Tower Lodge Care Center

Inspectors wroteBased on observation, interviews, record review, and review of facility documentation, it was determined that the facility failed to have a system in place to ensure that contracted staff had the appropriate competencies and skills to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, in accordance with standards of practice and individual resident care plans. This deficient practice had the potential to affect all residents who resided at the facility and was evidenced by the following: 1. On 4/16/26 at 1:24 PM, the surveyor reviewed the Resident Council Meeting Minutes for January, February and March 2026. The Resident Council Minutes dated 03/25/26, reflected the following: Residents were complaining about agency staff. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure that the menu was followed, and recipes were utilized to ensure meals were provided in a consistent manner. The deficient practice was identified for 7 of 8 Residents who attended a resident council meeting and had the potential to affect all residents who resided at the facility. The evidence was as follows: On 04/17/26 at 10:35 AM, the surveyor conducted a resident meeting with eight residents in attendance. When asked about the meals, 7 of 8 residents stated the food quality was poor, the food was served cold and the meal trays would be left to sit in the hallway while staff were doing other things. One resident stated they have been living on sandwiches for the past six months because the food was not good. [...]

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure meals were served at appetizing and palatable temperatures. The deficient practice occurred for 7 of 8 residents who attended a resident council meeting and for 2 of 2 test meals on 2 of 3 resident units (Ruby and Emerald) and had the potential to affect all residents who resided at the facility. The evidence was as follows: On 04/17/26 at 10:35 AM, the surveyor conducted a resident meeting with nine residents in attendance. When asked about the meals, 7 of 8 residents stated the food quality was poor, the food was served cold and the meal trays would be left in the hallway while staff were doing other things. One resident stated they have been living on sandwiches for the past six months because the food was not good. [...]

Inspectors wroteBased on observations, interviews, record review and document review it was determined that the facility failed to regularly provide a nourishing bedtime snack for the residents. The deficient practice was identified for 8 of 8 residents who attended a resident council meeting (Resident #2, # 4,# 7, #25 #,45, #46, #50,and Resident #53) and had the potential to affect all residents who resided in the facility, and was evidenced by the following: A review of the meal Tray Delivery Times provided by the facility on 04/22/26 at 11:15 AM, reflected the following: The meal tray delivery schedule included the following information: Meal trays for the [NAME] Unit were scheduled to be delivered for dinner at 5:09 PM and for breakfast at 8:14 AM, (indicative of a 15 hour and 5 minute time span between the two meals); [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to a) ensure potentially hazardous foods were stored and handled in a manner to prevent food-borne illness, b) the kitchen equipment was maintained in a clean and sanitary manner, and c) staff practiced appropriate hand hygiene and glove use to prevent contamination from foreign substances and limit the potential for the development a foodborne illness. This deficient practice affected all residents who resided at the facility and was evidenced by the following: [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to issue the proper required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) for 1 of 1 resident (Resident #25) and the NOMNC for 2 of 2 residents (Resident #62 and Resident #63 ) reviewed for Beneficiary Notification. This deficient practice was evidenced by the following:On 4/17/26 at 11:23 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a list of residents who were discharged from the facility within the last six months from a Medicare covered Part A stay (helps cover the cost of skilled nursing facility care including rehabilitation services). The surveyor randomly chose three residents (one who remained in the facility and two who were discharged ) and requested copies of the Beneficiary Notices. [...]

Inspectors wroteBased on interview, record review and review of other pertinent documents, it was determined that the facility failed to ensure a thorough investigation was completed and documented to determine the causal factor of injuries of unknown origin and to ensure that abuse or neglect had not occurred. This deficient practice occurred for 2 of 2 residents reviewed for injuries of unknown origin, Resident #40 who was identified with a swollen left index finger, and Resident #47 who was identified with a scab wound on the left abdomen area measuring 4 centimeters (cm) by 3 cm. The deficient practice was evidenced by the following:Refer to F689 1. On 4/20/26 at 11:30 AM, the surveyor reviewed the electronic medical record (EMR) for Resident #40. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure: a) adequate supervision was provided to a resident to prevent falls, b) consistently initiate new fall prevention interventions in response to falls, c) current care plan interventions to prevent accidents were consistently implemented. This deficient practice occurred for 2 of 2 residents (Resident #40 and #47) reviewed for falls and were identified as being at high risk for falls.

Inspectors wroteBased on observation, interview, record review and document review it was determined that the facility failed to ensure that a resident with a history of Urinary Tract Infections (UTI) received appropriate incontinence care to prevent further UTI's and provide appropriate care and services to restore continence and maintain resident dignity. This deficient practice was evidenced for 1 of 1 resident (Resident #61) reviewed for continence care and was evidenced by the following: On 04/16/26 at 11:34 AM, the surveyor interviewed Resident #61 about the care received at the facility and asked Resident #61 about rehabilitation and toileting care provided. Resident #61 stated, I cannot walk, I just go in my pants. Resident #61 stated I know when I have to go, it was a matter of getting out of bed. Resident #61 stated, now they were getting physical therapy. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documents, it was determined that facility failed to ensure a resident received the appropriate pain management by accurately administering pain medications according to the physician's orders. This deficient practice was identified for 1 of 1 resident reviewed for pain management (Resident #61) and evidenced by the following:The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed (a) to properly secure one of two medication carts and (b) to administered medications in a timely manner in accordance with professional standards of nursing practice for 1 of 1 residents reviewed for pain (Resident # 61). This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review and document review it was determined that the facility failed to ensure that a resident received physician ordered rehabilitation services as indicated and was not based on the ability to pay for the services. This deficient practice was evidenced for 1 of 1 resident (Resident #61) who had a history of falls, impaired functional status and was reviewed for rehabilitation services. The deficient practice was evidenced by the following: On 04/16/26 at 11:34 AM, the surveyor interviewed Resident #61 while they were seated in their wheelchair, about the care received at the facility and also asked about the high sided bed that was observed. Resident #61 stated it's awful, I have a bad back and it is bothering me. When asked if they knew why they had the scoop type bed, they stated they never told me. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documentation it was determined that the facility failed to accurately complete portions of the Minimum Data Set (MDS), an assessment tool to facilitate the plan of care, to accurately reflect the resident's status as of the Assessment Reference Date (ARD) for 1 of 5 residents reviewed (Resident #5). The deficient practice was evidenced by the following:On 4/16/2026 at 9:12 AM, the surveyor observed Resident #5 in bed lying on an air mattress and stated they wanted to rest. [...]

Inspectors wroteBased on observation, interview and record review it was determined that the facility failed to ensure a physician ordered diet for a resident with dysphagia was provided per physician order for 1 of 1 Resident (Resident #14) reviewed for therapeutic diet order. The evidence was as follows: On 04/20/26 at 8:29 AM, surveyor completed a test tray observation on the [NAME] Unit and requested a replacement tray for Resident #14 from a Dietary Staff (DS) that was present and the DS stated the diet was wrong as the resident came in over the weekend and the kitchen did not get the diet order. The Meal Tray ticket for Resident #14 documented the following diet: Regular Texture, CCD (Controlled Carbohydrate) No Added Salt, Thin Fluid Diet. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow appropriate infection control practices for the administration of medications for 2 of 2 nurses during the medication observation pass. The evidence was as follows:1. On 4/17/26 at 8:20 AM, during the medication observation pass, the surveyor observed a Registered Nurse (RN) remove out a bingo card (medication administration system for tablets) from a medication cart and popped out one tablet and placed it in his bare hands. The RN was then observed putting the tablet with his bare hands into a medication cup in preparation of administering a medication to a resident. At that time, the surveyor interviewed the RN who stated that he touched the medication with his bare hands because he had no gloves because he was unable to find a box on the medication cart. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation it was identified that the facility failed to offer residents the pneumonia (PNA) vaccination. This deficient practice was identified for 2 (two) of 5 (five) residents, (Resident # 2 and # 5), reviewed for vaccination status and was evidenced by the following:1. The surveyor reviewed Resident #2's medical record which revealed the following:On 4/16/2026 at 8:40 AM, the surveyor observed Resident #2 in their room, lying on an air mattress, eating breakfast, and stated she was receiving therapy. On 4/17/2026 at 11:02 AM, a review of the electronic medical records (EMR) revealed diagnoses which included but not limited to muscle weakness (generalized); personal history of (healed) traumatic fracture; [...]

Inspectors wroteBased on review of the Payroll-Based Journal (PBJ) Staffing Data Report, Nurse Staffing Reports, interview, and facility documentation, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 15 of 15 weekends reviewed. The deficient practice was evidenced by the following: A review of the PBJ staffing Data submitted for the 3rd quarter (April, May and June) of 2024 revealed the facility triggered for RN coverage for 8 consecutive hours/day. Further review revealed Infractions Dates: 04/06 (SA-Saturday); 04/07 (SU-Sunday); 04/13 (SA); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 04/28 (SU) 05/04 (SA); 05/05 (SU); 05/11 (SA); 05/12 (SU); 05/18 (SA); 05/19 (SU); 05/25 (SA); 05/26 (SU) 06/01 (SA); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/22 (SA); 06/23 (SU); 06/29 (SA); [...]

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 9/16/24 at 9:46 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: In the food preparation area, the surveyor observed the following: [...]

Inspectors wroteBased on observation, interview, record review and facility documentation it was determined that the facility failed to maintain professional standards of clinical practice by not notifying the physician of a weight discrepancy for 1 of 2 residents (Resident #38) reviewed for nutrition. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 09/13/23 from 09:57 AM until 11:10 AM the surveyors, who were accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. In the first refrigerator a box of individual containers of cranberry juice had a typed label of 9/24 and a handwritten label of 8/24. The FSD stated he will throw them away just to be sure. 2. In the first refrigerator, there were two white cups of liquid with no label and no date. The FSD identified the cups as being lactose free milk. The FSD stated the cups should have been dated and that he will discard. 3. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation it was determined that the facility failed to revise care plans for 2 of 14 residents reviewed (Resident #35 and Resident #8) for care plan revision and was evidenced by the following: 1. On 09/13/23 at 11:28 AM, the surveyor observed Resident #35 in the dayroom in a wheelchair during activities. On 09/13/23 at 1:30 PM, the surveyor reviewed the residents Electronic Medical Record (EMR) progress notes which indicated that Resident #35 was hospitalized [DATE]. Review of the annual Minimum Data Set (MDS), an assessment tool dated 06/18/23 revealed that Resident #35 had a Brief Interview of Mental Status of 99, meaning the resident was unable to complete the assessment due to cognitive impairment. Medical diagnoses included, but were not limited to heart disease, hypertension (high blood pressure), and dementia. [...]

Inspectors wroteBased on observation, interview, and review of facility documentation it was determined that the facility failed to notify the physician of incomplete pacemaker checks for Resident #39, 1 of 1 resident reviewed for pacemakers. This was evidenced by the following: On 09/13/23 at 10:37 AM, the surveyor observed Resident #39 in the room sitting on the side of the bed. On 09/14/23 at 09:56 AM, the surveyor observed the resident laying in bed, there was a stop sign across Resident #39 door and the resident said it was to stop any other residents from entering. Review of the admission Record revealed Resident #39 had medical diagnoses which included, but were not limited to heart failure, atherosclerosis (build up of fats in the arteries), and presence of cardiac pacemaker (a device to send electrical pulses to help your heartbeat at a normal rate and rhythm). [...]