Resident #3 arrived at the facility with multiple fracture diagnoses, including displaced fractures of her second and third metatarsal bones in her right foot and a history of falling. Between September and November 2025, she hit the floor four separate times.
Her first fall happened on September 14 in the bathroom. The nurse's notes described finding her "on the floor next to the toilet" after she tried transferring from her wheelchair without calling for help. "When transferring from wheelchair to toilet she started to wet herself causing her feet to become slippery," the notes stated.
Three days later, staff found her sitting on the floor beside her bed at 12:30 a.m. This time she had "noticeable swelling & bruising to the left cheek bone area" and rated her pain at 6 out of 10. Nurses gave her Tylenol.
She fell again on October 13 while trying to move electrical cords out of her way. A nursing assistant delivering her supper tray discovered her on the floor. The woman said she had been sitting on her bed and "attempted to get up to wheelchair and move cords out of her way and fell."
Her fourth documented fall occurred November 13 in the bathroom. Staff found her "laying on the floor in front of the toilet" after she tried using the restroom alone. She told nurses she "lost her balance and fell" while pulling up her pants.
Despite four falls in eight weeks, administrators never revised her care plan to address the obvious safety risks.
Another resident experienced similar neglect after falling from a wheelchair. Resident #2 fell forward out of her wheelchair on November 26, but her care plan remained unchanged when federal inspectors arrived three weeks later.
When inspectors questioned staff about the missing safety updates, both the Director of Nursing and another supervisor confirmed the violations. S4STAFF, interviewed on December 19, reviewed both residents' records and "confirmed it was not revised to reflect" any of the documented falls that had occurred before the inspection began.
The Director of Nursing gave identical confirmation during his interview the same day. He acknowledged that Resident #3's care plan should have been updated after her September, October, and November falls, and that Resident #2's plan should have reflected her November wheelchair incident.
Care plan updates serve as the primary mechanism for preventing repeat falls in nursing homes. When residents experience falls, federal regulations require facilities to analyze the circumstances and implement specific interventions tailored to each person's risk factors and physical limitations.
For Resident #3, whose medical history already included foot fractures and neuropathy, the repeated bathroom falls suggested clear patterns that safety planning should have addressed. Her first fall involved slippery conditions during toilet transfers. Her final fall occurred while she attempted to dress herself unassisted after using the bathroom.
The facility's own incident reports documented each fall with specific details about timing, location, and circumstances. Staff recorded that Resident #3 consistently attempted activities without calling for assistance, despite her documented fall history and lower extremity fractures.
Resident #2's wheelchair fall presented different safety concerns that also went unaddressed in care planning. The incident occurred more than three weeks before inspectors arrived, providing ample time for staff to assess her needs and implement preventive measures.
The violations affected multiple residents over several months, indicating systemic problems with the facility's approach to fall prevention and care plan management. Federal inspectors classified the deficiency as causing minimal harm with potential for actual harm to some residents.
Both residents' cases demonstrate how administrative failures can compound physical vulnerabilities. Resident #3's combination of foot fractures, neuropathy, and documented fall history created obvious red flags that repeated incidents should have triggered immediate care plan revisions and enhanced safety protocols.
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.