Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tower Lodge Care Center during CMS and state inspections, most recent first.
Agency staff were involved in multiple care and safety failures. Residents reported that agency staff did not answer call lights overnight and that services stopped after 4:00 PM on Fridays. A first-time agency RN wore a hospital badge instead of a facility badge, handled meds with bare hands, and left the med cart unlocked in the hallway. In a separate event, an agency CNA transferred a resident alone with a Hoyer lift, the resident slid to the floor, and the facility had no documented competency evaluation or orientation for the CNA.
Menu and recipe standards were not followed. Residents reported poor-quality, cold food and trays left in the hallway, and tray observations showed multiple mismatches between meal tickets and what was served, including missing or substituted breakfast items and incorrect jelly. The cook stated she did not have recipes, did not know what the egg bake was, and said different cooks prepared food differently.
Meals were not served at appetizing and palatable temperatures. In resident council, most residents who commented said food quality was poor, meals were cold, and trays were left in the hallway while staff did other tasks; one resident said they had been living on sandwiches for months because the food was not good. During meal observations, a CNA passed trays without help, trays were delayed, and food temperatures on two residents' trays were below expected hot and cold holding temperatures. The cook could not clearly explain the required tray temperatures.
A facility failed to regularly offer and document HS snacks for residents. During a resident council meeting, all residents said they were not offered a bedtime snack, while a CNA stated no HS snack was offered because residents went to bed after dinner and another said residents had to ask for one. The FSD could not provide a par level, snack quantities observed in the pantry did not match the census, and the DON relied on MAR documentation showing snacks were offered and a resident list showing all residents refused HS snacks.
Kitchen food safety and sanitation practices were deficient when a can opener had embedded debris, a Dietary staff member handled gelatin with long fingernails and no gloves, and a metal scrub pad was present despite being disallowed. Surveyors also observed blank food temperature logs, raw chicken and pre-cooked pancakes held at about 59 F and 57 F, and a Dietary staff member who touched a hair net, handled tray-line items, and washed hands for only 3 seconds instead of the required 20 seconds.
The facility failed to issue the required NOMNC and SNFABN for one resident and failed to issue the NOMNC for two other residents reviewed for beneficiary notification. The RSW said the prior SW kept the notices in a drawer, but the documents could not be located for the three residents. The DOR was supposed to notify the SW of the last covered day, and the SW would then obtain signatures from the resident or RP.
Incomplete Investigation of Injuries of Unknown Origin: The DON did not document a thorough investigation for two residents with unexplained injuries. One resident with severe dementia and total dependence had a skin tear and later a swollen finger, and the record lacked staff interviews from the shifts providing care. Another resident with dementia and dependence on staff developed a 4 cm by 3 cm abdominal wound, but there was no documentation that caregivers were interviewed to determine the cause; the facility concluded the wound was likely from unintentional friction without supporting staff statements.
A facility failed to provide adequate supervision and consistently implement fall prevention interventions for two high-fall-risk residents. One resident with severe dementia and limited communication fell during transfers, including an event where the resident slid out of a wheelchair during a Hoyer lift transfer performed by an agency CNA without the required 2-person assist; the CNA reported no orientation or competency validation. Another resident with dementia, impaired vision, and orthostatic hypotension had repeated unwitnessed falls, including multiple bathroom falls, while the record lacked documentation that planned toileting assistance, hourly rounds, reassurance checks, or other care plan interventions were consistently carried out.
A resident with a recent UTI, frequent bowel and bladder incontinence, and dependence for toileting did not receive an effective toileting program or documented continence plan. The resident reported knowing when they needed to void but being unable to walk, said staff sometimes became impatient, and described sitting in wet or soiled briefs for long periods. Surveyors found no bedside commode, no toileting program, and no documented IDT plan for mobility or transfer needs; the RD said therapy was not provided because the resident was private pay, while the DON and LNHA acknowledged the resident should have received therapy from day one.
A resident with chronic pain syndrome and stroke-related impairments reported ongoing pain and requested Tramadol while in a scoop bed. Surveyors observed that ordered pain medications, including Tramadol and scheduled Lidocaine patches, were not given on time or were not given at all, and staff acknowledged the missed and delayed administration. The RN and LPN both confirmed the resident did not receive the ordered pain treatment as scheduled.
Unlocked Medication Cart and Delayed Pain Med Pass: A resident with chronic pain and stroke-related deficits reported needing Tramadol and said pain meds were often late. Surveyors observed an unlocked, unattended med cart with drawers open, and the RN acknowledged it should have been locked. Record review showed the resident did not receive Tramadol and the scheduled Lidocaine patches on time, while multiple other 9:00 AM meds were administered late by an agency RN.
A resident with CVA, lumbar fractures, falls, gait instability, and impaired functional status was ordered PT/OT/ST on admission, but the facility did not provide rehab because the resident was private pay. The RD stated the resident was not assessed for functional status and that therapy notes indicated the resident would have to pay for services. The resident reported inability to walk and incontinence related to difficulty getting out of bed, while the CNA said no transfer guidance was provided and the physician expected the resident to receive rehab if needed.
A resident’s MDS was inaccurately completed for psychotropic medication and pneumonia vaccine status. The MDS did not code Seroquel despite an active order and administration during the look-back period, and it coded pneumonia vaccine as offered and declined even though the chart only showed a prior refusal with no documentation that it was offered or declined in the current period. The IP/ADON and MDSC/LPN acknowledged the documentation and coding errors.
Therapeutic Diet Not Provided Per Physician Order: A resident with dysphagia had a physician order for a CCD/NAS chopped, soft and bite-sized diet, but a meal tray observed by surveyors was served as regular texture with items including toasted raisin bread and regular jelly. Dietary and rehab records showed the diet order had been communicated to the facility, and the RD confirmed the tray contents did not match the ordered diet.
Infection control practices were not followed during medication administration for 2 nurses observed. An RN handled a tablet with bare hands before placing it in a medication cup because he did not have gloves available, and an LPN was observed washing her hands for less than the required 20 seconds away from running water. The facility's hand hygiene policy required scrubbing all surfaces of the hands for at least 20 seconds.
Failure to offer and document PNA vaccinations for two residents. One resident had intact cognition with prior Pneumovax 23 and a later Prevnar 20 refusal, but no 2025 record showing the vaccine was offered or declined. Another resident with dementia and metabolic encephalopathy also had prior Prevnar20 refusals, yet no 2025 documentation of an offer or declination. The IP/ADON acknowledged the missed offer and lack of documentation.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through a review of staffing data and interviews, revealing that no RN was scheduled for any of the weekends reviewed during the 3rd quarter of 2024. The DON acknowledged the lack of consistent RN coverage and stated that the facility would call 911 if needed.
The facility was found to have unsanitary conditions in the kitchen, including debris and grease on equipment and packaging, which could lead to contamination and foodborne illness. The Food Service Director was unable to explain the cause, despite a policy requiring regular cleaning.
A resident experienced a significant weight loss of 23.6 lbs within 24 hours, but the facility failed to notify the physician as required by their policy. The resident, with a history of congestive heart failure and on diuretic medication, was at risk for weight changes. The LPN responsible for entering the weight confirmed no documentation of physician notification, and the DON acknowledged the oversight. The facility's weight policy mandates reweighing and physician notification for significant weight changes, which were not followed in this case.
Agency Staff Competency and Medication Safety Failures
Penalty
Summary
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. Resident Council meeting minutes from March 2026 reflected resident complaints about agency staff, including requests for more regular staff and no agency workers. During a Resident Council meeting attended by 8 alert and oriented residents, all 8 stated the facility needed more help, that services stopped after 4:00 PM on Friday, that agency staff did not care, and that call lights were not answered overnight while staff were observed in the lounge. The DON acknowledged awareness of the concerns and stated the facility was trying to hire more full-time staff. On 4/17/26, a surveyor observed an RN at the medication cart wearing a hospital identification badge rather than a facility badge. The RN stated he was an agency nurse and it was his first time working at the facility. The DON stated the RN should not have been wearing the hospital badge and said the staffing agency was responsible for providing an identification badge. The same RN was then observed preparing medications by removing tablets from a bingo card and placing them first into his bare hand and then into a medication cup. He stated there were no gloves available on the medication cart and said he would avoid touching resident medication with his bare hands going forward. The RN was also observed leaving the medication cart ajar and unlocked in the hallway while he was not visible at either end of the hallway. The ADON observed the unlocked cart and stated the nurse should know not to leave it open. The DON later stated he had given the nurse a brief orientation on the medication cart at the start of the shift, but no documented orientation was provided. In a separate incident involving Resident #40, a CNA reported using a Hoyer lift to transfer the resident from bed to wheelchair, then turning to turn off the water when the resident slid to the floor. The facility did not further investigate whether a second staff member was present as required, and no competency evaluation or training for the agency CNA was provided before or after the fall. The CNA later stated she transferred the resident alone with the Hoyer lift and that she had not been educated by regular staff to familiarize herself with residents.
Menu and Recipe Standards Not Followed
Penalty
Summary
The facility failed to ensure that the menu was followed and that recipes were used to provide meals in a consistent manner. During a resident meeting, 7 of 8 residents stated the food quality was poor, the food was served cold, and meal trays were left in the hallway while staff were doing other things; one resident said they had been living on sandwiches for the past six months because the food was not good. During breakfast observations, a CNA on one unit passed 10 resident trays without assistance, and the last tray was not passed until 8:29 AM after the cart arrived at 8:12 AM. Tray observations showed multiple mismatches between the meal tickets and the food served, including scrambled eggs served instead of a Farmers Egg Bake, a breakfast roll missing, raisin toast served instead of the listed item, regular jelly provided instead of diet jelly, and a pancake served instead of the listed egg bake and breakfast roll. In the kitchen, the cook stated she did not know what the egg bake was, did not have any recipes, and did not use recipes, explaining that four different cooks worked there and everyone cooked differently. The menu review also found that recipes were requested for lunch and dinner items, but the cook stated she did not know if the Food Service Director had a recipe book and that she knew how to cook.
Meals Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure meals were served at appetizing and palatable temperatures. During a resident council meeting, 7 of 8 residents who commented said the food quality was poor, the food was served cold, and meal trays were left in the hallway while staff were doing other things. One resident stated they had been living on sandwiches for the past six months because the food was not good. On one unit, a breakfast cart arrived and one CNA began passing 10 resident trays without assistance from other staff. The last tray was not passed until 17 minutes after the cart arrived, and the surveyor removed that tray and requested a replacement. The meal tray for a resident on a regular texture, CCD, no added salt, thin fluid diet showed oatmeal at 120 F, scrambled eggs at 95 F, orange juice at 48 F, skim milk at 56 F, and coffee at 120 F. On another unit, a meal cart arrived and the second-to-last tray was passed about one hour later; the tray for a resident on a low-fat diet showed orange juice at 48 F, oatmeal at 117 F, skim milk at 54.7 F, and a pancake at 88.8 F. When asked, the cook stated hot food should be 179-186 F on the steam table and also stated it varied, and said the last tray served should not have a different temperature than the first tray.
Failure to Provide and Document Bedtime Snacks
Penalty
Summary
The facility failed to regularly provide a nourishing bedtime snack for residents. During a resident council meeting, 8 of 8 alert and oriented residents stated they were not offered a bedtime snack and were not aware the facility should offer one. The meal tray delivery schedule showed dinner trays were delivered at about 5:09 PM to 5:20 PM and breakfast trays at about 8:14 AM to 8:25 AM, leaving a span of about 15 hours between meals on the units reviewed. The Food Service Director stated that HS snacks were delivered to the units each evening, but could not provide a par level and described quantities that did not match the facility census of 55 residents. On unit pantry observation, the surveyor found only 2 peanut butter and jelly sandwiches, 11 pudding cups, and some cookies on one date, and 2 peanut butter and jelly sandwiches, 11 pudding cups, and some cookies on the next date. A CNA stated she could not locate documentation for HS snacks, and another CNA stated residents went to bed after dinner and no HS snack was offered, adding that residents should ask for a snack if they wanted one. The DON stated nurses signed the MAR that snacks were being offered and provided a resident list showing all residents refused HS snacks, but did not address the CNA statement or the snack quantities observed. The facility policy required all residents to be offered an HS snack and for acceptance or refusal to be documented at the time the snack was offered.
Kitchen Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
Food was not stored, handled, or prepared in a sanitary manner during kitchen observations, and kitchen equipment was found with embedded debris. During a kitchen tour with the Food Service Director present, a metal can opener attached to the table had food debris embedded on the blade, and the blue insert holding the can opener could not be removed because of caked-on, dark debris. A Dietary Staff member with very long fingernails was observed scooping gelatin into cups without gloves, and after being told to put gloves on, did so without first washing hands. Additional observations showed unsafe food handling and incomplete sanitation practices. A large metal pot scrubbing pad was observed in the kitchen by the pot sink washing area, and the Food Service Director acknowledged that metal scrubbers were not supposed to be used because they could shred. The food temperature log for breakfast was blank, as was the log for the prior dinner meal, and the staff member stated the temperatures were not filled out because there was no chance to do so and that only the oatmeal temperature had been taken. The surveyor also observed raw chicken sitting uncovered under partially placed foil on a sheet pan resting over a food preparation sink, with red liquid poured into the prep sink. The chicken was not labeled or dated and was measured at 59 degrees Fahrenheit. Pre-cooked pancakes in a plastic bag were also observed resting on top of a toaster while the staff member was cleaning, and the pancakes measured 57 degrees Fahrenheit. In another observation, a Dietary Staff member picked up a hair net outside the kitchen, entered the kitchen, handled condiments on the tray line, and washed hands for only 3 seconds after being asked about hand hygiene, despite stating that handwashing should last 20 seconds.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Advance Beneficiary Notice of Non-Coverage (SNFABN) for one resident and failed to issue the NOMNC for two additional residents reviewed for Beneficiary Notification. During record review and interviews, the Licensed Nursing Home Administrator provided a list of residents discharged from the facility within the last six months from a Medicare Part A stay, and the surveyor selected three residents for review. The Regional Social Worker stated that the prior Social Worker, who had resigned in March, kept the notices in a file in her drawer, but the notices could not be located for the three residents requested. The Regional Social Worker explained that when a resident was ending a Medicare Part A stay, the Director of Rehabilitation notified the Social Worker of the last covered day, and the Social Worker would have the notices signed by the resident or responsible party. The Director of Nursing, LNHA, President of Clinical Services, and Regional Nurse Consultant were notified of the concern, and the facility provided no further information.
Incomplete Investigation of Injuries of Unknown Origin
Penalty
Summary
The facility failed to complete and document a thorough investigation for injuries of unknown origin for two residents. For one resident, who had severe dementia, aphasia following a stroke, muscle weakness, and total dependence on staff for all ADLs, the record showed a skin tear to the left hand and later a swollen left index finger. The investigation report did not include follow-up interviews from staff on any of the three shifts who provided care before the unwitnessed injury was discovered, and the facility did not provide documentation from caregivers to determine the cause of the injury before the swelling was identified. For the second resident, who had dementia with behavioral disturbances, needed assistance with personal care, and had moderately impaired cognition, the record showed a wound to the left abdomen measuring 4 cm by 3 cm with flat tissue and underlying black tissue. The resident was dependent on staff for care, and the facility had no documentation of redness or other concerns from staff before the resident reported the wound to the NP. The incident audit report stated the wound was most consistent with unintentional friction, but there was no documentation that staff who cared for the resident were interviewed to determine a causal factor. The facility’s own policy for injury of unknown origin required an internal review that could include witness statements and a CNA or staff statement or investigation report. During interview, the DON stated that he would do a look back for 24 hours and collect statements from all staff who provided care, but he could not provide statements from the staff involved in either resident’s care and did not identify a cause for the injuries to ensure abuse and neglect had not occurred.
Failure to Provide Adequate Fall Supervision and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and fall prevention interventions for two residents who were identified as high risk for falls. One resident had severe dementia, was severely cognitively impaired, and required extensive assistance with mobility and transfers. The resident’s care plan included keeping the bed in the lowest position, anticipating needs, offering toileting assistance, using a Hoyer lift with 2-person assist for transfers, and maintaining a clutter-free environment. The record showed multiple falls, including falls during transfers and a fall in which the resident slid out of a wheelchair. Surveyor interviews with the CNA and LPN involved in the transfer on 8/22/25 showed conflicting accounts, and the CNA stated she transferred the resident with the Hoyer lift without another person present. The CNA also stated she had not received orientation, care observations, or education related to the required 2-person Hoyer transfer intervention. The record review for this resident also showed that after prior falls, the facility added interventions such as bilateral leg rests for wheelchair transfers, but the resident continued to fall. The Physical Therapy screen dated 8/22/25 documented education to nursing staff on Hoyer transfer sequencing and continued recommendation for 2-person Hoyer lift use. The DON could not recall what happened during the fall event and the facility did not provide the CNA’s file or competencies by the exit date. The agency contract identified the CNA as an independent contractor, and the facility stated there were no competencies completed for the agency CNA. A second resident, who had dementia, impaired vision, orthostatic hypotension, and a BIMS score indicating moderate cognitive impairment, had a care plan addressing falls related to poor safety awareness, impaired vision, and psychotropic medication use. The interventions included assisting with activities of choice, escorting to activities, offering toileting before and after meals and activities and at bedtime, hourly safety rounds, brief reassurance visits between hourly rounds, and toileting assistance every 2 hours as needed. The resident sustained 10 unwitnessed falls between 8/26/25 and 2/22/26, including 3 falls in the bathroom. The incident reports and investigations did not document when the resident was last observed, when toileting or incontinence care was last provided, or whether the resident had been offered or assisted with toileting as planned. The facility could not provide documentation that the care plan interventions for toileting, reassurance checks, or temporary emotional support were implemented, and no targeted interventions were identified based on the root causes of the repeated falls.
Failure to Provide Toileting and Incontinence Care for Resident with UTI History
Penalty
Summary
The facility failed to ensure that a resident with a history of urinary tract infections received appropriate incontinence care to prevent further UTIs and to support continence and dignity. The resident stated they knew when they needed to use the bathroom but could not walk and would “just go in my pants.” The resident also reported that staff sometimes became impatient and that they would sit in wet or soiled briefs for long periods. During observation, the resident’s room was found to have no bedside commode, and the resident described sharing a bathroom with multiple other residents in adjoining rooms. Record review showed the resident had diagnoses including syncope, falls, lumbar fractures, and a recent UTI identified during a hospital admission after a fall and head injury. The hospital record documented a positive urine culture and antibiotic treatment for the UTI. The MDS coded the resident as frequently incontinent of urine and bowel, dependent for toileting, and without a trial toileting program or bowel toileting program. The care plan included impaired functional status and fall risk, with an intervention to offer or assist with toileting during care, before and after meals and activities, and at bedtime, but there were no interventions to restore continence, no toileting program, and no commode use documented. The surveyor also found that the facility had not obtained or documented an interdisciplinary plan of care for the resident’s functional status and toileting needs. The Rehabilitation Director stated the resident had not received PT because the resident was private pay and did not want to pay for services, and also stated the resident had not been assessed for functional status and that toileting would have been a nursing judgment. The DON and LNHA acknowledged that the resident should have received therapy from day one and that transfer status was important for safety. The CNA stated there was no documentation on how to transfer the resident and that staff had to use judgment and get another staff member to assist. The resident stated no toileting plan had ever been set up and described wearing a diaper that did not catch all the urine, with urine running down the legs.
Failure to Administer Ordered Pain Medications
Penalty
Summary
The facility failed to ensure safe and appropriate pain management for a resident by accurately administering pain medications according to physician orders. Resident #61 was alert and oriented, had a history that included chronic pain syndrome, hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage affecting the left non-dominant side, and an unspecified fracture of the third lumbar vertebra. The resident was observed in a scoop bed and told surveyors that the mattress was uncomfortable and that they were having pain and needed Tramadol. During the survey, the resident stated that the nurse came but never administered the Tramadol and that this happened all the time. The resident also reported ongoing leg pain. Review of the e-MAR showed that the resident did not receive the ordered Tramadol 50 mg tablet and did not receive the scheduled 9:00 AM Lidocaine 4% patches at the time the resident complained of pain. The resident later stated that the Lidocaine patch helped with pain and was unsure whether a new patch had been applied. The CNA stated that after being informed of the resident’s pain complaint, she notified both nurses that the resident needed pain medication. An LPN later checked the resident and acknowledged that the resident did not have the Lidocaine patch on the left shoulder, approximately 4 hours after the CNA was alerted. The LPN acknowledged that the resident did not receive Tramadol or Lidocaine patches and stated that the agency nurse covering the unit was behind in giving medications. The RN responsible for the resident acknowledged that he did not administer the pain medication, stated that he was new to the facility and behind in medication administration, and said he should have administered the resident’s pain medications in a timely manner.
Unlocked Medication Cart and Delayed Pain Medication Administration
Penalty
Summary
The facility failed to properly secure one of two medication carts and failed to administer medications in a timely manner for a resident reviewed for pain management. The resident was alert and oriented, had a history that included chronic pain syndrome, hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage affecting the left non-dominant side, and an unspecified fracture of the third lumbar vertebra with routine healing. The resident also had a quarterly MDS indicating cognitive skills for daily decision-making were intact. During observation, a surveyor saw an unlocked and unattended medication cart parked at the far end of the hallway by the nursing station with no residents nearby. The surveyor was able to open all medication drawers and expose the medications inside the cart. The ADON confirmed the cart was open, and the RN later acknowledged that the medication cart should have been locked before being left unattended. The RN was from an agency and did not return to the cart until several minutes later. The resident told the surveyor that they were in pain and needed Tramadol, and the CNA said she would notify the nurse. Later, the resident stated they still had not received the pain medication and said this happened all the time. Review of the e-MAR showed the resident did not receive Tramadol 50 mg and the scheduled 9:00 AM Lidocaine 4% patches at the time requested. The medication administration audit showed multiple 9:00 AM medications were given late, including Cymbalta at 11:33 AM, Gabapentin at 11:26 AM, Tylenol Arthritis Pain at 11:32 AM, and several other scheduled medications at 11:32 AM or 12:56 PM. The Tramadol remained not administered, and the resident’s Lidocaine patches were not observed on the left shoulder when checked by an LPN.
Rehab Services Withheld Based on Ability to Pay
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered rehabilitation services and did not base access to those services on the resident’s ability to pay. The resident had diagnoses including syncope, collapse, unspecified fall, and fractures of the second and third lumbar vertebrae, along with a history of CVA, impaired functional status, and falls. On interview, the resident stated they could not walk, were incontinent because they could not get out of bed in time, and said that once therapy began it was helping them and that they wanted to walk. Record review showed that rehabilitation services were ordered on admission, including PT, OT, and a speech therapy screen/evaluation and treatment as indicated. The resident’s admission MDS showed dependence for dressing, hygiene, and toileting, and indicated a fall in the month before admission. The care plan identified impaired functional status and risk for falls, with interventions for PT/OT evaluation and treatment as ordered. Hospital records also documented that PT was recommended and that the resident had recurrent syncope, recurrent falls, gait instability, and urinary incontinence. During interview, the RD stated the resident was not provided therapy when admitted because the resident was private pay, and that therapy notes reflected the resident would have to pay for services. The RD also stated the resident was not assessed for functional status and that nursing judgment was used for care needs such as toileting and mobility. The resident was later evaluated and treated after a change in payer status. The CNA stated she had not received directives from PT or nursing regarding the resident’s transfer method and had to rely on her own clinical judgment and another CNA for assistance. The physician who completed the H&P stated he expected the resident to receive rehabilitation services if needed and was unaware the resident had not received them because of inability to pay.
MDS Inaccurately Coded for Psychotropic Medication and Pneumonia Vaccine Status
Penalty
Summary
The facility failed to accurately complete portions of the MDS for one resident, whose record included diagnoses of metabolic encephalopathy and unspecified dementia. During the survey, the resident was observed in bed on an air mattress and stated they wanted to rest. The Significant Change MDS dated 3/20/26 coded a BIMS score of 13/15, indicating intact cognition, and did not code any antipsychotic medication in Section N. It also coded that pneumonia vaccine was offered and declined in Section O. Record review showed the resident had an order for Seroquel 50 mg twice daily for schizoaffective disorder, and the March 2026 EMAR showed the medication was administered for 7 days within the MDS look-back period. The resident’s care plan also documented psychotropic medication use related to schizoaffective disorder. In addition, the EMR immunization record showed Prevnar20 was offered and refused in 2024, but there was no documentation in 2025 or 2026 that the pneumonia vaccine was offered or declined. The IP/ADON stated the family was against vaccinations and that the refusal had been verbally offered last year without documentation, and the MDSC/LPN acknowledged missing the Seroquel coding and coding the pneumonia vaccine based on the 2024 refusal rather than current documentation.
Therapeutic Diet Not Provided Per Physician Order
Penalty
Summary
The facility failed to ensure that a physician-ordered therapeutic diet was provided for a resident with dysphagia. Resident #14 had a physician order dated 4/17/26 for a CCD/NAS diet with chopped, soft and bite-sized texture. During a test tray observation on 4/20/26, the resident’s meal tray ticket listed a regular texture CCD/NAS thin fluid diet, and the tray contained items including scrambled eggs, oatmeal, toasted raisin bread, and regular jelly. A dietary staff member stated the diet was wrong because the resident had come in over the weekend and the kitchen did not get the diet order. The medical record review showed a dietary communication slip dated 4/17/26 signed by the speech therapist for chopped textures/thin liquids, and the Rehabilitation Director confirmed the dietary department received the order the same day it was written. The speech therapy encounter note documented swallow precautions, a regular texture lunch tray at the time of the visit, and a change to chopped texture/mechanical soft chopped solids. When asked about the tray contents, the Rehabilitation Director stated that toasted raisin bread was not okay on the ordered diet. The facility policy stated that therapeutic diets would be provided when there was a nutritional indication.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to follow appropriate infection control practices during medication administration for 2 of 2 nurses observed. During a medication pass, an RN removed a bingo card from the medication cart, popped out a tablet, and placed it in his bare hands before putting it into a medication cup for administration to a resident. When interviewed at the time, the RN stated he touched the medication with his bare hands because he did not have gloves and could not find a box on the medication cart, and he stated he would place medication directly into the medication cup going forward. During another medication pass, an LPN was observed washing her hands after administering medications to a resident. She wet her hands, added soap, and lathered her hands away from the stream of water for less than 5 seconds before placing her hands under running water and lathering for another 15 seconds before rinsing. When interviewed, the LPN acknowledged that she scrubbed her hands for less than 20 seconds away from the stream of water and stated that she should have scrubbed her hands for 20 seconds. The facility's hand hygiene policy required scrubbing all surfaces of the hands for at least 20 seconds.
Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer the pneumococcal (PNA) vaccine to 2 of 5 residents reviewed for vaccination status. Resident #2 was observed in their room on an air mattress eating breakfast and stated they were receiving therapy. The medical record showed diagnoses including generalized muscle weakness, a healed traumatic fracture, and unspecified dementia, while the MDS dated 3/2/26 showed a BIMS score of 15/15 and indicated the PNA vaccine was not offered. The immunization record showed Pneumovax 23 was given on 3/7/2019 and Prevnar 20 was refused on 11/12/24, but there was no documentation in 2025 that the vaccine was offered or declined. Resident #5 was observed in bed on an air mattress and stated they wanted to rest. The medical record showed diagnoses including metabolic encephalopathy and unspecified dementia, and the MDS showed a BIMS score of 13/15 with the PNA vaccine not offered. The immunization record showed Prevnar20 was offered and refused on 5/1/24 and 10/21/24, but there was no documentation in 2025 that the vaccine was offered or declined. The IP/ADON stated she was responsible for overseeing vaccinations, acknowledged she did not offer the PNA vaccine to Resident #2 in 2025, and stated she should have documented refusals in the medical record and obtained a signed declination form.
Deficiency in RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified through a review of the Payroll-Based Journal (PBJ) Staffing Data Report, Nurse Staffing Reports, interviews, and facility documentation. Specifically, the facility did not have an RN scheduled for any of the weekends reviewed during the 3rd quarter of 2024, covering April, May, and June. The absence of an RN was confirmed for multiple weekends, including specific dates in April, May, and June, as well as for additional dates in September. During the survey, it was noted that the facility relied on Licensed Practical Nurses (LPNs) during these times, with the Director of Nursing (DON) being available by phone. The DON acknowledged the lack of consistent RN coverage on weekends and stated that the facility would call 911 if needed. The facility's staffing policy, reviewed in April 2024, indicated that there should be at least one registered professional nurse on duty during all day shifts, with a temporary absence not exceeding 72 hours. However, this policy was not adhered to, as evidenced by the lack of RN coverage on the specified weekends.
Unsanitary Kitchen Conditions Observed
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment and equipment, which could lead to contamination and potential foodborne illness. During an inspection, the surveyor observed several unsanitary conditions in the food preparation area, including tan-colored debris on the door and handles of standing refrigerator #1, a brown substance on the packaging of styrofoam plates, and a brown substance on the microwave oven door and handle. Additionally, a thick brown grease-like substance was found on seven of eight stove knobs and one of two oven handles. In the dry storage area, similar unsanitary conditions were noted, with tan-colored debris on the door and handles of the produce standing refrigerator. The Food Service Director (FSD) acknowledged that the equipment should be clean but could not explain the cause of the contamination. The facility's policy on cleaning and sanitation, revised in August 2024, requires the food service staff to maintain sanitation through a comprehensive cleaning schedule, which was evidently not followed.
Failure to Notify Physician of Significant Weight Discrepancy
Penalty
Summary
The facility failed to maintain professional standards of clinical practice by not notifying the physician of a significant weight discrepancy for a resident reviewed for nutrition. The resident, who was admitted with diagnoses including hypertension, congestive heart failure, and a cardiac pacemaker, was on a care plan that required monitoring for weight changes due to their medical history. The resident's weight was recorded as 158.2 lbs on one day and 134.6 lbs the next, indicating a significant weight loss of 23.6 lbs within 24 hours. Despite this discrepancy, there was no documentation that the physician was notified, which was a requirement per the facility's policy. The Licensed Practical Nurse (LPN) responsible for entering the weight into the electronic medical record confirmed that there was no progress note or documentation on the Medication Administration Record (MAR) indicating that the physician was informed of the weight change. The Director of Nursing (DON) also reviewed the records and verified the absence of documentation regarding physician notification. The DON stated that a reweight should have been conducted to confirm the accuracy of the weight change, and the physician and dietitian should have been alerted. The facility's weight policy and scale accuracy procedures, revised in October 2023, require that significant weight changes be reweighed for accuracy and that the physician be notified of any weight loss or gain. However, these procedures were not followed in this instance, leading to a deficiency in maintaining professional standards of care. The surveyor's findings were presented to the facility's administration, including the Licensed Nursing Home Administrator (LNHA) and the DON, who acknowledged the oversight.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Careone At Wall | 1.4 mi | ★★★★★ | 12 | 0 |
| Complete Care At Wall Llc | 1.7 mi | ★★★★★ | 2 | 1 |
| Jersey Shore Post Acute Rehabilitation And Nursing | 1.9 mi | ★★★★★ | 0 | 0 |
| Coral Harbor Rehabilitation And Healthcare Center | 2.3 mi | ★★★★★ | 14 | 0 |
| Imperial Care Center | 2.4 mi | ★★★★★ | 17 | 0 |
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