Inspection Reports for
Life Care Center of Lagrange
0770 NORTH 075 EAST, LAGRANGE, IN, 46761
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
This visit was for the investigation of Complaint IN00459564.
Complaint Details
Complaint IN00459564 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations of Complaint IN00459564 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census: 44
Total Capacity: 44
Payor Type Census: 1
Payor Type Census: 26
Payor Type Census: 17
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 0
Date: May 13, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00456894 and IN00458782.
Complaint Details
Complaint IN00456894 and Complaint IN00458782 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00456894 and IN00458782 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 44
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 22
Census Payor Type - Other: 18
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 7, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Life Care Center of LaGrange was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 44
Capacity: 87
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Life Care Center of LaGrange was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements for participation in Medicare/Medicaid. The facility is fully sprinklered, has a fire alarm system with smoke detection, and a propane powered emergency generator.
Report Facts
Certified beds: 87
Census: 44
Emergency generator power: 30
Inspection Report
Annual Inspection
Census: 51
Capacity: 51
Deficiencies: 4
Date: Mar 11, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaints IN00452893 and IN00453955.
Complaint Details
Complaints IN00452893 and IN00453955 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in several areas including failure to provide oral hygiene for a dependent resident, failure to maintain tube feeding supplies properly, administration of unnecessary antibiotics, and inadequate employee training and orientation. No deficiencies were cited related to the complaints investigated.
Deficiencies (4)
Failed to ensure a resident received oral hygiene for 1 of 5 residents reviewed (Resident 10).
Failed to ensure maintenance of a tube feeding for 1 of 1 resident reviewed (Resident 10).
Failed to ensure freedom from unnecessary medications for 1 of 3 residents reviewed (Resident 17).
Failed to ensure employees received 6 hours of dementia training upon new hire for 2 of 5 employees reviewed and failed to ensure employees received a 2 step Tuberculosis skin test and specific orientation for 5 of 5 employees reviewed.
Report Facts
Census: 51
Total Capacity: 51
Medicare Residents: 3
Medicaid Residents: 30
Other Residents: 18
Deficiency Completion Date: Apr 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tina Grostefon | Executive Director | Signed the report |
| RN 25 | Registered Nurse | Interviewed regarding oral care and tube feeding deficiencies related to Resident 10 |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447079 at Life Care Center of LaGrange.
Complaint Details
Complaint IN00447079 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00447079 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 49
Total Capacity: 49
Medicaid Census: 33
Other Payor Census: 16
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Date: Nov 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444623.
Complaint Details
Complaint IN00444623 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 3
Medicaid residents: 31
Other residents: 16
Inspection Report
Follow-Up
Census: 45
Capacity: 100
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Emergency Preparedness Survey conducted on 05/02/24 by the Indiana Department of Health in accordance with 42 CFR 483.73.
Findings
At this PSR, Life Care Center of LaGrange was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73.
Inspection Report
Follow-Up
Census: 39
Capacity: 39
Deficiencies: 0
Date: May 22, 2024
Visit Reason
This visit was a Post Survey Review (PSR) to the Annual Recertification and State Licensure Survey completed on March 28, 2024.
Findings
Life Care Center of Lagrange was found to be in compliance with 410 IAC 16.2-3.1 related to the PSR to the Annual Recertification and State Licensure Survey.
Report Facts
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 6
Inspection Report
Routine
Census: 44
Capacity: 100
Deficiencies: 13
Date: May 2, 2024
Visit Reason
The survey was conducted as an Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey to assess compliance with federal and state regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements including failure to annually review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, Training and Testing, and Testing Requirements. Life Safety Code deficiencies included hazardous area enclosure issues, sprinkler system installation and maintenance problems, portable fire extinguisher mounting heights, uncovered electrical outlet, smoking regulation violations, and oxygen trans-filling room deficiencies.
Deficiencies (13)
Failed to review and update the Emergency Preparedness Plan annually.
Failed to review and update the Emergency Preparedness Policies and Procedures annually.
Failed to review and update the Emergency Preparedness Communication Plan annually.
Failed to review and update the Emergency Preparedness Training and Testing Plan annually.
Failed to conduct annual Emergency Preparedness training for staff.
Hazardous area (Central Supply room) door was not self-closing or automatic closing.
Mixed quick response and standard sprinklers installed in the same smoke compartment (kitchen pantry).
Missing escutcheon on sprinkler in corridor outside room 405.
Corroded sprinkler head in laundry room by washers.
Nine portable fire extinguishers mounted with the top of extinguisher more than five feet above the floor.
Electrical outlet in attic above room 401 missing faceplate.
Smoking area outside service hall exit had cigarette butts disposed in a plastic trash can instead of a metal container with self-closing cover.
Oxygen trans-filling room not protected with one-hour fire-resistive construction due to an unsealed hole in the wall and staff not properly trained on trans-filling procedures.
Report Facts
Certified beds: 100
Census: 44
Deficiencies cited: 13
Sprinkler heads inspected: 30
Portable fire extinguishers inspected: 24
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Thompson | Administrator | Named as Administrator who reviewed findings and plans of correction |
Inspection Report
Annual Inspection
Census: 41
Capacity: 41
Deficiencies: 3
Date: Mar 28, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 24 to March 28, 2024.
Findings
The facility was found deficient in posting nurse staffing information daily, developing quality improvement plans for recurrent environmental concerns, and maintaining a safe, functional, sanitary, and comfortable environment free of hazards such as damaged handrails, missing baseboards, and improperly installed flooring.
Deficiencies (3)
Failed to ensure nurse staffing hours were posted for 3 of 4 days reviewed.
Failed to ensure quality improvement plans were developed for identified recurrent environmental concerns.
Failed to provide a safe, functional, sanitary, and comfortable environment; handrails missing finish, missing baseboards, drywall damage, and raised/buckled vinyl plank flooring observed.
Report Facts
Census SNF/NF beds: 41
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 29
Census Payor Type - Other: 8
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Thompson | Executive Director | Named in plan of correction and administrative responses |
| Director of Nursing | Interviewed regarding nurse staffing posting deficiencies | |
| Maintenance Director | Interviewed regarding environmental and flooring deficiencies | |
| Executive Director | Interviewed regarding environmental concerns and QAPI meetings |
Inspection Report
Re-Inspection
Census: 45
Capacity: 100
Deficiencies: 0
Date: Aug 7, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/26/23 by the Indiana Department of Health.
Findings
Life Care Center of LaGrange was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 100
Census: 45
Inspection Report
Re-Inspection
Census: 43
Capacity: 43
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2023-06-07.
Findings
Life Care Center of Lagrange was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census SNF/NF: 43
Census Payor Type Medicare: 1
Census Payor Type Medicaid: 32
Census Payor Type Other: 10
Inspection Report
Life Safety
Census: 45
Capacity: 100
Deficiencies: 5
Date: Jun 26, 2023
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related NFPA codes.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies related to fire alarm system maintenance, fire alarm out-of-service policy, sprinkler system out-of-service policy, fire drills, and electrical receptacle testing in resident rooms.
Deficiencies (5)
Failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72; no documentation of semi-annual visual inspection after annual inspection.
Failed to provide a complete written policy for fire alarm system out-of-service procedures including notification to Indiana Department of Health via the IDOH Gateway link.
Failed to provide correct written policies for sprinkler system impairment procedures including notification to Indiana Department of Health via the IDOH Gateway link.
Failed to conduct fire drills on each shift for 1 of 4 quarters; missing third shift fire drill for fourth quarter of 2022.
Failed to ensure non-hospital grade electrical receptacles at 55 resident sleeping rooms were tested at least annually.
Report Facts
Certified beds: 100
Census: 45
Fire alarm systems: 1
Resident sleeping rooms: 55
Fire drills missing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Stanley | Interim Executive Director | Signed the report |
| Maintenance Director | Interviewed and involved in findings related to fire alarm system, fire watch plan, sprinkler system, and fire drills | |
| Administrator | Interviewed and involved in findings review |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 45
Deficiencies: 0
Date: Jun 7, 2023
Visit Reason
This visit was for the investigation of Complaint IN00409388 and Complaint IN00408833, conducted in conjunction with a Recertification and State Licensure Survey.
Complaint Details
Complaint IN00409388 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to Complaint IN00409388 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of complaints.
Report Facts
Census: 45
Total Capacity: 45
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 31
Census Payor Type - Other: 12
Inspection Report
Annual Inspection
Census: 45
Capacity: 45
Deficiencies: 9
Date: Jun 7, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00408833 and IN00409388.
Complaint Details
Complaint IN00408833 was investigated with no deficiencies related to the allegations cited. Complaint IN00409388 was investigated as part of this survey.
Findings
The facility was found deficient in multiple areas including failure to provide wheelchair mobility assistance, honoring shower schedules, ensuring clear code status documentation, completing comprehensive assessments after significant change, culturally appropriate communication, nutritional interventions for weight loss, proper respiratory care, trauma-informed care, and maintaining a safe and sanitary environment.
Deficiencies (9)
Failed to ensure wheelchair mobility was provided for 1 of 4 residents reviewed (Resident 3).
Failed to ensure resident request for a shower schedule was honored for 1 of 4 residents reviewed (Resident 24).
Failed to ensure code status was clearly indicated for 1 of 16 residents reviewed (Resident 149).
Failed to ensure a comprehensive assessment was completed upon a significant change in condition for 1 of 4 residents reviewed (Resident 28).
Failed to ensure culturally appropriate communication interventions were attempted in a non-English speaking resident (Resident 28).
Failed to ensure interventions were implemented to correct significant weight loss for 2 of 8 residents reviewed (Resident 41 and Resident 23).
Failed to ensure oxygen tubing was properly stored and labeled when not in use for 1 of 3 residents reviewed for respiratory care (Resident 8).
Failed to ensure a personalized plan of care was initiated related to post-traumatic stress disorder for 1 of 1 resident reviewed (Resident 24).
Failed to ensure the environment was maintained in 5 of 5 rooms reviewed affecting 5 residents (Residents 9, 10, 12, 26, and 38) with issues including chipped paint, cracked floor tiles, stained carpeted walls and floors, and damaged handrails.
Report Facts
Survey dates: June 1, 2, 5, 6, and 7, 2023
Census: 45
Total capacity: 45
Weight loss percentage: 5.7
Weight loss percentage: 10.66
Weight loss percentage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Stanley | Interim Executive Director | Signed the report |
| Assistant Director of Nursing | Interviewed regarding oxygen tubing and code status issues | |
| Registered Nurse 3 | Interviewed regarding notification of physician for nutritional concerns | |
| Certified Nurse Aide 5 | Interviewed regarding communication needs of Resident 28 | |
| Licensed Practical Nurse 6 | Interviewed regarding wheelchair mobility for Resident 3 | |
| Certified Nurse Aide 7 | Interviewed regarding wheelchair mobility for Resident 3 |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 44
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404252 regarding staffing concerns at the facility.
Complaint Details
Complaint IN00404252 was substantiated with federal/state deficiencies cited related to allegations of insufficient staffing, especially on weekends, impacting resident safety and care.
Findings
The facility failed to maintain adequate nursing staff levels to implement fall prevention interventions and meet personal needs for 2 of 6 residents reviewed. Staffing shortages, especially on weekends, contributed to falls and unmet resident needs.
Deficiencies (1)
Failed to maintain adequate staffing levels to implement fall prevention interventions and meet personal needs for residents.
Report Facts
Census: 44
Total Capacity: 44
Medicare Census: 1
Medicaid Census: 34
Other Payor Census: 9
Nurse PPD: 1.08
CNA PPD: 2.25
Residents requiring 2 staff assistance: 17
CNA PPD on 3/4/23: 1.77
CNA PPD on 3/5/23: 1.95
Nurse PPD on 3/11/23: 0.56
CNA PPD on 3/11/23: 2.19
Nurse PPD on 3/12/23: 0.56
CNA PPD on 3/12/23: 1.63
Nurse PPD on 3/18/23: 0.84
CNA PPD on 3/18/23: 1.63
CNA PPD on 3/19/23: 1.5
Nurse PPD on 3/25/23: 0.53
CNA PPD on 3/25/23: 2.25
Nurse PPD on 3/26/23: 0.55
CNA PPD on 3/26/23: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ready | RVP/HFA | Signed the report |
| Staff 3 | Interviewed regarding Resident R's fall and staffing issues | |
| Director of Nursing | Director of Nursing | Interviewed about staffing schedules and challenges |
| Interim Administrator | Interim Administrator | Provided Facility Assessment document and staffing data |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 29, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00404252 completed on March 29, 2023.
Complaint Details
Investigation of Complaint IN00404252 completed with findings of compliance.
Findings
Life Care Center of LaGrange was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00401059 and IN00401073.
Complaint Details
Complaint IN00401059 - No deficiencies related to the allegations are cited. Complaint IN00401073 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00401059 and IN00401073 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 43
Total census: 43
Payor type census: 1
Payor type census: 34
Payor type census: 8
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 0
Date: Oct 17, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391508.
Complaint Details
Complaint IN00391508 was substantiated, but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 43
Medicare residents: 5
Medicaid residents: 34
Other payor residents: 4
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 0
Date: Sep 27, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00389341.
Complaint Details
Complaint IN00389341 - Substantiated. No deficiencies related to the allegations are cited.
Findings
The complaint IN00389341 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 43
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 34
Census Payor Type Other: 4
Inspection Report
Re-Inspection
Census: 44
Capacity: 100
Deficiencies: 0
Date: Sep 16, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/11/22 was performed by the Indiana Department of Health in accordance with 42 CFR Subpart 483.90(a).
Findings
At this PSR Survey, Life Care Center of LaGrange was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Report Facts
Facility capacity: 100
Census: 44
Inspection Report
Life Safety
Census: 44
Capacity: 100
Deficiencies: 7
Date: Aug 11, 2022
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including a corridor exit door not meeting width requirements, hazardous storage rooms lacking proper fire protection, fire alarm system lacking current smoke detector sensitivity testing, sprinkler heads loaded with debris, pass-through windows lacking smoke detection, missing fire drills on one shift for one quarter, and improper use of multi-plug adaptors in resident rooms.
Deficiencies (7)
Corridor mechanical room exit door did not meet the required 28 inch opening width; measured 20 inches due to pipes blocking the door.
Two storage rooms on the 500-hall with large amounts of combustible storage and greater than 50 square feet were not protected as hazardous areas due to lack of self-closing or automatic closing doors.
Fire alarm system lacked current documentation of smoke detector sensitivity testing; last test dated February 2018.
Four sprinkler heads in the kitchen were loaded with dirt and grease.
Two offices with pass-through windows greater than 20 square inches lacked electrically supervised automatic smoke detection.
Fire drills were not conducted on each shift for one quarter; specifically, no third shift fire drill for the fourth quarter of 2021 was conducted.
Resident room 211 used a multi-plug adaptor as a substitute for fixed wiring, which is not permitted.
Report Facts
Certified beds: 100
Census: 44
Sprinkler heads loaded: 4
Storage rooms: 2
Pass-through windows: 2
Fire drills missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and involved in observations and corrective actions for multiple deficiencies | |
| Administrator | Interviewed and involved in observations and corrective actions for multiple deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 26, 2022
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey was conducted.
Findings
Life Care Center of Lagrange was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
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