Heather Knoll Retirement Village: Undocumented Care - OH
The next morning, June 2, the resident left the facility by ambulance, unresponsive.
That sequence, confirmed by the nurse herself during a federal inspection on August 15, sits at the center of a documentation failure that inspectors cited at the 110-bed Tallmadge facility following a complaint investigation. The resident, identified in inspection records only as Resident #1, had been admitted to Heather Knoll with chronic diastolic congestive heart failure, an anxiety disorder, and syncope and collapse, a condition involving episodes of fainting or loss of consciousness. She was discharged on June 2, 2025, after being transported to the emergency department.
The emergency department encounter note from that day tells the story the nursing home's records do not. Emergency medical technicians reported that Heather Knoll staff had called because the resident was not acting like herself. When the family arrived at the facility, they found her unresponsive. The emergency department listed altered mental status as the chief complaint.
The husband's account, recorded in that same emergency department note, adds a detail that makes the undocumented assessment harder to explain away. He told emergency personnel that he had visited the nursing home the day before, that his wife had been acting confused, and that he had told the staff. She had not been evaluated at that time, the note says.
That last line is contradicted by the nurse.
Licensed Practical Nurse #810, interviewed by inspectors at 12:11 p.m. on August 15, said she vaguely remembered the husband reporting concerns about confusion and that she had assessed the resident on that date. She confirmed she did not document the assessment. She also said she did not identify a change in the resident's condition.
Nearly three hours later, at 3:03 p.m., inspectors spoke with LPN #810 again. Her memory had sharpened. She confirmed she remembered the husband coming to her on June 1 around lunchtime with concerns that the resident had experienced a decline. She confirmed she assessed the resident. She confirmed she found no changes in condition. And she confirmed she neglected to document the assessment in the resident's medical record.
The word she used, according to the inspection report, was neglected.
What that undocumented assessment contained, what the nurse observed, what questions she asked, what the resident said, what vital signs if any were checked, none of that exists in the medical record. It was never written down. The only account of what happened during that assessment comes from a nurse who described her own recollection, months later, as vague.
Heather Knoll's records for Resident #1 show a woman with intact cognition at the time of her admission assessment. She was always incontinent of bowel and bladder and was not enrolled in a toileting program. Those details come from her admission Minimum Data Set assessment, the standardized federal tool nursing homes use to track resident condition. Her cognitive status makes the husband's report of confusion more significant, not less. This was not a resident whose baseline included disorientation. When her husband said she was acting confused, he was describing something he did not recognize.
The inspection report classifies the violation as causing minimal harm or potential for actual harm. That classification reflects the regulatory framework inspectors apply, not a judgment that the gap in the record was inconsequential. A nursing home's medical record is how care gets communicated between shifts, between providers, between the facility and the emergency department that receives a resident at two in the morning. When a nurse assesses a resident and documents nothing, the next clinician who touches that resident works without information that existed. The emergency department team that received Resident #1 on June 2 had the husband's account. They did not have the nurse's.
Inspectors noted that this finding was an incidental discovery, surfaced during the course of the complaint investigation rather than as its primary focus. The underlying complaint that triggered the inspection is not described in the publicly available report. What inspectors found when they pulled three resident records to check for accurate documentation was that one of the three had a gap significant enough to cite.
One of three.
The facility census at the time of the inspection was 110 residents.
LPN #810 is not accused of providing negligent care. The inspection report does not allege that her clinical judgment on June 1 was wrong, that the resident was deteriorating in ways the nurse should have caught, or that a documented assessment would have changed what happened the following morning. The violation is narrower than that. It is that an assessment occurred, a husband's concern was heard, a clinical interaction took place, and none of it was recorded anywhere.
What the record shows, for anyone who looks at it, is a resident who was assessed at admission, whose husband raised an alarm, and who was then transported unresponsive to an emergency department. The assessment in between, the one that might explain the gap, does not appear. It happened in a hallway or a room somewhere in that building around lunchtime on a Sunday, and then it disappeared.
The husband, whose name does not appear in the inspection report, visited his wife and saw something that worried him enough to find a nurse. He told the nurse. The nurse looked at his wife and formed a conclusion. And then the conclusion went unrecorded, the visit went undocumented, and the next morning his wife was found unresponsive when the family arrived.
The inspection report does not say what happened to Resident #1 after June 2. It does not say whether she recovered, whether she returned to the facility, or whether her family received any explanation for what the medical record failed to capture. The record ends where the ambulance begins.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heather Knoll Retirement Village from 2025-08-15 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 22, 2026 · Our methodology
HEATHER KNOLL RETIREMENT VILLAGE in TALLMADGE, OH was cited for violations during a health inspection on August 15, 2025.
The next morning, June 2, the resident left the facility by ambulance, unresponsive.
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.