The Lodge at Tangi Pines

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store foods under sanitary conditions. The facility failed to ensure:1. Food requiring refrigeration after opening was refrigerated, and2. Food items were dated after opening. This deficient practice had the potential to affect 92 residents who were provided meals from the facility's kitchen. Review of the facility's policy titled Date Marking for Food Safety dated 2026 revealed in part, the following:2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.4. The marking system shall consist of a color-coded label, the day/date of opening, and the day/date the item must be consumed or prepared. During the initial tour of the facility's kitchen on 04/13/2026 at 8:12 a.m. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to ensure nursing staff sanitized insulin vial stoppers prior to extracting insulin for 3 (#3, #7, and #97) of 4 residents observed for insulin administration. Review of the facility's policy titled Medication Administration dated 2025, revealed in part, the following:Policy: Medications are administered by licensed nurses in a manner to prevent contamination or infection. Review of Insulin Manufacturer's Insert revealed in part, the following:For insulin vials (and other multi dose vials), the rubber stopper is not sterile and can harbor microorganisms. Therefore, cleaning before use is essential to reduce contamination risk. [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement a comprehensive person-centered care plan for 1 (#68) of 3 residents reviewed for falls. The facility failed to ensure Resident #68's care plan was implemented for transfers with a mechanical lift. Review of Resident #68's Clinical Record revealed an admission date of 06/29/2017. Further review revealed Resident #68 had diagnoses which included a fracture of an unspecified part of neck of right femur, generalized muscle weakness, and Alzheimer's Disease. Review of Resident #68's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/03/2026, revealed Resident #68 was dependent on staff for chair/bed-to-chair transfers. Further review revealed a Brief Interview for Mental Status (BIMS) of 03, indicating severe cognitive impairment. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies for 1 (#68) of 3 residents reviewed for falls. Review of Resident #68's Clinical Record revealed an admission date of 06/29/2017 with diagnoses including fracture of unspecified part of neck of right femur dated 03/25/2026. Review of Facility's Incident Log, dated December 2025 to present, revealed in part, the following:Witnessed Fall Incident:Resident #68, 03/24/2026 at 6:15 a.m. Incident Location: Resident RoomPerson Preparing Report: S10LPN Review of Resident #68's Nurse Progress Notes, dated 03/25/2026, revealed, in part, the following:03/25/2026, 4:30 p.m., signed S11LPN: Resident noted to be screaming from bed. Upon entry into resident room, swelling was noted to Resident Right upper thigh area. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's plan of care was revised by failing to update fall interventions for each fall for 3 (#1, #2 and #3) of 3 residents reviewed for falls.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure interventions for falls were implemented as identified on the care plan for 1( #1) of 3 residents reviewed for falls.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident's personal funds were not susceptible to misappropriation by an employee of the facility for 1 (#46) of 21 residents reviewed in the initial pool. The facility failed to protect Resident #46 from misappropriation of funds by S9CNA which lead to Resident #46 experiencing psychosocial harm. This deficient practice resulted in physical and emotional harm on 03/28/2025, when Resident #46 experienced vomiting, depression, shame and embarrassment due to financial manipulation by S9CNA. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to ensure food was properly labeled, sealed, and dated in the refrigerator and dry storage area of the facility's kitchen. This deficient practice had the potential to affect the 90 residents who were served food from the kitchen.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure alleged violations involving misappropriated funds were reported to the administrator immediately and to the state agency within twenty four hours after the allegations were made for 1 (#46) of 21 residents reviewed in the initial pool. The facility implemented corrective actions, which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (#39) of 3 (#39, #54, and #71) residents reviewed for hospice care. The facility failed to ensure Resident #39 was coded correctly for hospice care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident's plan of care was revised by failing to update advance directive code status for 1 (#71) of 24 residents reviewed for code status in the initial sample.

Inspectors wroteBased on interviews, record reviews, and observations, the facility failed to maintain an infection control program designed to provide a safe, sanitary environment, and to help prevent the development and transmission of disease and infection for 2 (#17 and #52) of 3 (#17, #52, and #71) residents observed for wound care.

Inspectors wroteBased on interviews and record review, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#4) of 2 (#4 and #51) residents reviewed for wound care.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infection. The facility failed to ensure staff practiced proper hand hygiene and cleaning techniques during incontinence care for 1 (#13) of 3 (#13, #71, and #90) residents reviewed for incontinent care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure all complaint surveys since the last annual survey were available for resident review.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to protect the residents' right to be free from psychosocial harm by Resident #3 for 4 (#1, #R4, #R5, and #R7) of 7 (#1, #2, #3, #R4, #R5, #R6, and #R7) sampled residents reviewed for abuse. This deficient practice resulted in an actual psychosocial harm on the morning of 02/24/2024 when Resident #3, a cognitively intact resident, was observed kissing Resident #1, a severely cognitively impaired resident, on the cheek. Resident #3's nonconsensual inappropriate sexual advances and psychosocial harm continued for Resident #1. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an allegation of sexual abuse was reported immediately, to the facility Administrator and to the State Survey Agency for 1 (#1) of 7 (#1, #2, #3, #R4, #R5, #R6, and #R7) residents sampled for abuse.

Inspectors wroteBased on record review and interview, the facility failed to ensure an alleged incident of resident to resident sexual abuse was thoroughly investigated for 1 (#3) of 7 (#1, #2, #3, #R4, #R5, #R6, and #R7) sampled residents reviewed for abuse.

Inspectors wroteBased on interviews and record review the facility failed to develop a comprehensive person-centered plan of care for 1 (#3) of 7 (#1, #2, #3, #R4, #R5, #R6, and #R7) residents reviewed in the final sample.