The extensive alterations appeared across multiple units and involved powerful pain medications including fentanyl patches, morphine tablets and hydromorphone. When asked why residents were refusing medications already removed from packaging, one unit manager told inspectors: "I guess because the nurses don't ask the residents if they want their meds."
On November 21, inspectors examining the Maple unit's high medication cart discovered "multiple cross-outs" on controlled substance logs. The pattern extended throughout October and November records.
For Resident 45's hydromorphone supply, nurses crossed out entry 49 dated October 6 and wrote "waste" on the same line. Entry 44 from October 18 was crossed out with an arrow pointing to a new date of October 19. Entry 22 from November 14 at 2:00 PM was crossed out and replaced with November 15 at 11:40 AM on the same line.
The alterations continued. Entry 21 dated November 16 was crossed out, with a circled replacement entry for November 17 written across the page. Entry 20 from November 17 was crossed out and replaced with an entry for November 20.
Resident 168's fentanyl patch records showed similar irregularities. Entry 5 dated November 16 was crossed out, marked as an "error," and replaced with November 17.
For Resident 142's morphine sulfate tablets, an entry dated November 14 at 4 AM was crossed out and changed to 9:00 AM the same day. Another entry for 9:00 PM that day was crossed out and marked "error."
Some changes involved medications marked as refused. Resident 134's pregabalin entry for November 5 at 9:00 AM was crossed out and marked "refused."
The facility's own training materials specifically prohibited such practices. A pharmacy consultant's education sheet included in October training stated under "DO NOT": "Use arrows, extraneous marks."
The Director of Nursing had conducted facility-wide training on October 9 titled "Controlled Substance Accountability & Diversion Prevention." The training objectives included demonstrating "accurate documentation on the narcotic sign-in and count sheet."
When questioned about the cross-outs on November 25, the Director of Nursing told inspectors that "cross-outs meant errors." No explanation was provided for why so many errors occurred or why proper correction procedures weren't followed.
Facility policy required specific steps when narcotic discrepancies occurred: reporting to the Director of Nursing, conducting investigations to reconcile discrepancies, and involving the administrator and potentially law enforcement for unresolved issues.
The inspection revealed no evidence these protocols were followed despite the extensive alterations.
Unit Manager 2, responsible for the Maple unit where many alterations occurred, could not explain why medications were being refused after nurses had already removed them from blister packaging. The response suggested nurses were dispensing controlled substances without confirming residents wanted them.
During a November 25 meeting with survey teams, administrators and the Director of Nursing were presented with concerns about the "multiple crossed outs" on controlled substance logs across Pine and Maple units.
The facility provided no further information to explain the pattern of alterations or demonstrate compliance with federal narcotic accountability requirements.
Federal regulations require nursing homes to maintain accurate records of controlled substances to prevent diversion and ensure proper medication management. The extensive cross-outs and unexplained changes documented at Tallwoods raised questions about the facility's ability to account for powerful pain medications prescribed to vulnerable residents.
The violations occurred despite recent training emphasizing proper documentation and the facility's own policies prohibiting the exact practices inspectors discovered throughout the medication records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tallwoods Care Center from 2025-11-26 including all violations, facility responses, and corrective action plans.