Tower Lodge Care Center

In the surveyor’s words

From the most serious findings on record at Tower Lodge Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 8, 2021

  Based on observation, interview, medical record review, and review of other facility documentation, it was determined that the facility failed to implement Transmission Based Precaution mitigation strategies in a timely manner to prevent the transmission of COVID-19. This deficient practice was identified for 25 of 25 residents (Residents #4, 5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24, 25,26,27 and #28) who were exposed to two known COVID-19 positive staff members on 3 of 3 nursing units; during a Covid-19 survey conducted on 1/6/2021 and was evidenced by the following: Part A. 1. On 1/6/2021 at 2:30 PM, the DON/IP provided the team team with a document titled: Timeline, dated 11/26/2020. […]

• Immediate jeopardy, isolatedF835Jan 8, 2021

  Based on interview, review of medical records and other pertinent facility documentation, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure that the facility was in compliance with the following regulatory requirement which affected the safety of all residents in the facility. The Administrator failed to a.) ensure the implementation of Transmission Based Precautions (TBP) in a timely manner to prevent the transmission of COVID-19 and b.) by not appropriately identifying residents exposed to COVID-19 as persons under investigation (PUI). This placed 25 of 25 residents on 3 of 3 units at risk for Covid-19 Infection. […]

• No harm, potential for more than minimal, widespreadF725Apr 22, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF803Apr 22, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF804Apr 22, 2026

  Based 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. […]