Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Care Inn Of La Grange during CMS and state inspections, most recent first.
Unlocked Medication Cart Left Unattended: Medication Cart #1 was observed unlocked near the nurses desk with no staff nearby and the drawers facing the 300 hall entrance. LVN A stated she was responsible for locking the cart but left it unlocked after being distracted by another staff member. LVN B, the DON, and the Administrator all stated medication carts are expected to be locked when not in use, and the facility policy required medications and biologicals to be stored in locked compartments and carts not left unattended if open.
RN coverage was not maintained for 8 consecutive hours a day, 7 days a week. Staffing records showed multiple days with no RN hours, and interviews revealed the ADON handled scheduling, believed an RN was not always required because the NP visited frequently, and thought a waiver may have been applied for. The DON said she did not know the RN scheduling requirement, and the ADM said open RN positions and an RN resignation contributed to the missed coverage.
Resident Council meetings were held in the dining room, and a confidential resident group meeting was interrupted by staff three times during a 30-minute period. Three residents said interruptions sometimes occur during council meetings because the meetings are held in the dining room. The ACTD said the dining room was the only available area, staff were told by word of mouth not to enter, and the DON and ADM acknowledged residents have the right to meet privately and that the facility policy requires space and privacy for council meetings.
Improper Wound Care and Hand Hygiene During Pressure Ulcer Treatment: An ADON failed to follow standard precautions and wound care technique for two residents with pressure ulcers. For one resident with an unstageable heel injury, she handled supplies without hand hygiene, used an unclean overbed table, cleaned the wound by swiping across it, and applied xeroform in a balled-up manner. For another resident with a Stage III sacral wound, she used an unclean table, did not change gloves or perform hand hygiene, cleaned across the wound instead of the wound bed, and applied collagen and calcium alginate to the outside of the wound rather than into the wound bed and tunneling.
Infection Control Failures During Wound Care: An ADON failed to follow standard precautions while providing wound care to two residents with pressure ulcers. She prepared supplies and performed treatment without proper hand hygiene, used unclean surfaces and contaminated handling practices, and applied dressings and wound products incorrectly during care of a heel ulcer and a coccyx ulcer. The observations documented repeated glove use without changes, no hand hygiene during or after treatment, and wound-cleaning techniques that crossed contaminated areas and did not protect the wound bed.
Pest Control Program Not Maintained: Surveyors observed 2 dead cockroaches behind the ice machine in the dining area on 2 separate observations, and residents reported seeing roaches throughout the facility. Staff interviews showed the building was known to have water bugs/cockroaches, pest sightings were inconsistently tracked, and record review documented repeated reports of roaches and gnats in multiple areas despite routine pest control service.
Expired medications were found on the Unit 2/200 hall med cart, including Benadryl, Meclizine, and normal saline eye drops. MA B stated the items were expired and should not have been on the cart, and the DON confirmed they were expired and should have been removed. The facility policy stated outdated or deteriorated meds are to be handled through the dispensing pharmacy.
Resident rooms in multiple shared rooms did not meet the required 80 square feet per resident. Surveyors observed 12 rooms that were too small, and a measured room showed bed spaces of 75 and 76 square feet. The HSK Dir, DON, and ADM were not aware of the specific room-size requirement, and the ADM said a room-size waiver request had been submitted but its status was unclear.
A resident with chronic kidney disease, vascular dementia, and urinary incontinence had urine collected via in-and-out catheter and then had a Foley catheter inserted by an RN without prior physician orders, despite facility policy and expectations that the MD be consulted for any new treatment or medical device. Documentation showed the MD had only been contacted for a U/A order and that no catheter orders existed for the period reviewed. The ADON confirmed that physician orders were required for catheter use to ensure appropriate care and monitoring, and the RN acknowledged not notifying the MD as required.
A resident with CKD, gout, vascular dementia, and urinary incontinence was catheterized without required physician orders. Nursing notes documented that an RN obtained a urine specimen via in-and-out catheterization and then inserted a Foley catheter, with significant urine output recorded, despite the physician having only ordered a urinalysis. Review of physician orders showed no orders for either an in-and-out or Foley catheter. In interviews, the RN admitted she did not contact the physician for catheter orders, and the ADON confirmed that facility protocol required physician authorization for catheters and other new treatments, with no documentation that the MD had been notified.
Surveyors found a medication cart unlocked and unattended near the dining room entrance, with drawers facing the hallway and the locking mechanism protruding, while the assigned RN was inside the dining room passing meal trays and unable to observe the cart. Visitors were seen walking near the unsecured cart. In interviews, the RN stated she thought she had locked the cart, confirmed she held the only keys, and acknowledged that residents and visitors had access to the medications when the cart was left unlocked. The DON stated that carts are required to be locked unless the nurse is standing at the cart administering meds, and record review showed a written policy requiring all meds and biologicals to be stored in locked compartments with access limited to authorized personnel.
The facility failed to maintain food safety and sanitation standards, with expired lunch meat and improperly stored pancakes and waffles found in the kitchen. In the emergency food storage, expired and damaged water bottles were observed. Additionally, dietary staff did not follow handwashing procedures, risking cross-contamination. These deficiencies were confirmed through interviews with staff.
A facility failed to provide trauma-informed care for a resident with PTSD, as the care plan did not identify potential triggers or include specific interventions for PTSD. Despite having multiple mental health diagnoses, the resident did not receive a psychiatric evaluation to assess current needs. The facility lacked a specific policy for trauma-informed care, and the DON admitted to not being qualified to evaluate mental health conditions.
A facility failed to protect a resident's personal healthcare information when an LVN left a computer screen open in the hallway, exposing the resident's data. The resident, with multiple health conditions and moderate cognitive impairment, had their information visible while the LVN performed wound care. The LVN acknowledged the HIPAA violation, and the DON emphasized the importance of maintaining privacy.
A facility failed to refer a resident with severe cognitive impairment and psychotic disorders for a Level II PASARR evaluation after a significant change in mental health status. The necessary form to prompt the evaluation was not submitted, potentially depriving the resident of needed mental health services. The facility lacked a formal PASARR policy, relying instead on general guidelines.
An LVN left a treatment/nurse cart unlocked and unattended, which contained medications and needles, outside a resident's room while performing wound care. The LVN admitted to forgetting to lock the cart, and the DON confirmed the expectation for staff to secure medication carts to prevent unauthorized access. The facility's policy requires medications to be stored securely to prevent tampering or misuse.
A facility failed to maintain an effective infection control program during wound care for a resident with a stage II pressure ulcer. An LVN did not set up a clean field for supplies and used improper cleaning techniques, risking cross-contamination. The resident, with multiple health issues and cognitive impairment, was at risk for pressure ulcers. The LVN acknowledged not following aseptic techniques, and the facility's policy lacked specific guidance on wound care.
The facility failed to meet the required square footage for all 49 resident rooms, with each room being less than the mandated 80 square feet for multiple resident rooms or 100 square feet for single resident rooms. This deficiency could restrict the amount of resident care equipment and personal effects that could be accommodated, limit residents' ability to move about the room, and decrease their quality of life. The Administrator mentioned a past waiver request for room size and intended to request another waiver.
Unlocked Medication Cart Left Unattended
Penalty
Summary
Medication Cart #1 was observed near the nurses desk with the locking mechanism protruding outward, indicating the cart was unlocked, and the drawers were facing toward the entrance to the 300 hall. No nurses or staff were near the cart at the time of the observation. The facility failed to ensure the cart was locked and that medications were secured from access by other staff, residents, or visitors. During interviews, LVN A stated she had been trained on medication storage and that the nurse assigned to a medication cart was responsible for locking it, but she left the cart unlocked because she got distracted by another staff member. LVN B stated medication carts were expected to be locked any time staff walked away from them and that the nurse was responsible for locking the cart. The DON and Administrator both stated the carts should always be locked when not in use, and the Administrator stated routine checks were made during the day to ensure the carts were locked. The facility's Medication Labeling and Storage Policy stated all medications and biologicals are to be stored in locked compartments and carts are not to be left unattended if open or otherwise potentially available to others.
RN Coverage Not Maintained Daily
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week during 13 of 64 days reviewed in the first quarter of 2026. Staffing records showed no RN hours on 13 specific days in January, February, and March 2026, including multiple weekends and one Monday. The facility policy dated 08/2022 stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week, and the TAC Title 26 requirement cited in the report also required RN coverage for at least eight consecutive hours a day, seven days a week unless waived. During interviews on 03/05/2026, the ADON stated she was responsible for making the nursing schedule and said the facility was supposed to have an RN scheduled every day, but she believed the facility did not have to have an RN because the NP came in frequently and she thought a waiver had been applied for. The DON stated she did not know the policy for RN scheduling requirements and did not know the facility needed an RN 8 hours a day every day. The ADM stated the ADON was responsible for ensuring RN coverage 8 hours a day, 7 days a week, and said the facility did not have an RN for 10 days in February due to an RN resignation and that two RN positions were open.
Resident Council Meetings Lacked Privacy
Penalty
Summary
The facility failed to provide a private space for resident council meetings and a confidential resident group meeting. During a confidential group interview and observation in the facility dining room on 3/04/2026 at 2:00 PM, five residents were present and the meeting was interrupted by facility staff three times within a thirty-minute period. Three residents stated that interruptions sometimes occur during Resident Council meetings because the meetings are held in the dining room. Interviews with facility leadership showed that the ACTD stated the Resident Council meeting could be held privately in the dining room and that signs could be posted, but also stated the dining room was the only available area and that staff were informed by word of mouth not to enter. The DON stated residents must have a private space to meet without interruptions and that a lack of privacy could negatively impact residents. The ADM stated the dining room has two doors that can be closed, but acknowledged there was a lack of communication about the meeting and that residents have the right to meet privately. The facility policy stated the resident council group is provided with space, privacy, and support to conduct meetings.
Improper Wound Care and Hand Hygiene During Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and failed to provide wound treatment in a manner consistent with professional standards of practice for two residents with pressure ulcers. One resident was a female with dementia, rhabdomyolysis, and osteoarthritis who had an unstageable deep tissue injury to the right heel and was ordered to have the wound cleansed with wound cleanser, then covered with xeroform and a silicone bordered gauze dressing. During observed wound care, the ADON handled supplies without hand hygiene, placed supplies on an unclean overbed table, donned gloves without hand hygiene, removed the old dressing, and cleaned the wound by swiping up and down and across the wound. The ADON then gathered the xeroform into a slight ball before placing it on the wound and covered it with the outer dressing. No hand hygiene was performed after the treatment. A second resident was a male with dementia, CHF, and a sacral pressure ulcer who was assessed with severe cognitive impairment and a Stage III pressure ulcer. He had an order to cleanse the sacral wound, apply collagen particles and calcium alginate, and cover with a silicone bordered super absorbent dressing. During observed wound care, the ADON placed supplies on wax paper, used hand sanitizer in the hall, entered the room without cleaning the overbed table, left the room to get a gown, returned without hand hygiene, donned gloves, and handled the dirty overbed table and door with the same gloves. She then continued wound care without hand hygiene or glove changes while staff assisted with turning the resident. For this resident, the ADON cleaned across the wound from the outside across the wound rather than cleaning the inside of the wound bed, allowed the resident’s left buttock skin to fall over the wound while she obtained other supplies, and did not reclean or change gloves. She applied the collagen to the outside of the wound instead of the wound bed and placed calcium alginate over the tunneling without placing it inside the 3 cm deep wound. No glove changes or hand hygiene were performed during the wound care, and no hand hygiene was performed after the treatment. In interview, the ADON stated she did not know she needed to clean the overbed table, did not wash her hands or change gloves during wound care, and stated she applied the dressings the way she was taught.
Infection Control Failures During Wound Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program during wound care for two residents. One resident was a female with dementia, rhabdomyolysis, osteoarthritis, and an unstageable right heel pressure ulcer. Her care plan directed treatment for the heel wound, and the physician order required cleansing the right heel with wound cleanser, patting dry, applying xeroform, and covering with a silicone bordered gauze dressing. During observation of the wound treatment, the ADON prepared supplies outside the room without hand hygiene and without gloves, touched multiple surfaces, and placed wound supplies on wax paper. She entered the room without cleaning the overbed table, then donned gloves without hand hygiene. While treating the heel wound, she removed the dirty dressing, sprayed wound cleanser on gauze, and cleaned the wound by swiping up and down and across the wound. Without changing gloves or performing hand hygiene, she removed the xeroform from the package, gathered it into a slight ball, and placed it on the wound before applying the outer dressing. She then removed her gloves, returned the wound cleanser to the cart without wiping it down, and did not perform hand hygiene after the treatment. A second resident was a male with dementia, CHF, and a Stage III coccyx pressure ulcer with 3 cm depth. His care plan and physician order directed cleansing the sacral wound, applying collagen particles and calcium alginate, and covering with a silicone bordered super absorbent dressing. During observation, the ADON gathered supplies on wax paper, used hand sanitizer in the hall, placed the supplies on an unclean overbed table with water rings and food particles, left to get a gown, then returned and donned gloves without hand hygiene. She handled the dirty overbed table and opened and re-closed the door with gloved hands, then continued wound care without hand hygiene or glove changes. She cleaned across the wound from the outside in, allowed surrounding tissue to fall over the wound while obtaining supplies, and applied collagen to the outside of the wound rather than the wound bed and calcium alginate over the tunneling rather than inside the 3 cm depth. No hand hygiene was performed after the treatment.
Pest Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an effective pest control program and failed to ensure the dining room was free of pests. On 03/03/2026, a surveyor observed 2 large dead cockroaches in a silver pan behind the ice machine in the dining area. On 03/04/2026, the same observation was made again, with 2 large dead cockroaches seen in the silver pan behind the ice machine in the dining area. During interviews, residents reported seeing roaches throughout the facility. The HSK Dir stated the pest control company comes every 60 days or as needed and acknowledged the building is known to have a problem with water bugs, which he identified as cockroaches. The Dietary MNG said she had not personally seen roaches in the kitchen but had started her own Pest Sighting Log after taking over. The HSK D stated he had seen bugs on cockroach traps in residents’ rooms and usually where water was standing, and he was not aware of a logbook to report sightings. The ADM stated she would log pest sightings in the binder if she saw signs of pests and said the building is checked monthly. Record review showed the last monthly pest control service was completed on 2/5/2026 and included multiple reports of roaches and gnats in several areas, including the hazmat closet, kitchen, nurses’ station, med room, room [ROOM NUMBER], hallways, and common areas. The facility policy stated the facility shall maintain an effective pest control program and keep kitchens, kitchen areas, and dining areas clean, free from garbage and debris, and protected from rodents and insects.
Expired Medications Found on Medication Cart
Penalty
Summary
The facility failed to ensure medications used in the facility were stored in accordance with currently accepted professional principles and that expired medications were removed from the 200 hall medication cart. During observation on 03/04/2026 at 11:34 AM, the Unit 2 medication cart contained a bottle of Benadryl expired on 01/2026, a bottle of Meclizine expired on 01/2026, and a bottle of normal saline eye drops expired 05/2025. These expired medications were still present on the cart at the time of the surveyor's observation. In interview on 03/04/2026 at 11:36 AM, MA B stated the Benadryl, Meclizine, and normal saline on the 200 hall cart were expired and should not have been on the cart, and that everyone who worked on the carts was responsible for checking for expired medications, but they had been missed. In interview on 03/04/2026 at 11:20 AM, the DON stated the medications were expired and should not have been on the medication cart, and that it was everyone's responsibility to look for and remove expired medications. Review of the facility's Medication labeling and storage policy dated February 2023 stated medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received, and that outdated or deteriorated medications are to be handled through the dispensing pharmacy.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to provide resident bedrooms that measured at least 80 square feet per resident in multiple resident rooms. Based on observations, interviews, and record review, 12 of 30 resident rooms reviewed for environment—Rooms 202, 204, 207, 401, 403, 407, 501, 503, 504, 507, 509, and 510—did not meet the required square footage for the residents assigned to them. The report states that 24 residents lived in those rooms, and that the lack of adequate room size could limit the amount of resident care equipment and personal belongings that could be accommodated in the rooms. During the initial pool screening, surveyors observed that the 12 resident rooms did not have the required amount of living space for each resident. The HSK Dir measured one room and found bed A measured 75 square feet and bed B measured 76 square feet, and stated he did not recall the required square footage for resident rooms. The DON stated she was not aware of the specific square footage requirements, and the ADM stated she had not been successful in locating a room waiver and later found documentation showing a waiver request had been submitted in December 2024, though the status was unclear. No facility policy regarding required resident room size or square footage was provided to the survey team upon exit.
Failure to Obtain Physician Orders for Catheterization
Penalty
Summary
The deficiency involves the facility’s failure to consult with a resident’s physician and obtain required physician orders before performing an in-and-out catheterization and inserting a Foley catheter. The resident was an elderly male with chronic kidney disease stage 3B, gout due to renal impairment, vascular dementia with severely impaired decision-making, and total dependence on staff for hygiene, dressing, transfers, and management of bowel and bladder incontinence. His comprehensive care plan included monitoring labs and urinary output, reporting significant changes to the MD, and following physician orders to ensure necessary care and services. On the date in question, nursing notes documented that a urine sample was collected using an in-and-out catheter with sterile technique, and that 1000 mL of tea-colored urine with sediment and odor was obtained. The same note reflected that a 16 French catheter with a 10 mL balloon was inserted at that time, and a later note documented 400 mL of amber urine with mucus draining from the Foley catheter. Review of the physician orders for the relevant months showed there were no orders for either an in-and-out catheter or a Foley catheter for this resident. Another nursing note from earlier that afternoon showed that the on-call physician had been contacted and had given new orders only to collect a urinalysis (U/A). In an interview, the RN who performed the procedures stated that the resident needed an in-and-out catheter to obtain urine for the U/A, that the resident was having difficulty with the in-and-out catheter, and that she then inserted a Foley catheter. She acknowledged she did not contact the physician for either the in-and-out catheter or the Foley catheter and stated that facility protocol required contacting the physician anytime a resident might need a catheter, IV, or any new treatment. The ADON confirmed that the expectation was for the nurse to obtain physician orders for any catheter and that there was no documentation indicating the physician had been contacted about the need for catheters. The facility’s policy on physician orders stated that physician orders are essential for the comprehensive care of residents and to ensure they receive necessary care and services.
Unauthorized Catheter Insertion Without Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and physician orders. The resident was an elderly male with chronic kidney disease stage 3B, gout due to renal impairment, vascular dementia with severely impaired decision-making, and incontinence of bowel and bladder. His comprehensive care plan identified risks related to chronic kidney disease, potential renal failure, fluid volume deficit, and the need to monitor and report abnormalities in urinary output and other symptoms to the physician. On the identified date, nursing documentation showed that a urine specimen was collected using an in-and-out catheter, during which 1000 mL of tea-colored urine with sediment and odor was obtained, and a 16 French catheter with a 10 mL balloon was inserted. Later that same day, nurses’ notes documented 400 mL of amber urine with mucus draining from a Foley catheter. The physician orders for the months reviewed did not contain any order for an in-and-out catheter or for a Foley catheter for this resident. Earlier that afternoon, the on-call physician had been contacted and had given an order only to collect a urinalysis. In interview, the RN who performed the catheterization stated the resident needed an in-and-out catheter to obtain urine for the urinalysis, that the resident was having difficulty with the in-and-out catheter, and that she then inserted a Foley catheter. She acknowledged she did not contact the physician for either the in-and-out catheter or the Foley catheter and stated that facility protocol required contacting the physician any time a resident might need a catheter, IV, or any new treatment. The ADON confirmed that the expectation was for the nurse to obtain physician orders for both types of catheters and that there was no documentation indicating the physician had been contacted about the need for catheters. The facility’s policy on physician orders stated that physician orders are essential to ensure residents receive necessary care and services, and the surveyors found that no such orders existed for the catheterization performed on this resident.
Unlocked Medication Cart Left Unattended in Hallway Near Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and biologicals were stored in locked compartments and accessible only to authorized personnel, as required by facility policy and State and Federal laws. On the morning of 01/13/2026 at 8:35 a.m., surveyors observed Medication Cart #1 unlocked and positioned against a wall near the entrance to the dining room, with the drawers facing the hallway. The locking mechanism was protruding outward, and the State Surveyor was able to open the drawers and take photographs. At that time, the RN responsible for the cart (RN A) was in the dining room passing out meal trays to residents and was unable to view or monitor the cart. Visitors were later observed walking down the hall near the still-unlocked cart. During interview, RN A stated she believed she had locked the cart before entering the dining room to assist with breakfast and expressed surprise that it was unlocked. She confirmed she had the only set of keys for that cart and acknowledged that residents and visitors had access to the medications when the cart was left unlocked. RN A reported she had been in-serviced on the requirement to keep medication carts locked when not in use but could not recall the date of the in-service. In a separate interview, the DON stated that medication carts were expected to be locked unless the nurse was standing at the cart administering medications, with no exceptions, and confirmed that staff had been in-serviced on this expectation, though she also could not recall the date. Review of the facility’s Medication Labeling and Storage policy, dated 2001, documented that all medications and biologicals must be stored in locked compartments, with only authorized personnel having access to keys, and that carts used to transport medications must not be left unattended if open or otherwise available to others.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen and emergency food storage areas. In the kitchen, a bag labeled as lunch meat was found with a manufacturer expiration date that had already passed, yet it was still being used. Additionally, in the freezer, bags of pancakes and waffles were found torn, exposing their contents to potential contamination. These observations indicate a failure to properly store and manage food items, which could lead to food spoilage and contamination. In the emergency food storage area, eight gallons of water were found to be expired, and three additional gallons were damaged, with punctures causing leakage. This oversight in managing emergency supplies suggests a lack of regular checks and proper rotation of stock, which is crucial for ensuring the safety and quality of emergency provisions. Furthermore, dietary staff did not follow proper handwashing procedures, as observed when a staff member handled trash and then continued food preparation without washing hands. This lapse in hygiene practices poses a risk of cross-contamination, which could compromise food safety. Interviews with the dietary manager and staff confirmed these expectations and acknowledged the potential negative outcomes of these deficiencies.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, a male with multiple mental health diagnoses including schizoaffective disorder, bipolar disorder, major depressive disorder, generalized anxiety disorder, and PTSD, was admitted to the facility without a care plan that identified potential PTSD triggers. Despite having a care plan that addressed various mental health conditions, the plan did not include specific interventions for PTSD triggers, which is crucial for trauma-informed care. The resident's care plan included interventions for other mental health conditions such as depression, schizoaffective disorder, bipolar disorder, and anxiety, but lacked specific strategies to address PTSD. The facility did not conduct a psychiatric evaluation to identify PTSD triggers or to assess the resident's current mental health needs. The Director of Nursing (DON) acknowledged that the PTSD diagnosis was carried over from the previous facility and that no behaviors were observed that warranted a psychiatric evaluation. However, the DON admitted to not being qualified to evaluate mental health conditions and recognized the potential for missing out on resources that could benefit the resident. The facility did not have a specific policy for trauma-informed care or PTSD, as confirmed by the DON. The Administrator (ADM) expressed that it was expected for PTSD triggers to be identified through education, care plans, and charts, but this was not done for the resident. The ADM acknowledged that reaching out to psychiatric services would have been appropriate, and the lack of evaluation by psych services could result in the resident missing out on necessary services.
Breach of Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records. During an observation, it was noted that a Licensed Vocational Nurse (LVN) left a computer screen open in the hallway, displaying a resident's personal healthcare information, while she entered the resident's room to perform wound care. This incident involved a male resident with multiple diagnoses, including acute kidney failure, hypertension, diabetes mellitus type II, and dementia. The resident was assessed to have moderate cognitive impairment and required assistance with activities of daily living. The incident was acknowledged by the LVN, who admitted that leaving the computer screen open could lead to a breach of the resident's confidential information, constituting a violation of the Health Insurance Portability and Accountability Act (HIPAA). The Director of Nursing (DON) confirmed that it was the facility's expectation to keep residents' health information private to prevent HIPAA violations. The facility's policy on resident rights, which includes the right to privacy and confidentiality of records, was not adhered to in this instance.
Failure to Refer Resident for PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with a significant change in mental health status for a Level II PASARR evaluation. The resident, a female admitted with diagnoses including psychotic disorder with delusions and hallucinations, was not referred to the appropriate state-designated authority after being diagnosed with these conditions. The resident's records indicated severe cognitive impairment and active diagnoses of anxiety and psychotic disorders, yet the necessary PASARR evaluation was not completed. The facility's MDS coordinator acknowledged that the required form to prompt a PASARR evaluation was not submitted, which could result in the resident missing out on necessary mental health services. The facility's PASARR policy was found lacking, as the Director of Nursing stated there was no formal policy in place, and they simply followed PASARR guidelines. Interviews with staff revealed that the resident should have been referred for services as a precaution, and the absence of a referral could lead to increased behavioral issues. The failure to complete the PASARR evaluation was identified during a review of the resident's electronic medical records, which did not show a completed evaluation despite indications that one was necessary.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in locked compartments, as required by professional principles. On 12/11/2024, an LVN left a treatment/nurse cart unlocked and unattended outside a resident's room while performing wound care. This cart contained treatment supplies, medications, and needles, which could have been accessed by residents. During an interview, the LVN admitted to forgetting to lock the cart and acknowledged the importance of securing it to prevent unauthorized access. The Director of Nursing (DON) confirmed the expectation that staff should lock medication and treatment carts to maintain security and prevent resident access to harmful items. The facility's medication storage policy from 12/2018 mandates that medications be stored securely to prevent tampering, exposure, or misuse.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper wound care provided to a resident with a stage II pressure ulcer. During an observation, an LVN did not set up a clean field for treatment supplies and used a cleaning technique that risked cross-contaminating the pressure ulcer. The LVN placed treatment supplies on a piece of wax paper on the resident's overbed table without cleaning the table or moving personal items. Additionally, the LVN brought an entire box of gloves into the room, which she later acknowledged should not have been returned to the treatment cart due to contamination. The resident involved was a male with multiple diagnoses, including acute kidney failure, hypertension, diabetes mellitus type II, and dementia, and was assessed to have moderate cognitive impairment. The resident required moderate to dependent assistance with all activities of daily living and was at risk for pressure ulcers. The LVN admitted to not following proper aseptic techniques, such as failing to reclean the wound after the resident's skin came into contact with it, which could lead to infections. The facility's policy on infection control did not specifically address wound care, contributing to the deficiency.
Deficiency in Resident Room Size
Penalty
Summary
The facility failed to ensure that all 49 resident rooms met the required square footage, with each room being less than the mandated 80 square feet for multiple resident rooms or 100 square feet for single resident rooms. This deficiency was identified in rooms numbered 101 through 608. The lack of adequate space could restrict the amount of resident care equipment and personal effects that could be accommodated, limit residents' ability to move about the room, and decrease their quality of life. During an interview, the Administrator mentioned that a waiver for room size had been requested in the past, although no physical copy was available, and the facility intended to request a waiver again. A review of the facility's CMS form 2567 from 2022 indicated a previous waiver request for F912, and the CMS form 672 from 2023 reflected a census of thirty-eight residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 97 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near La Grange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Rehabilitation And Nursing Center | 1.5 mi | ★★★★★ | 8 | 0 |
| Schulenburg Regency Nursing Center | 15.5 mi | ★★★★★ | 8 | 0 |
| Parkview Manor Nursing And Rehabilitation | 15.6 mi | ★★★★★ | 8 | 0 |
| Paradigm At The Oak | 15.7 mi | ★★★★★ | 30 | 3 |
| Towers Nursing Home | 16.6 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Care Inn Of La Grange.
100% money-back within 48 hours.
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.