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Lodge at Tangi Pines: Care Planning Failures - LA
Her medical record showed displaced fractures of the second and third metatarsal bones in her right foot....
Latest reports, citations, and penalties from CMS data
Her medical record showed displaced fractures of the second and third metatarsal bones in her right foot....
The resident, identified in inspection records only as Resident B, had been diagnosed with right breast cancer that had spread to her brain....
The sequence began when Resident #1 inappropriately touched Resident #2 in the breast area....
The incident occurred September 14 when LPN #2 abandoned Resident #5's medications during her rounds....
The violation was documented during a complaint inspection on December 21, 2025, at Brightmoor Nursing Center, LLC, a nursing home in Griffin, Georgia....
Federal surveyors assigned the violation a scope and severity level of D, indicating an isolated incident with potential for more than minimal harm....
The November incident unfolded during the morning routine when certified nursing aide CNA #1 wheeled Resident #7 to breakfast around 7:50 AM....
Resident #1 fell and fractured their left clavicle on August 22, 2025....
Hospital discharge orders were clear....
The resident, identified as R1 in inspection records, was recovering from a right femur fracture when the breathing problems began on November 23....
Resident 100 had been living at the facility since February with a Foley catheter that required enhanced barrier precautions under his care plan....
The documentation gap emerged when inspectors reviewed the medical record of Resident 9, who developed an open area on her coccyx....
The sequence began on December 16, 2025....
She was hospitalized the next day with diabetic ketoacidosis, acute kidney injury, encephalopathy, altered mental status, and dehydration....
Yet the facility's Minimum Data Set assessment recorded the same resident as simply "dependent" for bed mobility....
The January 8, 2026 inspection identified a violation categorized as isolated with potential for more than minimal harm, though no actual harm was documented....
She told the inspector she had been hit in the forehead by the weight mechanism of a Hoyer lift while being transferred....
These include antipsychotics, antidepressants, anti-anxiety medications, and mood stabilizers....
The CNA, identified in inspection records as CNA D, had been accused of abusing a resident during a whirlpool bath....
The discharge happened at 7:30 PM, according to the facility's own Discharge Summary....