LaGrange Trails of Journey LLC

In the surveyor’s words

From the most serious findings on record at LaGrange Trails of Journey LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880May 13, 2026

  Based on observations, staff interviews, and review of the facility policy titled, Glucometer Disinfection, the facility failed to ensure staff followed appropriate disinfection procedures for blood glucose monitoring devices. Specifically, staff failed to properly disinfect the glucometer between resident use during blood glucose monitoring observations for three of three sampled Residents (R) (R4, R2 and R3). This deficient practice placed residents at increased risk for infection transmission and cross-contamination. Findings Include:Observation on 05/12/2026 at 10:08 AM on Hall 300 (East Wing) with Licensed Practical Nurse (LPN) AA revealed R4 received a blood glucose check using a shared glucometer. […]

• No harm, potential for more than minimal, patternF761Jan 5, 2023

  Based on observation, interviews, and review of Storage of Medications Policy the facility failed to ensure that the medication storage room was locked for one of two storage rooms. Findings include: Observation on 1/4/2023 at 9:05 a.m. revealed the East Wing nurses' station was not attended. It was observed that the medication storage room was unlocked and the refrigerator containing medication was also unlocked. Further observation on 1/5/2023 at 9:00 a.m. revealed the medication storage room on the East Wing was still unlocked. However, the refrigerator containing medication was locked at this time. An interview with Licensed Practical Nurse (LPN) AA, on 1/5/2023 at 9:05 a.m. revealed that the door is supposed to be locked. She stated, oh well, and then locked it. […]

• No harm, potential for more than minimal, patternF880Jan 5, 2023

  Based on observation, staff interview, and review of the policy, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measure, the facility failed to ensure effective infection control practices were maintained for two residents (R) (#58 and #179) with the diagnosis of COVID-19; there was no supply of personal protective equipment (PPE) outside or immediately within the room for staff, inconsistent use of respirator masks and gloves and no observation of the use of gowns. The census was 83. […]

• No harm, potential for more than minimal, patternF677Oct 8, 2022

  Based on observations, interviews, record review, and facility policy review, the facility failed to providing bathing assistance for four residents of 20 residents (Resident (R) 5, R6, R8, and R10) reviewed for Activities of Daily Living (ADL) care. This failure had the potential to affect the residents' comfort, body image, increased the risk for skin breakdown, and increased the risk for infections. Findings include: Review of the facility's policy titled, ''Activities of Daily Living (ADLs), Supporting,'' revised 03/2018, stated ''Resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). […]

• No harm, potential for more than minimal, isolatedF759May 13, 2026

  Based on observations, staff interviews, record reviews, and review of the facility's policies titled, Medication Administration, Insulin Pen, and the package insert TRESIBA (insulin degludec) injection, for subcutaneous use, the facility failed to ensure the accurate administration of medications for four of 40 medication opportunities observed, resulting in a medication error rate of 10 percent for two residents(R) (R4 and R3) during medication administration. This deficient practice had the potential to negatively impact residents' clinical conditions and lead to complications in their current health statusFindings include:Observation on 05/12/2026 at 10:08 AM on Hall 300 (East Wing) with Licensed Practical Nurse (LPN) AA revealed R4 had a physician order for Calcium 600 (calcium… […]