Tallmadge Health & Rehab: Wound Care Failures Cause Harm - OH
The inspection, completed in October 2025, cited the facility for actual harm to residents, the most serious level of harm short of immediate jeopardy. The citation covered failures in how the facility identified, documented, and treated pressure injuries, open sores that develop when sustained pressure cuts off blood flow to skin and tissue, and which can deteriorate rapidly without consistent monitoring.
At the center of the findings was a gap that ran directly between the nursing staff and the aides. A regional director identified in inspection records only as RDO #400 acknowledged that documentation of open areas and wound dressings had been handled by a single aide. That aide, the director said, could have made a mistake. The nurses, meanwhile, were charting that there were no skin issues at all.
The two accounts cannot both be correct.
When an aide documents open wounds and a nurse documents no skin issues on the same resident, one of those entries is wrong. Inspectors did not conclude the aide was the error. The citation landed on the facility.
The violations were tied to five complaints filed separately with state regulators, complaint numbers 2624905, 2609502, 1404959, 1404954, and 1404955. Five complaints generating a single inspection and a finding of actual harm suggests the wound care breakdown was not a one-time documentation slip. It points to something more systemic, a pattern where residents arrived with existing wounds or developed new ones, and the facility's tracking failed to catch it, or failed to act when it did.
Pressure injuries are graded in stages. A stage one is redness that doesn't blanch. A stage four reaches bone. The difference between those outcomes, in most cases, is consistent assessment and early intervention. Weekly measurement of wound size, documentation of drainage, evaluation of the tissue around the wound's edge, and prompt orders from a physician when the wound changes, these are the steps that determine whether a pressure injury heals or destroys tissue.
The facility's own wound care policy, revised as recently as September 2023, laid out exactly what was required: initial assessment upon identification, weekly follow-up until closure, documentation of location, stage, size, drainage, pain, wound bed, surrounding tissue, and any signs of infection. Orders from providers were to be obtained for treatment.
None of that happened reliably for the residents named in these complaints.
RDO #400's explanation, that one aide was responsible for wound documentation and may have made errors, does not account for the nurses who recorded no skin issues. If the nurses had been assessing skin at all, they would have found what the aide found, or they would have found nothing and had reason to question the aide's entries. The inspection record does not reflect that anyone reconciled the discrepancy or looked into it before complaints brought inspectors to the door.
Pressure wounds in nursing home residents carry serious consequences. Left untreated, they become infected. Infections in wounds can spread to bone or enter the bloodstream. For elderly residents, particularly those with limited mobility, diabetes, or compromised circulation, a wound that a facility fails to catch in its early stage can become the injury that ends independent living, or ends a life.
The inspection record does not name the residents affected. It does not describe what their wounds looked like when inspectors arrived, or what treatment they ultimately received. What it records is that actual harm occurred, that the facility's own documentation was internally contradictory, and that five people or their families cared enough about what happened to file a formal complaint.
Five complaints. One finding of actual harm. One aide who may have made a mistake, and a nursing staff that said there was nothing to document.
Someone in that building had open wounds. The nurses said otherwise.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tallmadge Health & Rehab Center from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 11, 2026 · Our methodology
TALLMADGE HEALTH & REHAB CENTER in TALLMADGE, OH was cited for violations during a health inspection on October 9, 2025.
The inspection, completed in October 2025, cited the facility for actual harm to residents, the most serious level of harm short of immediate jeopardy.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.