Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Life Care Center Of Lagrange during CMS and state inspections, most recent first.
Two residents were not afforded adequate privacy and dignity, including one instance where an LPN administered an abdominal injection with the resident’s shirt lifted and the room door open, allowing others in the hallway to see the exposed abdomen, despite facility policy requiring privacy measures during medication administration. Another resident with severe physical and cognitive impairments, totally dependent on staff for dressing, was repeatedly observed in bed visible from the hallway without proper clothing and with the door open and privacy curtain not used, while leadership could not provide documentation or clear rationale for the lack of clothing despite a resident rights policy requiring dignified care.
A resident with gout, bilateral leg pain, depression, PTSD, and dysphagia, and a BIMS score indicating intact cognition, was given a 500 mg acetaminophen tablet and water by an LPN, who then left the room without observing the medication being taken. The resident’s physician order required scheduled administration of acetaminophen for pain but did not authorize self-administration, and record review showed no completed Self-Administration of Medication assessment. Facility policy and the DON’s statements required staff to observe all medication consumption and allowed self-administration only with an appropriate assessment or specific order, but these requirements were not followed, resulting in a deficiency under 410 IAC 3.1-11(a).
Surveyors found that the facility failed to properly notify emergency contacts about the bed-hold policy for two residents who were transferred to the hospital. One cognitively intact resident with chronic kidney disease, diabetes, and a seizure disorder signed a bed-hold notification declining to hold the bed, but the resident’s emergency contact, who was also the durable power of attorney, was not notified when the resident became unresponsive and was sent to the hospital. Another resident with severe cognitive impairment, atrial fibrillation, lumbar fracture, wound dehiscence, and malnutrition was transferred to the hospital, and although the bed-hold policy was sent with EMTs and the emergency contact was informed of the transfer, there was no documentation that the emergency contact was informed of the bed-hold policy, even though the resident signed a form declining bed hold. No written facility policy on bed-hold notification was available for review.
A facility failed to provide necessary oral hygiene for a resident entirely dependent on staff for care. The resident, with severe cognitive impairment and multiple diagnoses, was observed with a dry, coated tongue and dry, caked lips. Despite the care plan and facility policy requiring oral care every 2 to 4 hours, the resident did not receive adequate oral hygiene, as confirmed by an RN.
A facility failed to maintain proper tube feeding for a resident with cerebral palsy and other conditions. The resident's tube feeding supplies were not changed daily as required, with containers dated two days prior. A nurse confirmed the supplies should be changed every 24 hours, per facility policy.
A resident with multiple diagnoses, including diabetes and chronic kidney disease, was administered antibiotics for a UTI without a supporting urinalysis, indicating a medication error. The facility's policy required staff to follow incident policy and performance improvement processes, but the Administrator was unaware of the error.
The facility failed to develop quality improvement plans for recurrent environmental concerns identified in annual surveys. Despite ongoing discussions in QAPI meetings, no formal performance improvement plan was in place, leading to repeated issues with the repair and maintenance of facility floors, walls, and handrails.
The facility failed to ensure a sanitary environment free of hazards on four halls where residents resided or received services. Observations revealed missing finish on handrails, missing baseboards, chipped drywall, and buckled flooring. The Maintenance Director and Executive Director acknowledged the issues but indicated no current plans for repairs.
The facility failed to post daily nurse staffing hours for 3 of 4 days reviewed. Observations showed the posted hours were outdated, and interviews with the DON and Administrator revealed they were unaware of the lapse. Facility policy requires daily posting of nurse staffing data.
Failure to Maintain Resident Privacy and Dignity During Care and While in Bed
Penalty
Summary
The deficiency involves failures to protect resident dignity and privacy by allowing residents' bodies to be exposed and visible from the hallway. In one instance, an LPN administered an abdominal injectable medication to a resident seated in a wheelchair in her room with the door wide open, allowing passersby in the hallway to see her exposed abdomen. Two unidentified residents were observed walking past and glancing into the room during the preparation and administration of the injection. The resident had diagnoses including type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, and social phobia, and a recent MDS showed mild cognitive impairment. The facility’s own policy on dose preparation and administration required that privacy rights be observed, including use of privacy curtains to avoid exposure, and the ADON stated that a privacy curtain should be pulled or the door closed when administering abdominal injections. In another instance, a resident with athetoid cerebral palsy, torticollis, spastic quadriplegic cerebral palsy, unidentified intellectual abilities, and aphasia was repeatedly observed from the hallway lying in bed without adequate clothing and with the room door open and privacy curtain not in use. On one observation, the resident had no clothing on and his upper body was naked and exposed; on subsequent observations, he was either wearing only a tee shirt with his lower body loosely covered by a sheet or unclothed with only a sheet covering from the waist down. The resident’s MDS indicated he was rarely or never understood and had severely impaired decision-making skills, and his care plan documented total dependence on staff for dressing tasks. The ADON stated she did not know why the resident was not wearing clothing, later reporting that staff said the family had not provided clothing, and the Administrator confirmed the resident had not worn a gown since admission with no documentation explaining why, despite a resident rights policy requiring care to be provided in a manner that promotes dignity.
Failure to Assess and Observe Resident Medication Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to complete a Self-Administration of Medication assessment and to observe medication administration for a resident who was effectively allowed to self-administer a drug. During observation, an LPN placed a cup containing one 500 mg acetaminophen tablet and a cup of water in front of Resident 5 and then left the room without maintaining visual observation of the resident consuming the medication. Resident 5 had diagnoses including gout, bilateral leg pain, depression, post-traumatic stress disorder, and dysphagia, and their most recent quarterly MDS showed a BIMS score of 15, indicating they were cognitively intact. Physician orders directed that one 500 mg acetaminophen tablet be administered three times daily for pain, but there was no order authorizing the resident to self-administer this medication. Review of clinical assessments over the period from 1/1/25 to 4/24/26 showed that no Resident Medication Self-Administration Assessment had been completed for this resident. The DON stated that staff were required to watch the administration of medication for each resident, and that residents could only self-administer medications when a Self-Administration Assessment had been completed and determined appropriate or when there was a specific order for self-administration. The facility’s current policy, dated 12/1/07, required staff administering medication to observe the resident’s consumption of the medication. Despite these requirements and the resident’s documented dysphagia, the LPN did not remain to observe the resident taking the acetaminophen, and no self-administration assessment or order was in place, resulting in noncompliance with facility policy and 410 IAC 3.1-11(a).
Failure to Notify Emergency Contacts of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure required bed-hold policy notification was provided to residents’ emergency contacts during hospital transfers. For one resident with chronic kidney disease, diabetes, and a seizure disorder, the record showed a BIMS score of 15, indicating no cognitive deficit. A progress note documented that the physician ordered a hospital transfer when the resident was not responding, and an Indiana Bed Hold Notification was signed by the resident declining to have the bed held. The Administrator stated that the resident was their own responsible party, but also indicated that the resident’s sister was both the durable power of attorney and emergency contact, and that she should have been contacted when the resident was not responding. There was no documentation that the emergency contact was notified of the bed-hold policy. For a second resident with atrial fibrillation, lumbar fracture, lumbar wound dehiscence, and malnutrition, the discharge MDS and care plan documented severe cognitive impairment. A progress note indicated the resident was transferred to the hospital and that the bed-hold policy was sent with the EMT, and that the emergency contact was made aware of the transfer. However, neither the progress note nor the transfer form documented that the emergency contact was informed of the facility’s bed-hold policy. An Indiana Bed Hold Notification was signed by the resident declining to have the bed held, despite the documented severe cognitive impairment. The Administrator confirmed that this resident was cognitively impaired and that the emergency contact should have been notified of the bed-hold policy. No facility policy on bed-hold notification was available for review at the time of exit.
Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure proper oral hygiene for a resident who was entirely dependent on staff for all aspects of care. The resident, diagnosed with cerebral palsy, curvature of the spine, and curvature of the neck, was observed multiple times with their mouth open, tongue protruding, and lips dry with white caking. The resident's tongue was also covered with a dry, white coating. The resident's care plan indicated they were totally dependent on staff for oral care, and the facility's policy required oral care every 2 to 4 hours for dependent residents. However, observations and interviews revealed that the resident did not receive the necessary oral care, as confirmed by a registered nurse who noted the resident's extremely dry lips and tongue and acknowledged the need for oral care every 2 hours.
Failure to Maintain Tube Feeding Supplies
Penalty
Summary
The facility failed to ensure proper maintenance of a tube feeding for a resident diagnosed with cerebral palsy, curvature of the spine, and curvature of the neck. The resident, who was severely impaired and entirely dependent on staff for care, was observed with a tube feeding pump in their room. The resident's care plan indicated a requirement for tube feeding with nothing by mouth. However, the tube feeding formula and water containers were dated two days prior, indicating they had not been changed as required. A registered nurse confirmed that the tube feeding supplies were supposed to be changed daily and labeled with the date and time, in accordance with the facility's policy on enteral nutrition therapy, which mandates replacement every 24 hours.
Failure to Ensure Freedom from Unnecessary Medications
Penalty
Summary
The facility failed to ensure freedom from unnecessary medications for a resident, identified as Resident 17. The resident's medical record was reviewed, revealing diagnoses of diabetes, chronic kidney disease, Parkinson's, and coronary artery disease. The resident's Quarterly Minimum Data Set indicated no cognitive loss and the requirement of an indwelling urinary drainage catheter. A physician order dated June 12, 2024, prescribed an antibiotic injection for three days for a urinary tract infection (UTI). However, a progress note dated June 20, 2024, indicated that the antibiotics were completed for an unknown infection, and a medication error was made by the prescriber, as there was no urinalysis to support the UTI diagnosis. The Medication Administration Record confirmed the administration of the antibiotic injections on June 11, 12, and 13, 2024. During an interview, the Administrator was unaware of the resident receiving antibiotics without an infection. The facility's policy on medication-related errors required staff to follow incident policy and performance improvement processes in such cases.
Recurrent Environmental Concerns Not Addressed
Penalty
Summary
The facility failed to ensure quality improvement plans were developed for identified recurrent environmental concerns. During the annual survey completed on 6/7/23, issues regarding the repair and maintenance of facility floors, walls, and handrails were identified. The facility committed to correcting these issues by 6/30/23. However, the same concerns were found again during the annual survey completed on 3/28/24, indicating that the issues had not been adequately addressed or resolved. The QAPI committee, which includes various department heads such as the Executive Director, Director of Nursing Services, and Maintenance Director, reviewed segments of care including maintenance in their monthly meetings. Despite the ongoing discussion of environmental issues in these meetings, there was no current performance improvement plan in place to address the environmental deficiencies. This lack of a formalized plan contributed to the recurrence of the same issues in subsequent surveys.
Facility Failed to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to ensure a sanitary environment free of hazards on four halls where residents resided or received services. Observations revealed that handrails on the 200, 300, 400, and 500 halls had bare portions missing finish, and baseboards were missing throughout the 100, 200, 300, 400, and 500 halls. Additionally, drywall on portions of the walls below the handrails had grey linear marks scattered throughout, and the bottom of the drywall had chipped, jagged edges observed on all halls. A raised buckle in the vinyl plank flooring was observed on the 100 hall near the door to the maintenance office, and similar buckled areas were identified outside multiple rooms across different halls. The Maintenance Director indicated that repairs had been delayed due to problems with the company contracted to install flooring throughout the building and that he was not aware of any current plans for contractors to fix the flooring problems. The Executive Director, who began work in December 2023, was also not aware of any plans for repairs of the floor and had not been aware of handrail concerns. The facility's current policy titled Plant Operations, last reviewed on 7/12/23, indicated that the facility should maintain a safe, clean, and structurally sound environment. However, the observations and interviews conducted during the survey revealed that the facility had not adhered to this policy, resulting in an environment that was not safe, clean, or structurally sound. The Maintenance Director and Executive Director both acknowledged the issues but indicated that there were no current plans to address the flooring and handrail concerns. The findings highlight a significant deficiency in maintaining the facility's physical environment, which could potentially impact the safety and well-being of the residents, staff, and the public.
Failure to Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure nurse staffing hours were posted daily for 3 of 4 days reviewed. On multiple observations on 3/24/24, the nurse staffing hours posted near the facility entrance were dated 3/21/24. Interviews with the Director of Nursing (DON) and the Administrator revealed that both were unaware that the nurse staffing hours had not been updated for three days. The facility's current policy, dated 4/24/19, mandates that nurse staffing data must be posted every day at the beginning of each shift.
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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) |
|---|---|---|---|---|
| Waters Of Lagrange Skilled Nursing Facility, The | 0.4 mi | ★★★★★ | 10 | 0 |
| Froh Community Home | 10.4 mi | ★★★★★ | 0 | 0 |
| Orchard Pointe Health Campus | 15.2 mi | ★★★★★ | 7 | 0 |
| Avalon Village | 16.6 mi | ★★★★★ | 25 | 0 |
| Lutheran Life Villages | 17 mi | ★★★★★ | 2 | 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.