Tallwoods Care Center

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain kitchen equipment in a clean, safe and sanitary manner as evidenced by the following. On 11/19/25 at 10:47 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following in the kitchen:1. The can-opener blade had brown debris under the blade and screw area. The black interior removable sleeve of the can opener mount on the counter when removed had sticky, gelatinous substance on the outside and interior where the can opener shaft would rest . The FSD acknowledged and agreed it had not been cleaned or washed according to facility policy. 2. The microwave had multicolored food debris on the interior ceiling. The FSD acknowledged and agreed that it was not cleaned according to facility policy. 3. [...]

Inspectors wroteComplaint # 2638538Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure adequate procedures for maintaining accurate records, tracking, and timely investigation of discrepancies related to controlled substances leading to actual and potential drug loss or diversion. This deficient practice was identified for a.) 1 resident (Resident #78) reviewed for pharmaceutical services and for b.) 5 unsampled residents (Residents #45, #115, #134, #142, and #168) identified during medication storage inspection of 2 of 4 medications carts (Maple High, Pine Low, and Pine Swing) and was evidenced by the following:1.) On 11/19/2025 at 11:30 AM, the surveyor observed Resident #78 in bed awake. [...]

Inspectors wroteBased on observation, interview, review of medical records and other pertinent facility documents, it was determined that the facility failed to use appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice, by failing to 1.) follow appropriate disinfection of a shared resident care equipment during medication administration observation, and 2.) provide residents with appropriate products for hand hygiene during mealtime. This deficient practice was identified for 6 of 6 unsampled residents (Residents #163, #164, #104, #165, #166, and # 167) observed during medication administration and 1 of 3 dining room observations (1st Floor Pine Unit dining room). This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to initiate a physician's order (PO) for a resident's code status (refers to a patient's decision regarding the level of medical intervention they wish to receive in the event of a life-threatening crisis, such as cardiac or respiratory arrest). This deficient practice was identified for 1 [one] of 29 residents (Resident #139) reviewed was evidenced by the following:On 11/20/25 at 10:03 AM the surveyor observed Resident #139 lying in bed and watching TV. The Resident stated, the staff known I do not want nothing done and that I signed papers about my choice. On 11/20/25, at 10:20 AM, the surveyor reviewed the medical record for Resident #139. [...]

Inspectors wroteBased on observation, interview, and pertinent facility documentation, it was determined that the facility failed to maintain a homelike environment that was clean, safe, and sanitary. This deficient practice was identified for 1 of 3 units (Pine Unit). This deficient practice was evidenced by the following: On 11/20/2025 at 9:00 AM, in the lower side Pine Unit shower room, the surveyor observed that the ceiling vent contained black debris, and a piece of the drop ceiling was missing. A section of the drop ceiling was bulging, and the metal framing of the ceiling was stained red and brown. The first shower stall had hair in the drain and tan debris on the shower tile. The third shower stall was blocked off with yellow caution tape, and the drain was missing, leaving standing water that contained brown debris. [...]

Inspectors wroteBased on observation, interview, medical record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident's Interdisciplinary Care Plan (ICP) was resident specific and reflected accurate resident care. This deficient practice was identified for 1 (one) of 29 residents (Resident #139) reviewed was evidenced by the following: On 11/20/25 at 10:03 AM, the surveyor observed Resident #139 lying in bed, watching TV. The surveyor interviewed the resident regarding their code status (refers to a patient's decision regarding the level of medical intervention they wish to receive in the event of a life-threatening crisis, such as cardiac or respiratory arrest). The Resident stated, the staff know I do not want nothing done and that I signed papers about my choice. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: ensure that a resident received care and services for the provision of observation, documentation, and dressing changes to IV catheter, (a small plastic tube, placed in a vein for intermittent access) site consistent with professional standards of practice and facility policy. The deficient practice was identified for one (1) of one (1) resident reviewed for medication administration (Resident #120). As evidenced by the following: On 11/19/25 at 12:12 PM, the surveyor observed Resident #120 had an IV Catheter located in the right forearm. The surveyor observed the dressing was not labeled, dated, and loose. The adhesive of the dressing was peeling the entire circumference form the skin of the resident. The clip on the IV catheter was in the un-locked position. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documents, it was determined that the facility failed to: a.) ensure that all oxygen supplies were cleaned and stored according to nursing standards of practice and per facility policy b.) post cautionary signage to indicate that continuous oxygen therapy was in use for 1 of 2 residents (resident # 10). These deficient practices were evidenced by the following:On 11/19/25 at 10:54 AM, the surveyor observed on the door frame of residents #10 room. There was not any indication the resident was on oxygen (O2). [...]

Inspectors wroteComplaint # 2638538Based on observation, interview, and review of pertinent facility documents it was determined that the facility failed to properly store a controlled substance securely inside the medication room. The deficient practice was identified for 1 of 3 medication rooms inspected during the medication storage and labeling task was evidenced by the following: On 11/21/2025 at 11:48 AM, during an inspection of the Pine unit medication room with Unit Manager/ Licensed Practical Nurse (UM/ LPN) #1, the surveyor observed the metal narcotic box unlocked. Inside the narcotic box was a packaging labeled Lorazepam Intensol oral concentrate 2 milligram (mg) per milliliter (ml). Inside the packaging was a bottle filled with fluid labeled Lorazepam Intensol 2 mg/ml and a medicine dropper. UM/LPN #1 stated to the surveyor that the narcotic box should be locked at all times. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide a safe environment for its staff and its residents. This deficient practice was observed in the facility kitchen and was evidenced by the following:On 11/19/25 at 10:47 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following in the kitchen: Two- 6 burner units in the kitchen. On 11/19/25 at 11:15 AM the surveyor interviewed the Food Service Director (FSD) who stated that only 4 burners on each stove were operational (totaling 8 of 12), They have not worked since he was employed and that he told maintenance about the issue, but it was never fixed. The FSD was unable to provide documentation of the notification to maintenance. Ie . (email, or maintenance log) of the 4 -faulty burners reporting to provide to the surveyor. [...]

Inspectors wroteBased on record review, review of facility documents and policy and interviews, the facility failed to ensure one resident (Resident (R) 346) was protected from sexual abuse by another resident (R347). The facility then placed resident (R348) at risk for serious harm by placing R347 in R348's room following the sexual abuse incident. On 04/11/24, a past-noncompliance immediate jeopardy (IJ) situation was determined to exist related to the facility's failure to ensure residents were safe from sexual abuse. The IJ was determined to exist on 01/23/22 when an act of sexual abuse occurred to R346. The IJ was removed on 01/24/22 when R347 was placed in a private room. The Administrator was informed and provided the IJ template on 04/11/24 at 5:00 PM that the past noncompliance IJ situation existed . The facility provided an IJ Removal Plan that was accepted on 04/11/24 at 6:59 PM. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the dish washer sanitizer level was maintained at a level required to sanitize the dishes. This had the potential to affect 146 of 146 residents in the facility.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure that five of 12 residents (Resident (R) 17, R19, R61, R128 and R297) reviewed for side rails had a comprehensive care plan developed that addressed the use of side rails of 32 sampled residents.

Inspectors wroteBased on observation, record review, interviews, and facility policy review, the facility failed to attempt to use appropriate alternatives prior to installing bed rails; failed to assess the residents for the risk of entrapment from the bed rails; failed to review the risks and benefits of the bed rails with the resident or resident representative; and failed to obtain informed consent prior to installation or use of the side rails of 11 of 11 residents (Resident (R) 17, R19, R61, R128, R297, R6, R23, R54, R57, R196, and R197) reviewed for accident hazards of 32 sampled residents.

Inspectors wroteBased on record review, interview, and review of the Resident Assessment Instrument (RAI manual), the facility failed to ensure that two residents (Resident (R) 2 and R65) out of 32 sampled residents' Minimum Data Set (MDS) assessments were completed and transmitted in a timely manner.

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 11/17/2021 from 11:19 AM to 12:09 PM the surveyor, accompanied by the Food Service Manager (FSM) observed the following in the kitchen: 1. Upon entry to the dish room, the surveyor observed the dietary aide (DA) loading the high temperature dish machine with racks of dirty dishes. The DA then proceeded to walk over to the clean side of the dish machine to unload cleaned and sanitized dishes. The surveyor asked the DA if she should handle the cleaned and sanitized dishes after handling the dirty dishes. The DA stated, I can't touch the cleaned dishes because I will cross contaminate. [...]

Inspectors wroteBased on observation, interview, review of the medical record and other facility documentation, it was determined that the facility staff failed to ensure that resident's were free from verbal abuse for 1 of 30 residents reviewed for abuse, (Resident #93). This deficient practice was evidenced by the following: On 11/15/2021 at 10:17 AM, the surveyor was standing at the nurses station on the Maple unit. A staff member, later identified as a Certified Nursing Assistant (CNA #1), was in the lobby area of the unit with a resident, later identified as Resident #93. The surveyor heard CNA #1 say to the resident You don't shake your soda you weirdo. At approximately 10:35 AM, the surveyor reported this to the Administrator and Director of Nursing (DON). The DON said this was not appropriate. The Administrator said he would immediately go and start an investigation. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation it was determined that the facility failed to provide care consistent with professional standards necessary to prevent the risk of an infection from developing during a wound care observation, on 1 of 3 residents investigated for pressure ulcers, (Resident #61). The deficient practice was evidenced by the following: On 11/10/2021 at 9:40 AM, during a wound care observation for Resident #61's left heel pressure ulcer, the surveyor observed the Unit Manager (UM) use a pair of scissors to cut and remove a wound dressing that revealed a date of 11/9. After cutting the dressing, the UM placed the scissors into her shirt pocket without cleaning them. [...]