The resident, identified as Resident #3 in the inspection report, arrived at the facility with diagnoses including right foot fractures, a history of falling, and nerve damage. Her medical record showed displaced fractures of the second and third metatarsal bones in her right foot.
On September 14, a certified nursing assistant found her on the bathroom floor next to the toilet. The resident told nurses she needed to use the bathroom but didn't call for help. When transferring from her wheelchair to the toilet, she started to wet herself, causing her feet to become slippery.
Three days later, nurses discovered her sitting on the floor beside her bed at 12:30 a.m. She had noticeable swelling and bruising on her left cheek. Staff gave her Tylenol for pain she rated 6 out of 10.
Nearly a month passed before the next fall. On October 13, a nursing assistant delivering her supper tray found her on the floor again. The resident said she was sitting on her bed and tried to get up to her wheelchair when she fell while moving cords out of her way.
The fourth fall happened November 13 in the bathroom. Nurses found her lying on the floor in front of the toilet. She told them she went to the restroom unassisted and lost her balance when she stood to pull her pants up.
Despite this pattern of falls, staff never revised her care plan to include interventions that might prevent future accidents. When inspectors interviewed facility staff on December 19, they confirmed the care plan remained unchanged from her admission.
A second resident experienced similar neglect. Resident #2 fell forward out of their wheelchair on November 26. Staff documented the incident but never updated the resident's care plan to address fall prevention.
The Director of Nursing confirmed both oversights during interviews with inspectors. He acknowledged that care plans should have been revised after each fall to reflect the residents' changing needs and implement safety measures.
Federal regulations require nursing homes to develop comprehensive care plans for each resident and update them when conditions change. Falls represent a significant change in a resident's condition, particularly for someone already diagnosed with a history of falling and mobility issues.
For Resident #3, the repeated bathroom falls suggested specific environmental hazards. Her first fall involved wet conditions that made her feet slippery. The fourth fall occurred during a routine transfer from toilet to standing position, indicating potential balance or strength issues that required intervention.
The facility's failure to revise care plans left both residents vulnerable to additional falls. Care plan updates typically include specific interventions such as increased supervision, assistive devices, environmental modifications, or physical therapy referrals.
Staff interviews revealed they were aware of the regulatory requirement to update care plans following falls. Both the nursing staff member and Director of Nursing told inspectors the plans should have been revised but weren't.
The inspection occurred following a complaint, though the specific nature of the complaint wasn't detailed in the available documentation. Inspectors classified the violation as causing minimal harm or potential for actual harm to some residents.
Resident #3's case was particularly concerning given her complex medical history. She entered the facility with existing fractures and nerve damage that already compromised her mobility and balance. The facility's failure to address her repeated falls through care plan modifications potentially exposed her to serious injury.
The four falls occurred in different settings and circumstances, suggesting multiple risk factors that required assessment and intervention. Her bathroom falls alone indicated the need for specific safety measures during toileting activities.
Both residents' situations demonstrated a systemic failure in the facility's approach to fall prevention and care plan management. The violations occurred over several months before inspectors arrived, indicating an ongoing pattern rather than isolated oversights.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Lodge At Tangi Pines from 2025-12-19 including all violations, facility responses, and corrective action plans.