Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lagrange Trails Of Journey Llc during CMS and state inspections, most recent first.
Improper Glucometer Disinfection Between Resident Uses: An LPN used one shared glucometer for three residents and cleaned only the strip insertion area with an alcohol swab after each blood glucose check instead of disinfecting the entire device with approved sanitizing wipes. The LPN stated she could not locate disinfecting wipes, while the DON confirmed the facility expected glucometers to be disinfected between resident uses with approved wipes and air-dried per protocol.
Medication administration errors resulted in a 10% error rate during observation. An LPN gave a resident Calcium 600 + D instead of the ordered calcium carbonate, withheld ordered antihypertensives without physician hold parameters based on nursing judgment, and administered Tresiba without properly priming the insulin pen or holding it in place long enough, with leakage noted at the injection site.
Staff did not ensure privacy for two residents with indwelling urinary catheters, as their catheter drainage bags were observed without required privacy covers, leaving urine visible to others. Both residents had little to no cognitive impairment and required catheter care per facility policy, which mandates privacy bags at all times. Staff interviews confirmed awareness of the policy and the expectation for privacy covers.
Staff did not ensure resident bathrooms were kept clean and sanitary, as evidenced by the presence of brown substances, soiled items, and strong odors of urine and feces in multiple restrooms. Housekeeping and CNA staff had unclear responsibilities for cleaning bodily fluids, resulting in unsanitary conditions despite facility policy requirements.
A resident was transferred to a hospital without receiving the required written bed hold notice, as confirmed by both an LPN and the DON. Facility policy mandates that this information be provided at the time of transfer, but no documentation was found in the resident's records to show compliance.
A resident with a history of urinary tract infection and heart failure had an indwelling urinary catheter placed following a verbal physician order, but the order was not transcribed into the electronic medical record as required by facility policy. Observations confirmed the catheter was in use, and an LPN acknowledged the omission. The DON stated that staff are expected to document and transcribe physician orders directly into the electronic health record.
A resident with chronic respiratory conditions did not receive oxygen therapy at the prescribed flow rate, as the concentrator was set below the ordered amount. Additionally, the resident's nebulizer mask was left unbagged and not changed per facility policy, exposing it to the environment. The DON and Regional Nurse Consultant confirmed these deficiencies.
Three residents did not receive multiple doses of their physician-ordered medications due to pharmacy order rejections, billing issues, and communication problems between facility staff and the pharmacy. Missed doses were documented in the MAR, and staff interviews confirmed delays and difficulties in obtaining medications, with some instances lacking proper documentation for the missed administrations.
Three medication errors occurred out of 30 opportunities when two residents did not receive scheduled doses of amlodipine, atorvastatin, and Tiadylt ER because the medications were unavailable at the time of administration. The CMT notified the LPN about the missing medications, and the DON later stated that staff should use the emergency supply if medications are not on the cart. This resulted in a medication error rate of 10 percent.
Improper Glucometer Disinfection Between Resident Uses
Penalty
Summary
Staff failed to follow the facility’s glucometer disinfection policy during blood glucose monitoring for three sampled residents. On 05/12/2026, an LPN used the same shared glucometer for R4, R2, and R3 on Hall 300 (East Wing). After each blood glucose check, the nurse cleaned only the strip insertion area of the glucometer with an alcohol swab rather than disinfecting the entire device as required by facility policy. During interview, the LPN stated that proper protocol required disinfecting the glucometer with approved sanitizing wipes between each resident use and allowing appropriate drying/contact time, but she could not locate disinfecting wipes in the medication room or on medication carts and said she had not been informed that alcohol wipes could be used instead. The DON later confirmed that glucometers were expected to be disinfected between resident use with approved sanitizing wipes and allowed to air dry according to facility protocol, that alcohol wipes were not appropriate for glucometer disinfection, and that sanitizing wipes were available in the facility.
Medication Administration Errors With Incorrect Drug, Withheld Antihypertensives, and Improper Insulin Pen Technique
Penalty
Summary
Medication administration errors occurred during observation of 4 of 40 medication opportunities, resulting in a 10 percent medication error rate for two residents. During one observation, an LPN administered Calcium 600 + D 10 mcg to a resident who had a physician order for Calcium 600 (calcium carbonate) 600 mg daily, which did not match the ordered medication. During another observation, an LPN obtained a resident’s blood pressure of 125/63 and heart rate of 101, then withheld both ordered antihypertensive medications, Amlodipine Besylate 5 mg daily and Losartan Potassium 50 mg daily, stating the blood pressure was too low despite no physician-ordered hold parameters. The same resident also had an order for Tresiba (insulin degludec) 100 units/mL, inject 30 units subcutaneously daily for diabetes mellitus. The LPN dialed the ordered dose but did not prime the insulin pen before administration. The pen was removed about two seconds after the final click, and medication leakage was observed at the injection site on the right upper arm. The nurse wiped the leakage with the resident’s shirt sleeve. During interview, the LPN stated she believed dialing the prescribed dose constituted priming the pen and gave inconsistent responses about how long the pen remained in place after injection. On follow-up, she stated she withheld the antihypertensive medications based on nursing judgment because the resident’s diastolic blood pressure was 63 and she believed the resident’s blood pressure was typically low at baseline. The DON stated staff were expected to administer medications according to active physician orders, follow ordered parameters, clarify missing parameters with the provider before withholding medications, and use proper insulin pen technique including priming and holding the injection in place for the required time.
Failure to Maintain Privacy for Residents with Indwelling Urinary Catheters
Penalty
Summary
Staff failed to maintain privacy for two residents with indwelling urinary catheters, as required by facility policy. For one resident with diagnoses including urinary tract infection and depression, observations showed the urinary catheter drainage bag was attached to the wheelchair without a privacy cover, leaving the urine visible to others. On a separate occasion, the same resident had a privacy bag covering only the drainage tubing, not the drainage bag itself. The resident required assistance for all activities of daily living and had little to no cognitive impairment. Another resident, with diagnoses including urinary tract infection and urethral stricture, was observed lying in bed with a urinary catheter drainage bag secured to the bed railing without a privacy cover. This resident also had little to no cognitive impairment and an indwelling urinary catheter. Staff interviews confirmed that all residents with urinary catheter drainage bags should have privacy covers, and that the facility policy requires privacy bags to be used at all times when catheters are in use.
Failure to Maintain Clean and Sanitary Resident Bathrooms
Penalty
Summary
Staff failed to maintain resident bathrooms in a clean and sanitary condition in three of seven observed restrooms. Observations revealed the presence of brown substances on handrails, toilet seats, and over-toilet seat handles, as well as soiled pads and washcloths with fecal odor left in the bathrooms. Strong odors of urine and feces were noted in all three bathrooms, and photographic evidence was obtained to document these findings. The facility's policy on routine bathroom cleaning requires removal of soiled linen, cleaning of wall attachments, support railings, and thorough disinfection of toilets, but these procedures were not followed as evidenced by the observed conditions. Interviews with housekeeping staff and the environmental supervisor indicated that housekeeping was responsible for general cleaning and disinfection, while CNAs were tasked with cleaning up bodily fluids. However, the division of responsibilities led to confusion and incomplete cleaning, resulting in unsanitary conditions. The administrator confirmed the expectation for clean resident rooms and bathrooms, with nursing staff responsible for bodily fluid cleanup and housekeeping for disinfection, but the observed deficiencies showed this process was not effectively implemented.
Failure to Provide Bed Hold Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written bed hold information to a resident and/or their representative at the time of transfer to a hospital, as required by both facility policy and regulatory standards. The policy specifies that written information regarding bed hold practices must be given both at admission and at the time of transfer for hospitalization or therapeutic leave. In the case reviewed, a resident was transferred to a short-term general hospital with return anticipated, but there was no documentation in either the electronic medical record or paper chart that the bed hold notice was provided at the time of transfer. Interviews with staff confirmed that the bed hold policy notice was not completed or given to the resident or their representative at the time of the hospital transfer. The LPN stated that nurses were responsible for this task but acknowledged it was not done for this resident. The DON also confirmed the omission, noting that the bed hold policy was not completed for the resident at the time of transfer. This lapse was consistent with the facility's practice prior to a recent change in procedure.
Failure to Transcribe Physician Order for Indwelling Urinary Catheter
Penalty
Summary
A deficiency occurred when staff failed to transcribe a physician's verbal order for an indwelling urinary catheter into the electronic medical record for one resident. The facility's policy requires that indwelling urinary catheters be used only when clinically necessary and that all such use be in accordance with physician orders, including documentation of the diagnosis, catheter size, and frequency of change. Despite this, review of the resident's order summary report showed no order for the catheter, even though a progress note documented a verbal order and the catheter was placed. Observations on two separate days confirmed the resident had an indwelling urinary catheter in place. The resident, who was admitted with diagnoses including urinary tract infection and congestive heart failure, reported the catheter was used to monitor urinary output due to fluid retention and heart failure. During interviews, an LPN confirmed that although a verbal order was received, it was not transcribed into the physician's orders, and the DON stated that staff are expected to document and transcribe such orders directly into the electronic health record.
Failure to Administer Oxygen Therapy per Physician Order and Maintain Sanitary Respiratory Equipment
Penalty
Summary
Staff failed to administer oxygen therapy according to the physician's order and did not maintain respiratory equipment in a sanitary manner for one resident. The resident, who had diagnoses including chronic obstructive pulmonary disease (COPD), chronic respiratory failure, unspecified chronic bronchitis, and hypoxemia with dependence on supplemental oxygen, had a physician's order for oxygen at two liters per minute (LPM) via nasal cannula continuously. However, observations revealed that the oxygen concentrator was set between one and one and a half LPM, which did not match the physician's order. Additionally, a nebulizer mask used by the resident was found hanging unbagged and exposed to the environment, with a date indicating it had not been changed in accordance with facility policy. The facility's policy required that nebulizer tubing and delivery devices be changed every 72 hours or as needed if soiled, and that delivery devices be kept covered in a plastic bag when not in use. Interviews with the DON and Regional Nurse Consultant confirmed these findings.
Failure to Obtain and Administer Physician-Ordered Medications as Prescribed
Penalty
Summary
The facility failed to ensure that physician-ordered medications were obtained from the pharmacy and administered at the designated times for three residents. For one resident with diagnoses including hypertension and hyperlipidemia, there were multiple documented instances where prescribed medications such as amlodipine besylate and atorvastatin calcium were not administered as ordered. The medication administration record (MAR) indicated missed doses, with pharmacy alerts showing that orders would not be filled due to rejection, requiring resubmission at a later date. Staff interviews confirmed that the medications were not available and that communication regarding missing medications was relayed to nursing staff. Another resident with chronic diastolic heart failure, Parkinsonism, and other conditions did not receive several doses of critical medications, including Sinemet, amiodarone hydrochloride, and apixaban, as ordered by the physician. The MAR showed missed doses without documented reasons or with codes indicating the need to see nurse notes. Pharmacy alerts indicated that some medication orders were rejected and not filled. Interviews with the DON and Corporate Nurse Consultant revealed that the process for reordering medications involved using the MAR, and if medications were unavailable, staff were expected to use emergency supplies or contact the pharmacy. A third resident with hypertension did not receive several doses of Tiadylt ER as ordered. The MAR reflected missed doses, some without documentation and others marked with a code for further explanation. Pharmacy staff indicated that a new order was required and that a billing issue delayed delivery. Additional interviews with facility staff and pharmacy personnel highlighted ongoing problems with the pharmacy reordering process and communication issues, resulting in delays in medication delivery and administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by three medication errors out of 30 opportunities observed for two residents. For one resident, physician orders indicated daily administration of amlodipine besylate and atorvastatin calcium, both scheduled for the morning. On the day of observation, these medications were unavailable for administration, and the Certified Medication Technician (CMT) reported the issue to the Licensed Practical Nurse (LPN), who was to locate or order the medications from the pharmacy. The CMT confirmed that the amlodipine had been ordered previously. For another resident, physician orders required daily administration of Tiadylt ER 24-hour oral 180 mg capsule, also scheduled for the morning. During observation, this medication was not available for administration and was not present in the emergency medication stock. The CMT confirmed the unavailability, and later, the Director of Nursing (DON) and Corporate Nurse stated that staff should obtain medications from the emergency supply if not available on the cart. These events resulted in a medication error rate of 10 percent, exceeding the acceptable threshold.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lagrange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peachtree Nursing And Rehabilitation Llc | 1.1 mi | ★★★★★ | 10 | 0 |
| Green Acres Care Center Llc | 5.1 mi | ★★★★★ | 13 | 0 |
| Diversicare Of Lanett | 13.6 mi | ★★★★★ | 0 | 0 |
| Eamc Lanier Nursing Home | 14.8 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Franklin | 17.2 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.