Tallwoods Care Center

In the surveyor’s words

From the most serious findings on record at Tallwoods Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 16, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 26, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Apr 16, 2024

  Based 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. Findings include: Review of the undated facility's policy titled, Dish Machine Policy and Procedure revealed it was the facility policy to test the chlorine level using test strips. According to the policy the chlorine level should be 50 to 100 PPM and should be tested at the start of running the dish machine. During an observation and interview on 04/08/24 at 9:52 AM, the Dietary Manager (DM) stated the dish washer was being used as a low temperature dish machine because the booster went out on 03/28/24. […]

• No harm, potential for more than minimal, patternF755Nov 26, 2025

  Complaint # 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… […]

• No harm, potential for more than minimal, patternF880Nov 26, 2025

  Based 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. […]