Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Grove Of Lagrange Park, The during CMS and state inspections, most recent first.
A resident with dementia, altered mental status, psychotic and mood disturbances, anxiety, incontinence, and a history of repeated falls was care planned as high risk for falls with bed and chair alarms, a non-skid pad, and activity-based diversion. Despite this, the resident, described by staff as impulsive, constantly self-propelling, wandering, and with almost no safety awareness, experienced multiple unwitnessed and inadequately supervised falls. In one event, the resident rose quickly from a dining chair and fell before staff could intervene, sustaining a nasal fracture. In another, the resident fell in her room while a CNA briefly left to obtain incontinence supplies; the bed alarm sounded at the nurse’s station, but staff were occupied and the room was not visible from the station, and the resident sustained a wrist fracture and facial swelling. Staff reported that the resident did not use the call light and that monitoring relied on periodic rounding, while facility policy called for routine checks at least every two hours and as needed based on individual needs.
A resident with end-stage liver disease and multiple related diagnoses had a significantly low BP documented during the day, but the RN on duty did not notify the physician or recheck vital signs during the following shift. The resident also refused HS medications, and this refusal was not reported to the physician. Later that night, another RN found the resident lethargic and in respiratory distress with very low BP and low SpO2, initiated O2, and sent the resident to the hospital via 911. The physician and ADON stated that such low BP readings and medication refusals should have been reported, and facility policy requires immediate physician consultation for significant changes in condition.
Several residents with incontinence and complex medical needs were not provided timely or adequate incontinence care, resulting in prolonged periods of being left soiled, foul odors, and soiled linens. Staff interviews and observations confirmed that required rounds and hygiene assistance were not consistently performed according to facility policy, which mandates checks and changes at least every two hours and before and after meals.
Two residents at high risk for falls were not provided with adequate supervision or proper use of assistive equipment as outlined in their care plans. In one case, a male resident was transferred without the required use of a gait belt, leading to a fall and injury. In another case, a female resident with cognitive impairment and an unsteady gait was not assisted with her walker, resulting in an unwitnessed fall and arm fracture. Staff interviews confirmed lapses in following facility policy and care plan interventions.
The facility failed to provide adequate nail care for two residents who were unable to perform this task themselves. One resident, with a history of hemiplegia, had long and dirty fingernails despite expressing a desire for them to be cut. Another resident had long and dirty fingernails and toenails, even after a request for care was made by his power of attorney. Staff interviews revealed inconsistencies in the execution and documentation of nail care, contrary to the facility's policy.
The facility failed to maintain proper sanitation levels in the dishwashing process and did not ensure cold foods were stored according to policy. Dietary aides were found using a dish machine with inadequate sanitizer levels, and a tub of ice cream was improperly stored in the freezer. These issues affected the quality of food service for 114 residents.
The facility failed to assist seven residents with personal hygiene and grooming, despite their medical conditions requiring such help. Observations showed residents with untrimmed nails, overgrown facial hair, and unclean clothing, indicating a lack of staff intervention. Care plans documented the need for extensive assistance, but these interventions were not effectively implemented.
The facility failed to provide adequate perineum and catheter care for four residents, leading to potential risks of urinary tract infections. CNAs did not properly clean the perineal area, including the inner corners and catheter areas, as required by facility policy.
The facility failed to prepare pureed consistency hamburger beef steaks for residents on pureed diets, affecting six residents. A cook initially prepared a granular mixture that required chewing, which was confirmed unsafe by the Regional Director of Operations. The facility's policy requires pureed foods to be homogeneous and pudding-like, which was not initially met.
The facility failed to follow infection control practices during incontinence care and blood glucose monitoring. CNAs did not change gloves or perform hand hygiene between tasks, and a nurse did not sanitize the glucometer between resident uses. These lapses were observed in six residents, contrary to the facility's policies.
A resident with serious mental illness was not re-evaluated for a PASARR II screening within the required timeframe, despite being overdue by seven weeks. The resident was admitted with bipolar disorder and major depressive disorder, and the initial PASARR Level I screening allowed a 60-day stay. The facility's policy required timely re-screening, which was not followed, as confirmed by the administrator and admissions director.
The facility failed to supervise a resident with dysphagia during meals, leading to coughing incidents without staff intervention. Additionally, a CNA did not use a gait belt when assisting another resident with transfers, despite the resident's history of falls and facility policy requiring gait belts for safety. The DON confirmed the need for supervision and gait belt use, as outlined in the facility's policy.
Failure to Adequately Supervise High-Risk Resident Leading to Multiple Falls and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free from accident hazards for a resident at high risk for falls. The resident was an older adult with dementia, altered mental status, psychotic and mood disturbances, anxiety, mixed incontinence, vitamin D deficiency, and a documented history of repeated falls. The care plan identified the resident as high risk for falls and included interventions such as use of a bed alarm when in bed, a chair alarm when in a wheelchair, a non-skid pad to minimize sliding from the chair, and encouraging participation in daily activities to provide diversion and reduce fall potential. Despite these identified risks and interventions, the resident experienced multiple falls. On one occasion, while staff were present in common areas, the resident stood up too quickly from a chair in the dining room and fell before staff could reach her, resulting in a nasal bone fracture. The incident report documented that the resident had been self-propelling around the unit and later had an unwitnessed fall after getting up from her wheelchair and losing balance, and she was found on the floor in front of the wheelchair with a nosebleed. Staff, including the DON and RNs, described the resident as very impulsive, constantly self-propelling and wandering, with almost no safety awareness, and noted that staff were expected to redirect her and keep track of her whereabouts. On another date, the resident had an unwitnessed fall in her room at the foot of her bed, resulting in a left wrist fracture and swelling around her left eye. A CNA reported that the resident was in bed after breakfast while the CNA briefly left the room, for less than a minute, to obtain incontinence supplies; during that time, the resident got out of bed and fell. The bed alarm sounded at the nurse’s station, but other aides were assisting residents and the RN at the station was on the phone, and the resident’s room and bed were not visible from the nurse’s station. Staff interviews confirmed that the resident did not use the call light due to dementia, frequently attempted to stand and walk unassisted, and that monitoring consisted of rounding and looking for the resident if she had not been seen in about 10 minutes. The facility’s policy required routine resident checks at least every two hours and as often as needed based on individual needs, but the post-fall investigation cited the resident’s getting up on her own and poor safety awareness as contributing factors, without addressing the effectiveness of the bed alarm or supervision in preventing the fall.
Failure to Notify Physician and Monitor Resident After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to recognize and respond appropriately to a significant change in condition and to notify the physician as required for a resident with complex medical issues. The resident had diagnoses including alcoholic cirrhosis of the liver with ascites, alcohol abuse, and hepatic encephalopathy. On one afternoon, the resident’s blood pressure was documented at 73/43, which the attending physician later stated was very low and should have been reported. The day/PM shift RN reported that the resident remained in bed, alert but weak, and acknowledged that she did not notify the physician of the low blood pressure, even though the physician had seen the resident earlier that day and the blood pressure was significantly low. The RN also stated that she did not recheck the resident’s vital signs during the PM shift. Later that night, the night shift RN found the resident in bed, lethargic and in respiratory distress, with vital signs showing blood pressure of 69/33 and oxygen saturation of 81%. The nurse initiated oxygen at 4 L/min via nasal cannula, after which the oxygen saturation increased to the mid-90s, and 911 was called to send the resident to the hospital. The resident was noted to be a full code. The day/PM shift RN also reported that the resident refused bedtime medications and that she did not notify the physician of this refusal. The physician and the Assistant DON both stated that significant changes, such as low blood pressure and refusal of medications, should be relayed to the physician, and facility policy on notification for change of condition requires immediate consultation with the physician when there is a significant change in the resident’s status.
Failure to Provide Timely Incontinence Care and Hygiene Assistance
Penalty
Summary
The facility failed to provide timely and adequate incontinence care and hygiene assistance to four residents, as evidenced by direct observations, interviews, and record reviews. One male resident with multiple diagnoses, including dementia, diabetes, and mobility impairments, was reported by a family member to have been left soiled for prolonged periods, with feces on his arms, hands, and under his fingernails. The family member stated that staff did not promptly provide hygiene assistance, and the incident was not documented in the facility's grievance records. Another male resident, cognitively intact and at risk for skin integrity impairment due to incontinence, was found in bed with soiled linens and a foul odor present in the room. The resident reported not being changed since the previous night, and staff confirmed that rounds had not been completed during the morning shift. Soiled linens and briefs were observed in the room, and staff indicated that rounds are sometimes delayed if other duties, such as showers, take priority. A female resident with a history of falls, malnutrition, and incontinence reported waiting approximately six hours to be changed after being soiled with feces, despite informing her assigned CNA. She was ultimately changed by the evening shift. Another female resident, also at risk for skin impairment, was found with a saturated brief containing urine and feces, and staff confirmed she had not been checked or changed prior to meals. Facility policy requires residents to be checked and changed at least every two hours and before and after meals, but this standard was not met for the residents reviewed.
Failure to Implement Fall Prevention Interventions and Proper Use of Equipment
Penalty
Summary
The facility failed to follow established interventions and policies to prevent falls and ensure the safe use of equipment for two residents identified as high risk for falls. In the first case, a male resident with multiple diagnoses including bilateral osteoarthritis, dementia, gait abnormalities, and a history of repeated falls required extensive assistance for mobility and transfers. During a transfer from wheelchair to toilet, the certified nursing assistant (CNA) did not use the gait belt as required, instead placing it around her own waist rather than the resident's. This improper use of equipment led to the resident losing balance and sliding to the floor, resulting in pain and a subsequent injury. Staff interviews confirmed that the gait belt was not used according to facility policy, and the CNA admitted to not applying the belt to the resident as trained. In the second case, a female resident with dementia, gait abnormalities, and a history of falls was care planned to use a walker and receive assistance with ambulation. Despite this, she experienced an unwitnessed fall while sitting in a chair, which resulted in a left arm fracture. Interviews with staff and the resident's family revealed that the walker, although present in her room, was not being used, and staff were not consistently assisting or cueing her to use it. The resident was known to have an unsteady gait, poor safety awareness, and cognitive impairment, yet was observed to get up unassisted and walk without the prescribed walker. Staff were unaware of the walker being part of her care plan, and the assistant director of nursing confirmed the resident did not have a walker at the time of the fall. Both incidents demonstrate a failure to implement and follow individualized fall prevention interventions as outlined in the residents' care plans and facility policy. The lack of proper supervision, failure to use assistive devices as required, and inadequate staff adherence to transfer protocols directly contributed to the residents' falls and resulting injuries. These deficiencies were identified through observations, interviews, and record reviews conducted by surveyors.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, R2 and R3, who were unable to perform this activity of daily living themselves. R2, who had a history of hemiplegia and other medical conditions, was observed with long and dirty fingernails. Despite expressing a desire for her nails to be cut, R2's care plan, which required staff to check and trim nails on bath days, was not followed. The Director of Nursing and staff indicated that nail care is typically performed during showers, but there was no documentation to confirm that this care was provided. Similarly, R3 was found with long and dirty fingernails and toenails, despite his power of attorney having requested nail care from the facility staff days prior. R3's care plan also specified that nail care should be performed on bath days. Staff interviews revealed inconsistencies in the execution and documentation of nail care, with some staff stating that nail care is done during showers and others noting that it is not consistently documented. The facility's nail care policy outlines the importance of regular nail maintenance to prevent infections, yet this was not adhered to for R3.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain proper sanitation levels in the dishwashing process and did not ensure that cold foods were stored according to facility policy guidelines. During an observation, a dietary aide was found washing dishes with a low-temperature dish machine that lacked adequate sanitizer levels. The sanitizer test strip remained white, indicating no chlorine presence, due to the sanitizer container being nearly empty. The dietary aide admitted to testing the sanitizer only before starting the dishwashing process and not in between, as per the facility's log. Another dietary aide also faced a similar issue with the dish machine, where the chlorine was not dispensing properly, and the test strip showed no chlorine presence until the regional director intervened. Additionally, the facility did not adhere to its food storage policy. In the reach-in freezer, spills of unknown substances were observed, and a tub of strawberry-flavored ice cream was found with a broken lid, not properly closed. The regional director acknowledged that the ice cream should have been stored correctly. These deficiencies affected the quality of food service provided to 114 residents who receive meals prepared in the facility kitchen.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene and grooming for seven residents who were identified as needing help with activities of daily living (ADLs). These residents had various medical conditions, including hemiplegia, dementia, and cerebral infarction, which impaired their ability to perform self-care tasks. Observations revealed that these residents had untrimmed and dirty fingernails, overgrown facial hair, and unclean clothing, indicating a lack of staff intervention in maintaining their personal hygiene. For instance, one resident with hemiplegia was unable to open or extend the fingers on her left hand and had long, jagged fingernails with black substances underneath. Despite expressing a desire for assistance, her nails remained untrimmed over consecutive days. Another resident with dementia was observed with long, curling chin hair and expressed a need for shaving, yet no assistance was provided. Similar issues were noted with other residents, who had long facial hair and dirty fingernails, and they all expressed a need for staff assistance, which was not provided. The Director of Nursing and other staff members acknowledged the residents' needs for assistance with personal hygiene, as documented in their care plans. These plans indicated that the residents required extensive or maximum assistance with personal hygiene, yet the facility failed to implement these interventions effectively. This lack of action resulted in the residents' personal hygiene needs being unmet, as observed during the survey.
Inadequate Perineal and Catheter Care
Penalty
Summary
The facility failed to provide adequate perineum and indwelling urinary catheter care to prevent urinary tract infections for four residents. On September 4, 2024, a resident with an indwelling urinary catheter did not receive proper cleaning as the CNA did not separate the labia to clean the inner corners and the catheter area. Another resident, heavily saturated with urine and with a strong odor, was not cleaned properly as the CNA used an up and down stroke on the outer labia without opening the labia to clean the inner corners, urethra, and inner groins. Additionally, another resident was not cleaned properly as the CNA used an upward stroke on the outer labia without separating the labia to clean the inner corners and inner groins. On September 5, 2024, a resident with a suprapubic catheter and redness on the perineum was not cleaned thoroughly as the CNA failed to clean the left side of the abdominal fold, penis, scrotum, and inner folds of the groins. The Assistant Director of Nursing confirmed that the staff must clean the full perineum, including the folds of the genitals, pubic area, abdomen, and groins, to prevent infection.
Failure to Prepare Proper Pureed Diets
Penalty
Summary
The facility failed to prepare pureed consistency hamburger beef steaks for residents on pureed diets, affecting six residents. During an observation of meal preparation, a cook was seen blending cooked hamburger beef steaks with beef broth, resulting in a granular mixture that required chewing. The Regional Director of Operations confirmed the granular consistency was unsafe and instructed the cook to blend the mixture again with additional fluid, achieving a smooth consistency. The facility's policy for pureed diets specifies that food should be homogeneous, cohesive, and pudding-like, with no coarse textures, which was not initially met in this instance. The diet order report confirmed that the affected residents were on pureed consistency diets.
Infection Control Lapses in Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to adhere to standard infection control practices during incontinence and catheter care, as well as during blood glucose monitoring. Certified Nursing Assistants (CNAs) V4, V5, and V6 were observed providing incontinence care to residents without changing gloves or performing hand hygiene between tasks. For instance, V4 and V5 did not change gloves or wash hands while assisting a resident with a bowel movement, and V6 touched contaminated surfaces and continued care without proper hand hygiene. Similarly, V19 changed gloves without washing hands and continued to apply barrier cream and clean the resident. Additionally, Nurse V7 failed to sanitize the glucometer machine before and after checking the blood glucose levels of two residents. The glucometer was placed back in the medication cart without being cleaned, contrary to the facility's policy. The Assistant Director of Nursing confirmed that staff are required to perform hand hygiene and sanitize equipment to prevent infection spread, as outlined in the facility's policies. These lapses in infection control practices were observed in six out of twenty-four residents reviewed for infection control.
Failure to Conduct Timely PASARR II Re-evaluation
Penalty
Summary
The facility failed to request a re-evaluation for a PASARR II screening for a resident diagnosed with serious mental illness (SMI) within the required timeframe. The resident, identified as R96, was admitted with diagnoses including bipolar disorder and major depressive disorder. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment, and the care plan noted a self-care performance deficit for activities of daily living (ADLs) due to the resident's mental health conditions. The initial PASARR Level I screening was conducted on May 14, 2024, with a 60-day convalescent care approval, requiring a re-screening by July 15, 2024, if the resident was to remain in the facility beyond this period. However, the re-evaluation was not conducted, making it seven weeks overdue. During the investigation, the facility's administrator, V1, and the admissions director, V14, provided information regarding the PASARR process. V1 indicated that the PASARR I did not suggest the need for a PASARR II, while V14 explained the procedure for reviewing and uploading PASARR reports from an electronic platform. V14 noted that if a resident's stay exceeded the initial 30 or 60-day approval, a PASARR II would be necessary. The facility's policy, revised on August 16, 2024, stated that residents with mental disorders or intellectual disabilities should receive a PASARR screening within the allowed timeframe, which was not adhered to in this case.
Lack of Supervision and Safety Measures for Residents
Penalty
Summary
The facility failed to provide adequate supervision during meal times for a resident with difficulty swallowing, identified as R98. R98, who has severe cognitive impairment and dysphagia, was observed eating without supervision in the dining room and in his room. On one occasion, R98 began coughing while eating, and no staff intervened to check on him. The resident's care plan included aspiration precautions, such as sitting upright and being monitored during meals, which were not followed. The Speech Therapist confirmed that R98 should not eat in a reclining position and requires general aspiration precautions. Another deficiency involved the failure to use a gait belt/transfer belt when assisting a resident, identified as R75, with transfers. R75, who has hemiplegia and dementia, was observed being assisted by a CNA without the use of a gait belt while transferring from a toilet to a wheelchair. The CNA acknowledged not using a gait belt and recognized its importance for safety. R75's medical records indicated a history of falls, and the facility's policy requires the use of gait belts for transfers to prevent accidents. The Director of Nursing confirmed that residents in the dining room should be monitored for choking and that gait belts should always be used during transfers. The facility's policy on gait belts, revised in July 2024, mandates their use for residents needing assistance during transfers and walking. These deficiencies highlight lapses in supervision and adherence to safety protocols, potentially compromising resident safety.
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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 La Grange Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Plymouth Place | 0.4 mi | ★★★★★ | 3 | 0 |
| Meadowbrook Manor - Lagrange | 1.4 mi | ★★★★★ | 4 | 0 |
| Aperion Care Westchester | 1.6 mi | ★★★★★ | 4 | 0 |
| British Home, The | 1.8 mi | ★★★★★ | 0 | 0 |
| Bella Terra Lagrange | 1.8 mi | ★★★★★ | 0 | 0 |
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