Tallwoods Care Center

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

(tab) was crossed out on amount # 38 dated 8/4/2025 at 10:20 AM. Across it was another date 8/6/2025 at 2:00 PM with an arrow pointing to the crossed-out date and time. Amount #35 dated 8/29/2025 at 9:00 AM was crossed out. An arrow pointed to another date 9/2/2025 at 11:22 (unspecified whether AM or PM) from

the crossed-out line.Resident #168's IPCDR for fentanyl 50 microgram/ hour patch was crossed out on amount # 5 dated 11/16/2025. An error was written above it and across it was written the date of 11/17/2025. On 11/21/2025 at 12:17 PM, during medication storage inspection of the Maple unit high medication cart with UM #2, the surveyor noted multiple cross-outs on the November 2025 IPCDR sheets.

A review of the narcotic logbook revealed the following:Resident #45's IPCDR for hydromorphone 4 mg tab was crossed out on amount #49 dated 10/6/2025 at 9:00 AM. Waste was written on the same line. Amount #44 dated 10/18/2025 at 18:13 was crossed out and an arrow pointed to a written date of 10/19/2025 with illegible time. Amount #22 dated 11/14/2025 at 2:00 PM was crossed-out and on the same line another date and time were written, 11/15/2025 at 11:40 AM. Amount #21 dated 11/16/2025 at 9:05 was crossed-out and across the page was written an encircled #21 dated 11/17/2025 at 12:00 PM. Amount #20 dated 11/17/2025 at 12:00 PM was crossed out. Across the page was written an encircled #20 dated 11/20/2025 at 1:00 PM. Amount #56 dated 10/29/2025 at 5:45 AM was crossed out and an arrow pointed to another date 11/14/2025 at 2:00 PM.Resident #142's IPCDR for morphine sulfate 15 mg tab dated 11/14/2025 at 4 AM was crossed out at amount #59. Across it was written 11/14/2025 at 9:00 AM. Below it was dated 11/14/2025 at 9:00 PM was crossed out and marked error.Resident #134's IPCDR for pregabalin 25 mg capsule dated 11/5/2025 at 9:00 AM, was crossed out and marked refused.On 11/21/2025 at 12:17 PM, during an interview with the surveyor, UM #2 was asked why the residents were refusing pain medications that were already removed from the blister packs. UM #2 stated I guess because the nurses don't ask the residents if they want their meds.On 11/25/2025 at 9:43 AM, during an interview with the surveyor, the DON stated that cross-outs meant errors.On 11/25/2025 at 11:03 AM, during a meeting with

the survey team, concerns for multiple crossed outs on IPCDR or narcotic declining sheets of Pine and Maple units were brought up to the administrator and DON.No further information was provided.A review of

the facility-wide in-service by the DON dated 10/9/2025 titled Controlled Substance Accountability & Diversion Prevention for nurses included under Objectives: After this in-service, staff will be able to 1.) Demonstrate accurate documentation on the narcotic sign-in and count sheet. A review of the supplementary education sheet included in the in-service titled Controlled Drug Substance Accountability from the pharmacy consultant included under DO NOT . Use arrows, extraneous marks. A review of facility-provided undated policy titled Narcotic Medication Process reflected under Discrepancies or changes in narcotic count: 1.) Must be reported to the DON. 2.) An investigation is conducted to reconcile any reported discrepancies. 3.) Any irreconcilable discrepancies get reported to the administrator and a further investigation is completed which may include law enforcement and other agencies.N.J.A.C. 8:39 11.2 (b), 29.2 (a)(d), 29.4 (k), 29.7(c)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Tallwoods Care Center

18 Butler Boulevard Bayville, NJ 08721

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Complaint # 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. On 11/24/2025 at 9:30 AM, during an interview with the surveyor,

the Director of Nursing (DON) stated that narcotic boxes should be kept locked. A review of facilityprovided undated policy titled Controlled Medication Storage Policy reflected the following under Procedures: 1.) All controlled substances must be stored in a double-locked system. N.J.A.C. 8:39 - 29.4 (h)

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