Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
141 residents
Based on a August 2024 inspection.
Census over time
Notice
Deficiencies: 0
Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 1
Aug 27, 2024
Visit Reason
The inspection was conducted in response to complaint NJ167953 to investigate alleged deficiencies related to staffing ratios at Tallwoods Care Center.
Findings
The facility was found to be not in compliance with New Jersey Administrative Code 8:39 regarding mandatory staffing ratios, failing to meet required CNA staffing levels on 5 of 14 day shifts reviewed. No residents were identified as affected, but the deficient practice had the potential to affect all residents.
Complaint Details
Complaint NJ167953 was substantiated with findings of deficient CNA staffing ratios on 5 of 14 day shifts from 08/11/2024 to 08/24/2024. The facility was educated and required to submit a Plan of Correction.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 5 of 14-day shifts reviewed, specifically deficient CNA staffing on multiple days. |
Report Facts
Census: 141
Sample Size: 4
Deficient shifts: 5
Required CNAs: 18
Actual CNAs on 08/11/24: 16
Actual CNAs on 08/15/24: 17
Actual CNAs on 08/17/24: 16
Actual CNAs on 08/18/24: 16
Actual CNAs on 08/24/24: 16
Residents on 08/11/24: 146
Residents on 08/15/24: 143
Residents on 08/17/24: 143
Residents on 08/18/24: 146
Residents on 08/24/24: 141
Inspection Report
Annual Inspection
Census: 146
Capacity: 180
Deficiencies: 10
Apr 16, 2024
Visit Reason
A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health from 04/08/24 through 04/16/24 to assess compliance with federal and state regulations.
Findings
The facility was found not in substantial compliance with 42 CFR 483 subpart B, with deficiencies including failure to protect residents from abuse, untimely completion and transmission of Minimum Data Set (MDS) assessments, incomplete comprehensive care plans for side rail use, improper use and documentation of bedrails, inadequate dishwasher sanitizer levels, staffing shortages, and life safety code violations related to fire safety and emergency preparedness.
Severity Breakdown
SS=J: 1
SS=D: 1
SS=E: 2
SS=F: 5
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure one resident was protected from abuse by another resident, resulting in an immediate jeopardy situation that was later removed. | SS=J |
| Failure to complete and transmit two residents' MDS assessments in a timely manner. | SS=D |
| Failure to develop and implement comprehensive care plans addressing the use of side rails for five residents. | SS=E |
| Failure to attempt appropriate alternatives, assess risks and benefits, and obtain informed consent prior to installing bedrails for 11 residents. | SS=E |
| Failure to maintain dishwasher sanitizer levels at required 50-100 ppm, risking inadequate sanitization of dishes. | SS=F |
| Failure to maintain required minimum direct care staff-to-resident ratios as mandated by New Jersey law over multiple periods. | — |
| Failure to equip the boiler room door with an automatic door closure as required by NFPA 101 Life Safety Code. | SS=F |
| Failure to perform smoke detection sensitivity testing every alternate year as required by NFPA 72 National Fire Alarm and Signaling Code. | SS=F |
| Failure to inspect and test fire doors annually in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. | SS=F |
| Failure to equip the emergency generator with a remote manual stop station as required by NFPA 110 Standard for Emergency and Standby Power Systems. | SS=F |
Report Facts
Survey Census: 146
Total Capacity: 180
Sample Size: 32
Deficiencies cited: 11
Dishwasher sanitizer level: 0
Dishwasher sanitizer level: 50
Staffing Deficiencies: 11
Staffing Deficiencies: 19
Staffing Deficiencies: 14
Staffing Deficiencies: 27
Staffing Deficiencies: 18
Staffing Deficiencies: 25
Staffing Deficiencies: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in abuse incident involving residents R346 and R347 |
| CNA1 | Certified Nursing Assistant | Interviewed about abuse incident and in-service |
| CNA2 | Certified Nursing Assistant | Interviewed about abuse incident and care for resident R347 |
| Detective 1 | Interviewed regarding abuse case | |
| DA1 | Dietary Aide | Observed not properly testing dishwasher sanitizer levels |
| Director of Maintenance | Responsible for fire safety door inspections, smoke detector testing, and generator remote stop installation |
Inspection Report
Routine
Census: 141
Deficiencies: 0
Mar 20, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample size: 7
Inspection Report
Routine
Census: 136
Deficiencies: 4
Nov 18, 2021
Visit Reason
Routine standard survey to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was not in substantial compliance with federal and state regulations, with deficiencies cited related to abuse prevention, pressure ulcer care, food safety, and staffing ratios.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility staff failed to ensure residents were free from verbal abuse; a CNA called a resident a 'weirdo'. | SS=D |
| Failure to provide care consistent with professional standards to prevent infection risk during wound care; scissors used without cleaning between uses. | SS=D |
| Failure to handle potentially hazardous food and maintain sanitation; improper hand hygiene observed in dietary aide. | SS=E |
| Facility failed to maintain required minimum direct care staff to resident ratios as mandated by New Jersey state law for 10 of 14 day shifts reviewed. | — |
Report Facts
Census: 136
Deficiency count: 4
Staffing deficiency days: 10
CNA staffing required: 18
CNA staffing actual: 13
CNA suspension duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA #1) | Named in verbal abuse finding for calling resident a 'weirdo'. | |
| Director of Nursing (DON) | Interviewed regarding abuse incident and staffing. | |
| Administrator | Reported abuse incident to NJ Department of Health and Office of Ombudsman. | |
| Unit Manager (UM) | Observed failing to clean scissors during wound care. | |
| Dietary Aide (DA) | Observed failing to perform proper hand hygiene before handling sanitized dishes. | |
| Food Service Manager (FSM) | Interviewed regarding dietary aide hand hygiene. | |
| Staffing Coordinator (SC) | Interviewed regarding staffing ratios and compliance. | |
| Licensed Practical Nurse (LPN) | Interviewed about census and staffing on Pine Unit. |
Inspection Report
Life Safety
Deficiencies: 2
Nov 18, 2021
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with Medicare/Medicaid participation requirements related to fire safety and emergency preparedness.
Findings
The facility was found noncompliant with emergency lighting and fire alarm system installation requirements. Specifically, the emergency generator room lacked battery backup emergency lighting, and the outside enclosed courtyard lacked audible and visible fire alarm notification devices.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide a battery backup emergency light above the emergency generator's transfer switches, independent of the building's electrical system and emergency generator. | SS=D |
| Facility failed to provide notification by audible and visible signals in the outside enclosed courtyard tied into the fire alarm system. | SS=D |
Report Facts
Smoke zones: 12
Stories: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Verified findings during inspection and responsible for monitoring corrective actions. | |
| Administrator | Notified of findings at Life Safety Code exit conference and responsible for quarterly review. |
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 1
Aug 16, 2021
Visit Reason
The inspection was conducted based on Complaint # NJ 146619 to determine compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility was found not in substantial compliance due to failure to maintain a complete and accurate medical record for documentation of a resident's treatments on the Treatment Administration Record (TAR), specifically for Resident #3. The facility also failed to follow its policy on charting and documentation.
Complaint Details
Complaint # NJ 146619 was substantiated as the facility failed to maintain complete and accurate medical records for Resident #3's treatment documentation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility staff failed to maintain a complete and accurate medical record for documentation of a resident's treatments on the Treatment Administration Record (TAR), with missing signatures for treatments on 7/2/2021 and 7/3/2021 for Resident #3. | SS=D |
Report Facts
Census: 136
Sample Size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Interviewed and agreed that staff failed to sign Resident #3's Treatment Administration Record | |
| Staff Educator | Re-in serviced all nurses on facility policy on documentation and signing of treatment administration records | |
| Director of Nursing | Receives audit reports from unit managers and shares information with QA committee |
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 0
Jun 17, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ138457 and NJ144007.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint numbers NJ138457 and NJ144007 were investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Sample Size: 8
Inspection Report
Abbreviated Survey
Census: 141
Deficiencies: 3
Dec 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found not to be in compliance with 42 CFR §483.80 infection control regulations, specifically failing to ensure appropriate infection control practices to prevent the spread of COVID-19 among staff and residents. Deficiencies included improper PPE doffing, failure to provide hand hygiene to residents before meals, and inadequate hand hygiene by staff.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Staff members failed to remove isolation gowns promptly after resident care, walking through common areas while still wearing gowns. | SS=E |
| Certified Nursing Assistants (CNAs) and other staff did not provide hand hygiene to residents prior to meal service. | SS=E |
| A porter failed to perform hand hygiene after removing dirty gloves and before donning new gloves. | SS=E |
Report Facts
COVID-19 positive residents: 34
COVID-19 positive staff: 19
Staff observed with deficient infection control practices: 6
Residents in census: 141
Sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Home Administrator (LNHA) | Participated in entrance conference and discussion of findings | |
| Director of Nursing (DON) | Provided information about COVID-19 positive residents and staff, infection control practices, and participated in discussion of findings | |
| Infection Preventionist (IP) | Newly hired, participated in entrance conference and infection control observations | |
| Occupational Therapy staff (OT #1 and OT #2) | Observed not removing isolation gowns promptly after resident care | |
| Certified Nursing Assistants (CNA #1 and CNA #2) | Observed failing to provide hand hygiene to residents before meals | |
| Speech Therapist (ST) | Observed not providing hand hygiene to resident before meal | |
| Porter | Observed failing to perform hand hygiene after glove removal |
Inspection Report
Routine
Census: 153
Deficiencies: 0
Nov 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 1
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