Waters of Lagrange Skilled Nursing Facility, The

In the surveyor’s words

From the most serious findings on record at Waters of Lagrange Skilled Nursing Facility, The, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 4, 2024

  Based on observation, interview, and record review, the facility failed to ensure staff effectively identified skin impairment on the left inner calf from friction and shear was correctly identified as a pressure injury, failed to ensure a physician's order was received prior to the use of a medical device, and failed to ensure a resident with a history of pressure injuries received effective treatment and services to prevent the wound from deteriorating, from developing infection, or to prevent the development of a second wound for 1 of 1 resident reviewed for wound care. […]

• No harm, potential for more than minimal, widespreadF812Sep 10, 2025

  Based on observation, interview and record review, the facility failed to ensure all opened food items were labeled and dated, expired food was discarded, and thermometers were properly maintained in cooled and frozen food storage areas in the kitchen. 71 of 71 residents residing in the facility were served food prepared in the kitchen.During an observation in the walk-in refrigerator, on 09/04/2025 9:28 AM, a Ziploc bag containing pink sliced meat had illegible markings on the package . A plastic sealed bag labeled ham had a date of 8/27/25. A thermometer on an upper shelf had a temperature of 16 degrees. No items in the refrigerator appeared frozen solid or had visible frost. […]

• No harm, potential for more than minimal, widespreadF725Oct 1, 2024

  Based on interviews and record review, the facility failed to ensure sufficient nursing staff to meet the anticipated and unanticipated needs for 82 of 82 residents residening in the facility receiving nursing services. Findings include: An Indiana Department of Health complaint intake, dated 9/10/24 at 8:14 PM, indicated on 9/10/24 one nurse, one QMA, and one CNA were scheduled in the building for the evening shift. The complaint indicated CNAs frequently work on a hall by themselves with over 30 residents to assist to bed. An as worked schedule form, verified by payroll records, dated 9/10/24, indicated one certified nurse aide worked between 6:30PM and 10:00 PM for a total of 89 residents. […]

• No harm, potential for more than minimal, widespreadF867Oct 1, 2024

  Based on observation, record review, and interview, the facility failed to ensure a process was in place to identify and correct deficiencies from re-occurring for 82 of 82 residents residing in the facility Findings include: The facility annual survey completed on 12/1/2023 identified noncompliance regarding failure to report, failure to investigate incidents, failure to follow care planned interventions to prevent accidents, failure to maintaining minimum staffing levels to ensure safety, and failure to investigate and identify underlying causes of resident specific behaviors. […]

• No harm, potential for more than minimal, patternF602Feb 3, 2025

  Based on interview and record review, the facility failed to ensure residents were free from misappropriation of property for 4 of 4 residents reviewed (Resident K, Resident L, Resident M, and Resident N). The deficient practice was corrected on 1/22/25 prior to the start of the survey and was therefore past non-compliance. Findings include: A facility-reported incident was submitted to the Indiana Department of Health on 1/10/25, which indicated potential misappropriation of resident property had occurred and the facility was investigating the allegation. On 2/3/25 at 3:10 P.M., the Director of Nursing (DON) was interviewed. She indicated she had been conducting routine compliance audits of controlled medication records when she noticed a pattern of administration. […]