Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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.
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.
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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
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 | — | 1 | 0 |
| Parkview Manor Nursing And Rehabilitation | 15.6 mi | — | 4 | 0 |
| Paradigm At The Oak | 15.7 mi | — | 12 | 3 |
| Towers Nursing Home | 16.6 mi | — | 3 | 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 August 2026) and official state health department websites.