Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tallwoods Care Center during CMS and state inspections, most recent first.
The facility failed to maintain accurate records and proper documentation for controlled substances, resulting in discrepancies, missing supervisor signatures, and alterations on narcotic inventory sheets. One resident's prescribed pain medication went missing without timely detection, and multiple errors and cross-outs were found on controlled drug records for several residents. Staff interviews revealed confusion about documentation practices, and facility policies did not adequately address monitoring or reconciliation of narcotic counts, leading to actual and potential drug loss or diversion.
A surveyor found a narcotic box containing Lorazepam Intensol oral concentrate left unlocked in a medication room. An LPN and the DON both confirmed that narcotic boxes are required to be locked at all times, and facility policy mandates a double-locked system for controlled substances.
A resident in a LTC facility was sexually abused by another resident, who was later moved to a room with another resident, placing them at risk. The victim was severely cognitively impaired and unable to consent. The facility's abuse prevention policy failed to prevent the incident, and staff were unaware of any prior inappropriate behavior by the perpetrator.
The facility failed to maintain the required chlorine sanitizer level in the dish washer, potentially affecting all residents. The Dietary Manager confirmed the sanitizer level was zero ppm due to a malfunctioning booster and clogged tubing. The Dietary Aide did not understand how to check the chlorine level, and the log lacked a section for documenting it.
The facility did not develop care plans for the use of side rails for five residents with conditions like MS, dementia, and fractures. Observations showed these residents using side rails, but their care plans lacked this intervention, confirmed by staff review.
The facility failed to assess residents for bed rail use, did not attempt alternatives, and did not obtain informed consent for 11 residents. Observations showed residents with side rails in use without necessary documentation or consent, despite facility policy requirements. The ADON confirmed the lack of quarterly assessments and documentation.
The facility failed to complete and transmit MDS assessments for two residents within the required timeframe. One resident with traumatic brain injury and paraplegia had their assessment completed and submitted late, as did another resident with Alzheimer's and mood disorders. The MDS Assistant confirmed the delays, which were documented in the residents' electronic medical records.
Failure to Maintain Accurate Controlled Substance Records and Investigate Discrepancies
Penalty
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.
Controlled Substance Storage Deficiency
Penalty
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.
Failure to Protect Resident from Sexual Abuse
Penalty
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.
Dish Washer Sanitizer Level Deficiency
Penalty
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.
Failure to Implement Side Rail Care Plans
Penalty
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.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
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.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bayville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Lake Healthcare And Rehabilitation | 2 mi | — | 0 | 0 |
| Community Medical Center Tcu | 6.7 mi | — | 0 | 0 |
| Complete Care At Holiday City | 6.9 mi | — | 6 | 0 |
| Complete Care At Bey Lea, Llc | 7.1 mi | — | 11 | 0 |
| Rose Garden Nursing And Rehabilitation Center | 8 mi | — | 20 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.