the kitchen and landing on the pole at the end of the steamtable and in front of the lowerator. The Dietary Manager verified the lowerator was dirty. On 07/31/25, the nursing unit refrigerator and microwave on D unit were observed with the ADON. The freezer contained a towel with pink/reddish stained frost and a blue plastic spoon in the frost. Towels were observed on each shelf inside the refrigerator with various stains on the inside, bottom, and door, and the microwave was heavily soiled with dried stains and food splatters. Review of the facility policy stated all foodservice equipment will be clean, sanitary, and in proper working order.
Pest Control Program Failed to Control Flies
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent flies in resident areas. Surveyors observed multiple flies in several resident rooms, including six flies on one resident’s bed, flies in another resident’s room, and flies in additional rooms on multiple dates. During interviews, residents reported that flies had been a problem for days or weeks, with one resident stating the flies got bad the prior week and another saying they were not better. Staff also confirmed the presence of flies during observations, including a housekeeping employee and an LPN. Flies were also observed in the activity room during resident council, where residents described the flies as a daily problem and showed that they had obtained or made their own fly swatters. Additional observations later showed flies still present in resident rooms, including one resident’s room where a fly was seen on the bed and another room where a resident’s son said he had just killed a fly. Facility pest control records documented treatment for fruit flies and house flies in specific rooms and later treatment for house flies in other rooms, while the facility policy stated that if a problem developed, the Environmental Services Director would contact the pest control company for an additional visit.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by multiple observations of unsanitary conditions in several resident rooms and bathrooms. In one room, an unknown liquid was found on the bathroom floor around the toilet, accompanied by a strong odor of urine, black staining around the toilet seal, and visible dirt and debris on the walls and ceiling. The toilet was continuously running, and residents reported that the bathroom always smelled. Staff confirmed the presence of urine on the floor and acknowledged that one resident frequently urinated on the bathroom floor. Despite having new tiles available, the bathroom had not been shut down for repairs. Repeated observations over several days continued to reveal strong urine odors and unclean conditions, with staff confirming and cleaning the area only after surveyor intervention. Other rooms were also found with unknown liquids, strong urine odors, and maintenance issues such as unattached floor trim and continuously running toilets. In one instance, a resident's room contained a plastic bag filled with clothes that emitted a strong odor of garbage and stale cigarettes, which was confirmed by staff to be dirty laundry. The facility's policy required regular collection of soiled linens, but this was not followed, contributing to the unsanitary environment. These findings affected six residents and demonstrated a pattern of inaction and insufficient maintenance of a clean, safe, and homelike environment.
IV Antibiotic Not Given as Ordered
Penalty
Summary
Drugs and biologicals were not administered in accordance with physician orders for one resident receiving IV antibiotics for suppressive therapy related to osteomyelitis and a stage IV pressure ulcer with exposed bone, tendon, or muscle. The resident had intact cognition and was ordered Piperacillin 3.375 grams IV every eight hours for 31 doses, with the order running from 07/09/25 through 07/19/25. However, the TAR showed Piperacillin was not administered on 07/15/25 because the course had been documented as complete. A progress note authored by an LPN stated that infectious disease had been contacted and said the resident had completed the IV antibiotic and the IV could be removed, and a later progress note stated the resident's IV could be removed and oral antibiotics were to begin. During interview, the LPN said she had received verbal orders to remove the IV and start oral antibiotics, but could not state who removed the IV. The DON stated the resident's IV had not been removed on 07/15/25 and that the resident removed it himself on 07/21/25, but the DON could not explain the LPN's note or why the antibiotic was not administered as ordered, and confirmed there was no documentation related to IV removal.
Incorrect Scoop Sizes Used for Pureed Diet Meal Service
Penalty
Summary
The facility failed to ensure the correct serving sizes were served for the pureed diet for 10 residents who received that diet. During lunch tray line observation, pureed chicken was served with the #10 ivory-handled scoop and pureed rice was served with the #12 green-handled scoop. The menu and diet guide for that meal indicated pureed chicken should have been served with the #8 grey-handled scoop and pureed rice with the #10 ivory-handled scoop. The scoop size chart showed the #8 scoop provided 4 ounces, the #10 scoop provided 3.25 ounces, and the #12 scoop provided 2.66 ounces. The Dietary Manager verified that the scoops used for the pureed chicken and pureed rice were not the correct scoops according to the menu and diet guide. The diet type report showed that Residents #14, #33, #36, #64, #71, #82, #84, #86, #91, and #105 received a pureed diet.
PRN Ativan Orders Lacked Stop Dates for Two Residents
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders for two residents had stop dates. Resident #9 was admitted with diagnoses including Parkinson's disease, dementia, psychotic disorder with hallucinations, visual and auditory hallucinations, delusional disorders, anxiety, major depressive disorder, chronic obstructive pulmonary disease, emphysema, asthma, hypertensive chronic kidney disease, atherosclerotic heart disease, hyperlipidemia, iron deficiency anemia, adjustment disorder, post-traumatic stress disorder, nightmare disorder, chest pain, obesity, osteoarthritis, vitamin D deficiency, and dysphagia. The physician order dated 06/28/25 showed Ativan 0.5 mg by mouth every six hours PRN for anxiety with no stop date, and the MAR showed the resident received the PRN Ativan repeatedly in June, July, and August 2025. The consultant pharmacist review dated 07/15/25 noted no apparent medication irregularities, and the Administrator verified on 08/08/25 that the PRN Ativan order had no stop date. Resident #107 was admitted on 11/30/22 with diagnoses including end stage renal disease, dependence on renal dialysis, congestive heart failure, type two diabetes mellitus, Alzheimer's disease, dementia, and anxiety disorder. The August 2025 physician orders included Ativan 1 mg by mouth every eight hours PRN for anxiety with a start date of 07/02/25 and no stop date. The July 2025 MAR showed the resident received the PRN Ativan on most days after the start date, and the August 2025 MAR showed additional administrations on 08/01/25 through 08/05/25. The DON verified on 08/05/25 that the PRN Ativan order had no stop date.
Failure to Provide Timely Nail Care
Penalty
Summary
The facility failed to ensure Resident #22, who was dependent on staff for personal hygiene, received adequate and timely nail care. Resident #22 was admitted with multiple diagnoses including hemiplegia and hemiparesis following nontraumatic hemorrhage affecting the right dominant side, stage five chronic kidney disease/end-stage renal disease, heart disease, anemia, dialysis, asthma, cirrhosis of the liver, ascites, dysphagia, Barrett's esophagus, acute respiratory failure, acquired absence of stomach, anxiety disorder, type II diabetes, and hypotension. The most recent quarterly MDS indicated the resident was dependent on staff for personal hygiene. During observation and interview, Resident #22 had long and unclean fingernails and stated he would like his nails cut. The LPN was informed that the resident wanted his nails cut and cleaned. The Administrator later stated the facility does not document nail care and there was no specific staff member assigned to nail care. The facility policy on Nail and Hair Hygiene Services stated routine care includes nail hygiene services such as trimming, cleaning, and filing.
Failure to follow wound care, medication parameters, and ordered dressing care
Penalty
Summary
The facility failed to identify maggots in Resident #5’s wound. Resident #5 was admitted with diagnoses including CHF, COPD, dementia, and diabetes, and was dependent on staff for toileting, bathing, and personal hygiene. Physician orders directed staff to cleanse the resident’s right toes, apply betadine daily and as needed, and the care plan identified the resident as at risk for altered skin integrity with interventions to administer treatments as ordered, complete weekly skin checks, encourage foot elevation, and evaluate the wound daily for changes. A progress note from the DON documented increased drainage, redness, swelling, and pain to the legs, and the physician ordered the resident sent to the hospital. A podiatry note stated the resident said staff did not take good care of her wounds and that she was unaware she had maggots in her wounds. The resident’s daughter later stated the hospital told her the resident had maggots in her wounds and that she believed the wounds had not been cared for daily as required. The facility also failed to administer Resident #5’s metoprolol according to physician orders. The order required metoprolol 50 mg daily, with instructions to hold the medication if systolic blood pressure was below 110 or heart rate was below 60. During observation, an LPN removed the medication from the card and administered it without obtaining a blood pressure or heart rate first, and the LPN confirmed this at the time of observation. In addition, the facility failed to ensure Resident #54’s chole drain dressing was performed according to physician orders. Resident #54 had diagnoses including malnutrition and Alzheimer’s and impaired cognition. The order required cleansing the chole site with normal saline and covering it with a drain sponge daily and as needed, but during observation the resident had a silicone dressing in place. The LPN stated she was unaware of the ordered dressing, while the DON confirmed the order was for a gauze dressing and the TAR documented that a gauze dressing had been completed.
IV Antibiotic Not Given as Ordered
Penalty
Summary
Residents were not kept free from significant medication errors when IV antibiotics were not administered according to physician orders for one resident with a stage IV pressure ulcer and osteomyelitis. The resident was admitted with intact cognition and had a care plan for suppressive antibiotic therapy related to osteomyelitis, with interventions to administer antibiotics per physician orders. The physician ordered Piperacillin IV 3.375 grams every eight hours for 31 doses beginning 07/09/25 and ending 07/19/25. Review of the TAR showed Piperacillin was not administered on 07/15/25 because the course was documented as complete. A progress note by an LPN stated infectious disease had been contacted and said the resident had completed IV antibiotics and the IV could be removed. The same LPN later documented that the resident’s IV could be removed and oral antibiotics were to begin, and stated in interview that she had received verbal orders to remove the IV and begin oral antibiotics. However, the DON stated the resident’s IV had not been removed on 07/15/25 and said the resident removed it himself on 07/21/25. The DON could not explain the LPN’s note or why the IV antibiotic was not administered as ordered, and confirmed there was no documentation related to IV removal.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that staff treated a resident with dignity and respect, as evidenced by an incident involving a State Tested Nursing Assistant (STNA) and a resident with severe cognitive impairment. The resident, who had a history of Alzheimer's disease, dementia, and other medical conditions, was observed by family members being spoken to loudly and sternly by the STNA in the dining room. The STNA attempted to reposition the resident in her wheelchair by grabbing the back of her pants, which led to a confrontation with the resident's family. The incident was reported to the Assistant Director of Nursing (ADON), who was present at the facility at the time. The ADON conducted interviews with the involved parties, including the STNA, who admitted to using a stern tone and physically assisting the resident to sit down due to concerns about the resident's safety. Witnesses, including another STNA and a resident, corroborated the family's account of the STNA's aggressive behavior, noting that the STNA could have handled the situation differently. The facility's policy on resident rights emphasizes providing care in a respectful manner and allowing residents to voice how they want to be treated. The incident was identified during a complaint investigation, highlighting a deficiency in the facility's adherence to its policy of treating residents with dignity and respect.
Failure to Notify Family of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the family or responsible party of a significant change in condition for a resident, identified as Resident #83. This resident was admitted with multiple diagnoses, including cerebral vascular disease, vascular dementia, and other chronic conditions. A review of the Minimum Data Set (MDS) assessments revealed a significant decline in the resident's ability to perform basic movements, such as sitting up from a lying position and standing from a sitting position, which required maximum assistance from staff. Additionally, a physician's order was noted for the administration of an antibiotic to treat a wound infection, yet there was no documented evidence that the resident's family or responsible party was informed of these significant changes or the new treatment. Interviews with facility staff, including the MDS Registered Nurse and the Director of Nursing, confirmed that the responsibility for notifying the resident's representative of significant changes lay with the licensed nurses. The facility's policy on Notification of Change in Condition outlined the requirement for notifying the resident's representative in cases of significant changes in physical, mental, or psychological condition, new treatments, and other specified circumstances. However, this policy was not adhered to in the case of Resident #83, leading to the deficiency noted in the report.
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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) |
|---|---|---|---|---|
| The Pinnacle Rehabilitation And Nursing Center | 1.1 mi | ★★★★★ | 8 | 0 |
| Tallmadge Health & Rehab Center | 2.4 mi | ★★★★★ | 6 | 0 |
| Heather Knoll Retirement Village | 2.7 mi | ★★★★★ | 2 | 0 |
| Falls Village Skilled Nursing & Rehabilitation | 4 mi | ★★★★★ | 0 | 0 |
| Divine Rehabilitation And Nursing At Canal Pointe | 4 mi | ★★★★★ | 2 | 0 |
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