Tallwoods Care Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain kitchen equipment in a clean, safe, and sanitary manner. During observation in the kitchen, the surveyor found brown debris under the can-opener blade and screw area, a sticky gelatinous substance on the removable sleeve of the can opener mount, multicolored food debris on the microwave interior ceiling, and baked-on food debris on 3 of 4 convention ovens. The Food Service Director acknowledged that these items had not been cleaned according to facility policy. Additional kitchen equipment was observed with visible buildup and debris. One of three coffee dispenser nozzles had white hard buildup, both 6-burner stove tops had debris on the grates and around the cooker hats, and the catch trays were filled with burnt food debris with a gelatinous greasy substance underneath the foil. The steam table had debris and sediment in every water well, the 4-slot toaster had orange and brown splatter with debris in the catch trays, and the ice machine had black discoloration around the interior rim. The ice scoop holder also had discoloration in the corners and a piece of cardboard garbage at its base, which the FSD stated should not have been there. The surveyor also observed that 7 of 7 cutting boards had etching and black discoloration, the oil fryer contained very dark oil with food debris, white sediment, and greasy exterior sides, and the griddle catch tray had copious amounts of black sediment and debris. The FSD stated the fryer had not been used for about a week before the observation and acknowledged that the equipment was not cleaned according to facility policy. The LNHA and DON later acknowledged the concerns, and facility policies reviewed by the surveyor required food-contact equipment to be cleaned and sanitized after use or at least daily, with specific instructions for items such as the can opener, tray line, and deep fryer.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services in accordance with professional standards, resulting in inadequate procedures for maintaining accurate records, tracking, and timely investigation of discrepancies related to controlled substances. This deficiency was identified through observations, interviews, and record reviews involving one resident with a physician's order for Percocet and several other residents during medication storage inspections. The investigation revealed that narcotic inventory sheets (NIS) and Individual Patient's Controlled Drug Record (IPCDR) sheets were not consistently signed by incoming and outgoing nurses as required, and supervisor signatures were missing for new narcotics added to the inventory. Alterations, including the use of white-out and cross-outs, were found on inventory records, and there was a lack of reconciliation between the number of narcotic medication cards and the corresponding IPCDR sheets. Additionally, the facility's policy did not address the monitoring and review of tracking forms for narcotic card removal or the matching of IPCDR counts with new narcotics delivered. A specific incident involved a resident who was prescribed Percocet for chronic pain. The facility received two 60-count cards of Percocet, but one card went missing, and the loss was not detected until a refill request was declined by the pharmacy. The investigation found that an agency nurse altered the narcotic count, and the missing medication and IPCDR sheet were not promptly identified. The nurses counted narcotic cards without confirming the medications inside, and the removal of narcotic cards was not properly documented on the tracking form. The Director of Nursing confirmed that the tracking form for the removed cards was not completed as required, and the monthly review process failed to detect the discrepancy. During medication storage inspections, multiple cross-outs and errors were observed on IPCDR sheets for several residents, including documentation of medication refusals after removal from blister packs and inconsistent recording of wasted or refused doses. Interviews with staff revealed a lack of clarity regarding proper documentation practices, and the facility's in-service education and policies did not adequately address the prevention of such documentation errors. The facility's failure to maintain accurate and complete records, promptly investigate discrepancies, and ensure proper documentation of controlled substances led to actual and potential drug loss or diversion.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to use appropriate infection control practices during medication administration when a RN took blood pressures on six residents and did not sanitize the shared BP cuff before or after use between residents. During observation, the RN obtained BP readings from Residents #163, #164, #104, #165, #166, and #167 and then proceeded with medication administration each time without disinfecting the cuff. The facility’s IP and DON later stated that nurses need to wipe down the BP cuff between residents using the purple-top sanitizing wipes, and the facility policy identified BP cuffs as non-critical reusable items that can be decontaminated where used. The facility also failed to provide appropriate products for resident hand hygiene during mealtime in the 1st Floor Pine Unit dining room. During lunch observation, a CNA assisted two residents with hand hygiene using alcohol free baby wipes with aloe and did not perform hand hygiene between assisting the residents. The CNA stated that the baby wipes were the type used by the facility for resident hand hygiene before meals and acknowledged she should have washed her hands between residents. The IP stated that residents should have had alcohol-based wipes on their meal trays, but if those were not available, staff may use alcohol free baby wipes; she also confirmed CNAs should perform hand hygiene between assisting each resident. The LNHA was unsure whether staff should be using alcohol free baby wipes for hand hygiene.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

During an inspection of one of the facility's medication rooms, a surveyor observed that the metal narcotic box was left unlocked. Inside the unlocked box was a package labeled Lorazepam Intensol oral concentrate 2 mg/ml, which included a bottle of the medication and a medicine dropper. The unit manager, an LPN, confirmed to the surveyor that the narcotic box should be locked at all times. The Director of Nursing also stated in an interview that narcotic boxes are required to be kept locked. A review of the facility's Controlled Medication Storage Policy indicated that all controlled substances must be stored in a double-locked system, in accordance with regulatory requirements.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to initiate a physician order for a resident’s code status, despite documentation showing the resident was DNR/DNI. Resident #139 was observed in bed watching TV and stated that staff knew he did not want anything done and that he had signed papers about his choice. The resident’s admission record listed chronic respiratory failure with hypoxia, COPD, and chronic congestive heart failure, and the quarterly MDS indicated the resident was cognitively intact with a BIMS of 13. The admission summary had a blank advance directive status and did not indicate the resident’s code status, even though a signed POLST dated 10/21/23 reflected DNR/DNI goals of care. The active order summary did not include a physician order for DNR/DNI, and the individualized comprehensive care plan did not contain a focus area or interventions consistent with the POLST. Progress notes documented that the NP spoke with the POA, brother-in-law, and wife about goals of care, advance directives, and resuscitation status, and they elected DNR/DNI, but the resident’s status was not reflected in a physician order. Nursing notes and social services documentation also identified the resident as DNR/DNI, and a later MD/NP progress note again confirmed the code status, yet no order was entered to reflect the resident’s preference.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a homelike environment that was clean, safe, and sanitary in the Pine Unit shower rooms. On 11/20/2025, the surveyor observed in the lower side Pine Unit shower room a ceiling vent with black debris, a missing piece of drop ceiling, a bulging ceiling section, and metal framing 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, had a missing drain, and contained standing water with brown debris. A motorized wheelchair was also stored in the shower room and was covered in a white, furry substance, with a torn cushion and missing pieces of fabric. In the high-side Pine Unit shower room, the surveyor observed a toilet missing its tank with a pink out-of-order sign on top and several missing pieces of shower stall trim. During interviews, the Housekeeping Director stated the unit used both shower rooms and that shower tiles were supposed to be power washed every Sunday, scrubbed monthly, and cleaned twice daily, but there was no formal schedule and cleaning depended on staffing. She stated the wheelchair should have been removed and that housekeeping should have notified nursing staff. The Director of Maintenance stated the wheelchair was not acceptable and should have been identified and removed if not in use, that the third shower stall had a clogged drain for one week, and that the toilet had been out of service for two weeks awaiting a tank part. He also stated the shower flooring and trim in the high-side shower room had been delaminating for about one month. A CNA stated she was unsure whether the shower room was cleaned daily, that the wheelchair had been there for quite some time, and that the condition of the shower room did not meet infection control standards, was not sanitary, and was not a homelike environment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #139’s Interdisciplinary Care Plan (ICP) was resident specific and reflected accurate resident care. The resident was observed lying in bed and watching TV, and stated that staff knew the resident did not want “nothing done” and had signed papers about that choice. The medical record showed the resident was admitted with chronic respiratory failure with hypoxia, COPD, and chronic congestive heart failure. The admission summary did not have the Advance Directive status completed, while the quarterly MDS dated 9/30/25 showed a BIMS score of 13, indicating the resident was cognitively intact. The record also showed a signed POLST dated 10/21/23 indicating DNR and DNI status, and a nurse practitioner progress note dated 9/17/23 documented discussion with the POA, brother-in-law, and wife about goals of care, advance directives, and resuscitation status, with DNR/DNI elected. However, the active OSR dated 6/24/25 did not include physician orders for the resident’s code status, and the ICP initiated on 5/25/25 did not reflect a focus area or intervention for DNR/DNI consistent with the POLST. Staff interviews confirmed that code status should be reflected in the resident’s orders and ICP, and the LNHA acknowledged uncertainty about whether the resident’s DNR/DNI status needed to be included in the ICP.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure safe, appropriate observation, documentation, and dressing changes for a resident’s IV catheter site. On 11/19/25 and again on 11/20/25, the surveyor observed Resident #120 with an IV catheter in the right forearm and noted that the dressing was not labeled or dated, was loose, and had adhesive peeling around the entire circumference from the resident’s skin. The clip on the IV catheter was also observed in the un-locked position. During a joint observation on 11/20/25, the Infection Preventionist confirmed that the IV dressing was not dated, the dressing was loose, and the lock/clip on the IV tubing was not set in the locked position, stating that it should not look like that and was not maintained according to facility policy. Resident #120’s record showed diagnoses including cerebral infarction, urinary tract infection, hemiplegia, and hemiparesis, and the most recent MDS reflected a BIMS score of 12, indicating moderately impaired cognition. The MAR included physician orders for IV vancomycin and meropenem, and the TAR included an order to monitor the IV insertion site for redness, swelling, warmth, tenderness, drainage, or dislodgement and to document findings per facility policy. The care plan also addressed antibiotic therapy related to a bloodstream infection with interventions to monitor and change according to facility policy. The facility policy required site assessment every shift, a transparent dressing kept clean, dry, and intact, dressing changes every 72 hours and sooner if needed, and documentation of insertion site date and time, site, catheter size, assessments, flushes, dressing changes, and removal.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that oxygen supplies were cleaned and stored according to nursing standards of practice and facility policy, and failed to post cautionary signage indicating that continuous oxygen therapy was in use for one resident. On observation, the resident's room door frame had no indication that oxygen was in use, even though the resident was observed on continuous O2 at 3 LPM with a humidified bottle attached to the concentrator. The resident also had nebulizer equipment on the nightstand, including a small volume nebulizer medication cup with mouthpiece, anti-spill T-piece, and tubing; the mouthpiece was attached and hooked around the siderail via extension tubing and was swinging in the open air, and the medication cup was still attached and not emptied of residual medication or dried. On a later observation, the nebulizer equipment was found in the resident's nightstand drawer with the drawer open, tubing hanging out, and the mouthpiece with medication cup still attached laid on top of the compressor inside the drawer. The medication cup had not been cleaned or bagged after medication administration. The resident had COPD, a BIMS score of 13 indicating intact cognition and decision-making, and care plan interventions for bronchodilator administration and monitoring for shortness of breath, hypoxia, and respiratory infections. The LPN unit manager stated that oxygen signage should be placed outside the room and that nebulizer medication cups should be rinsed, dried, and stored in a bag with the mask or mouthpiece, and the DON agreed that oxygen use and nebulizer treatments should be administered according to policy and nursing standards of practice.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe environment for staff and residents based on observations in the kitchen. On 11/19/25 at 10:47 AM, the surveyor observed two 6-burner stove units in the kitchen. During an interview on 11/19/25 at 11:15 AM, the FSD stated that only 4 burners on each stove were operational, for a total of 8 of 12 burners, and said they had not worked since he was employed. He stated that he told maintenance about the issue, but it was never fixed, and he was unable to provide documentation such as an email or maintenance log showing that the 4 faulty burners had been reported. He also stated that the LNHA was aware of the issue and said he did not think it mattered because the kitchen had been getting by with 8 burners. The surveyor also observed debris in the grates, cooking hats, and stove surface as cited in F812. The FSD acknowledged the surveyor's concerns and agreed that the condition could be a safety issue and/or a fire hazard for staff and residents. On 11/20/25, the LNHA acknowledged the concerns and stated that equipment should be repaired timely and maintained to prevent a safety hazard or injury and to ensure the safety of residents and staff. On 11/26/25, the survey team met with the LNHA and DON, who acknowledged and agreed with the concerns and had no other information to provide. Facility policies reviewed stated that kitchen equipment must be used, cleaned, and maintained safely, that damaged or malfunctioning equipment must be reported, and that equipment must be kept in safe, functional, and sanitary condition.

Penalty

Inspection fine: $13,452

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from sexual abuse by another resident, leading to a serious deficiency. On the evening of January 23, 2022, a nurse discovered one resident performing a non-consensual sexual act on another resident. The victim was severely cognitively impaired, with a BIMS score of zero, indicating an inability to consent or defend themselves. The perpetrator admitted to the act when questioned by the nurse. Following the incident, the perpetrator was initially moved to a room with another resident who was alert and oriented, as no private rooms were available. This action placed the new roommate at risk, as the perpetrator had already demonstrated sexually inappropriate behavior. The facility's records showed no prior documentation of the perpetrator exhibiting such behavior, and staff members were unaware of any previous incidents or warnings. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the failure to prevent the incident and the subsequent risk posed to another resident. The facility's investigation and interviews with staff revealed that the incident was unexpected, with no prior indications of the perpetrator's intentions. Despite the facility's policy against resident abuse, the measures in place were insufficient to prevent the occurrence of this serious incident.

Removal Plan

• The perpetrator was removed from the situation and placed on checks.
• The resident was moved to a private room.
• Police department was notified, and the situation was investigated.
• Staff were in-serviced on abuse prevention.
• The resident was arrested and placed in custody.
• The judge ordered the facility to readmit the resident.
• Request sent to the judge regarding continued behaviors.
• The resident was placed on checks.
• Bail was revoked with the resident returning to custody and did not return to the facility.

Penalty

Inspection fine: $13,452

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the dish washer sanitizer level at the required concentration to effectively sanitize dishes, potentially affecting all 146 residents. The deficiency was identified during an observation and interview with the Dietary Manager (DM) who revealed that the dish washer was being used as a low temperature machine due to a malfunctioning booster. Upon testing, the chlorine sanitizer level in the rinse water was found to be zero parts per million (ppm), contrary to the facility's policy which required a level of 50 to 100 ppm. Further testing confirmed the absence of chlorine in the rinse water, and it was discovered that the sanitizer was not flowing through the hose. Additionally, the Dietary Aide (DA) responsible for operating the dish washer did not understand how to check the chlorine level, as evidenced by his incorrect use of test strips. The log used to record dish washer operations did not include a section for documenting the chemical level of the chlorine, which was verified by the DM. The manufacturer's instructions for the sanitizer specified that the chlorine level should be maintained at a minimum of 50 ppm, but this was not adhered to, leading to the deficiency.

Penalty

Inspection fine: $13,452

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement comprehensive care plans addressing the use of side rails for five residents, as required by their policy. These residents, identified as having various medical conditions such as multiple sclerosis, muscle weakness, dementia, and fractures, were observed using side rails without corresponding care plans in place. The observations were made during different times, and the lack of care plans was confirmed through a review of the electronic medical records and interviews with facility staff. Specifically, residents were observed with bilateral half side rails in the up position during various activities, such as sitting up in bed, eating, or sleeping. Despite these observations, the care plans for these residents did not include any mention of side rails as an intervention. The Assistant Director of Nursing confirmed the absence of side rail care plans for these residents, indicating a failure to comply with the facility's policy on comprehensive person-centered care plans.

Penalty

Inspection fine: $13,452

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its policy regarding the use of bed rails, resulting in deficiencies for 11 residents. The policy required that each resident be assessed for the need for side rails upon admission or re-admission, and that alternatives be considered before installation. However, the facility did not attempt to use appropriate alternatives prior to installing bed rails for these residents. Additionally, there was no evidence of assessments being conducted to evaluate the risk of entrapment from the bed rails. Furthermore, the facility did not review the risks and benefits of bed rail usage with the residents or their representatives, nor did it obtain informed consent prior to the installation or use of the side rails. This was evident in the cases of residents with various medical conditions such as multiple sclerosis, dementia, and muscle weakness, who were observed with side rails in the up position without the necessary documentation or consent. The Assistant Director of Nursing confirmed that side rails were not being assessed quarterly as required, and that there was a lack of documentation regarding alternatives, risk-benefit discussions, and consent. This oversight affected residents with varying cognitive abilities and physical needs, highlighting a systemic issue in the facility's adherence to its own policies and procedures regarding bed rail usage.

Penalty

Inspection fine: $13,452

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely completion and transmission of Minimum Data Set (MDS) assessments for two residents, as required by the Center for Medicare and Medicaid Services (CMS) guidelines. According to the CMS Long-term Care Facility Assessment Instrument 3.0 User's Manual, the MDS completion date should be no later than 14 calendar days after the assessment reference date (ARD), and the transmission date should be within 14 days of the MDS completion date. However, for one resident with a traumatic brain injury and paraplegia, the quarterly MDS assessment with an ARD of March 2, 2024, was completed on March 21, 2024, and submitted on April 2, 2024. Similarly, another resident with Alzheimer's disease, major depressive disorder, and mood disorder had their quarterly MDS assessment with an ARD of March 1, 2024, completed on March 20, 2024, and submitted on April 2, 2024. The MDS Assistant confirmed during an interview that neither of the assessments was completed and submitted within the appropriate timeframe. This delay in the completion and submission of the MDS assessments for these residents indicates a failure to adhere to the required timelines set forth by CMS, as outlined in the Resident Assessment Instrument (RAI) manual. The findings were based on a review of the residents' electronic medical records, including the MDS Summary and Assessment History, which documented the completion and acceptance dates of the assessments.