The Lodge at Tangi Pines

In the surveyor’s words

From the most serious findings on record at The Lodge at Tangi Pines, in the surveyor’s own words.

• Actual harm, patternF602Apr 30, 2025

  Based 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. […]

• Actual harm, patternF600Mar 20, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2025

  Based 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. Findings: Review of the facility's undated policy titled, Food Receiving and Storage revealed the following, in part: Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation: All foods stored in the refrigerator or freezer will be covered, labeled, and dated. […]

• No harm, potential for more than minimal, patternF656Aug 12, 2026

  Based on record reviews and interviews, the provider failed to develop a comprehensive person-centered care plan for each resident in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (#1, #2, and #4) of 4 sampled residents reviewed. Findings: Resident #1Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE], with diagnoses which included Dementia and Bipolar Disorder. Review of Resident #1's MDS with an ARD of 07/14/2026 revealed the resident had a BIMS of 8, which indicated she was moderately cognitively impaired. Review of Resident #1's current Care Plan revealed the following, in part: Problem: alteration in behavior related to delusions, hallucinations. […]

• No harm, potential for more than minimal, patternF812Apr 15, 2026

  Based 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. […]