The Lodge At Tangi Pines

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

and fell forward out of wheelchair. Review of Resident #2's Care Plan revealed it was not revised to include interventions to address Resident #2's fall on 11/26/2025. On 12/19/2025 at 10:35 a.m., an interview was conducted with S4STAFF. She reviewed and confirmed Resident #2 had a fall on 11/26/2025. S4STAFF reviewed Resident #2's care plan and confirmed it was not revised to reflect Resident #2 fall which occurred on 11/26/2025 prior to the survey team entry on 12/17/2025 and should have been. On 12/19/2025 at 11:37 a.m., an interview was conducted with S1DON. He reviewed Resident #2's care plan and confirmed it was not revised to reflect Resident #2's falls on 11/26/2025 prior to the survey team entry and should have been. Resident #3Review of Resident #3's Clinical Record revealed she was admitted to

the facility on [DATE REDACTED], with diagnoses which included Fractures and Other Multiple Fractures, Right Foot Fracture, History of Falling, Hereditary and Idiopathic Neuropathy, Displaced Fracture of 2nd Metatarsal Bone, Right Foot and Displaced Fracture of 3rd Metatarsal Bone, Right Foot. Review of the facility's Incident Report revealed Resident #3 had an unwitnessed falls on the 09/14/2025, 09/17/2025, 10/13/2025, and 11/13/2025.Review of Resident #3's Nurse's Note revealed the following:09/14/2025 at 3:21 p.m. -The CNA called me, the nurse, to resident's room because resident was on the floor in bathroom. Upon entering

the room resident noted to be in the bathroom on the floor next to the toilet. Resident reports she needed to use the toilet and did not call for assistance. When transferring from wheelchair to toilet she started to wet herself causing her feet to become slippery. 09/17/2025 at 12:55 a.m.-Upon entering the room at approximately 00:30, resident was seen sitting on the floor beside her bed. Resident has noticeable swelling & bruising to the left cheek bone area. PRN Tylenol 650 MG administered for pain rated 6/10 by resident. Resident denies any other pain or discomfort.10/13/2025 at 6:47 p.m.- The nurse was called to the resident room. CNA was entering room to deliver supper tray and found resident on floor. Resident states

she was sitting on bed and attempted to get up to wheelchair and move cords out of her way and fell. She denies hitting her head or any injuries. 11/13/2025 at 1:30 p.m.- The nurse was called to resident's bathroom and upon entering resident was noted to be laying on the floor in front of the toilet. Resident #3 reports going to the restroom unassisted and when resident stood to pull pants up she lost her balance and fell. Review of Resident #3's Care Plan revealed it was not revised to include interventions to address Resident #3's fall on 09/14/2025, 09/17/2025, 10/13/2025 and 11/13/2025. On 12/19/2025 at 10:35 a.m., an

interview was conducted with S4STAFF. She reviewed and confirmed Resident #3 had a fall on 09/14/2025, 09/17/2025, 10/13/2025 and11/13/2025. S4STAFF reviewed Resident #3's care plan and confirmed it was not revised to reflect Resident #3's fall which occurred on 09/14/2025, 09/17/2025, 10/13/2025 and 11/13/2025 prior to the survey team entry on 12/17/2025 and should have been. On 12/19/2025 at 11:37 a.m., an interview was conducted with S1DON. He reviewed Resident #3's care plan and confirmed it was not revised to reflect Resident #3's falls which occurred on 09/14/2025, 09/17/2025, 10/13/2025 and 11/13/2025 prior to the survey team entry and should have been.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Lodge at Tangi Pines

10746 Hwy 16 Amite, LA 70422

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings: Review of

the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses which included Repeated Falls, Progressive Neurological Condition, and Parkinson's Disease with Dyskinesia. Review of the most recent MDS with an ARD of 10/07/2025 revealed Resident #1 had a BIMS of 3, which indicated severe cognitive impairment. Review of the most current Care Plan revealed the following:Problem: Potential for falls related to history of falls, decreased mobility, medication effects, confusion, poor safety awareness and impaired mobility. On 05/22/2024 Resident #1 slid off her bed and had a fall.Intervention: 05/22/2024: Resident given non-skid socks instead of wearing regular socks. On 12/17/2025 at 11:10 a.m., an observation was made of Resident #1 awake, sitting up in a wheelchair. An

observation was made of white socks on Resident #1's feet without non-skid bottoms. On 12/17/2025 at 11:11 a.m., an interview was conducted with S2STAFF. She stated Resident #1 was a fall risk. She observed and confirmed Resident #1 was not wearing non-skid socks. On 12/17/2025 at 11:25 a.m., an

interview was conducted with S3STAFF. She stated Resident #1 was a fall risk. She stated an intervention used to prevent falls for Resident #1 was to place non-skid socks on the resident. On 12/17/2025 at 11:29 a.m., an observation and interview was conducted with S3STAFF. She observed and confirmed Resident #1 was not wearing non-skid socks and should have been. On 12/17/2025 at 12:00 p.m., an interview was conducted with Resident #1's Representative. She stated she visited Resident #1 once or twice a week.

She Resident #1 had a history of falls. She stated Resident #1 does not wear non-skid socks. On 12/17/2025 at 2:50 p.m., an interview was conducted with S1DON. He stated he expected all staff to follow

a resident's care plan and implement fall interventions to prevent further falls. He reviewed Resident #1's care plan and confirmed Resident #1 had a fall intervention to place non-skid socks.

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