Inspection Reports for The Waters of Lagrange Skilled Nursing Facility
787 N DETROIT ST, IN, 46761
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 2, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving resident abuse prevention, behavior management, dementia care, emergency preparedness, and life safety code compliance. Several substantiated complaints cited issues such as verbal abuse, misappropriation of property, failure to prevent resident-to-staff altercations, and inadequate dementia care, along with fire safety and emergency preparedness deficiencies. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have made improvements over time, with recent inspections showing compliance following correction of prior deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
15.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
276% 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 July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Jul 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462101.
Findings
No deficiencies related to the allegations in Complaint IN00462101 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00462101 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 76
Census Payor Type: 6
Census Payor Type: 57
Census Payor Type: 13
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Mar 26, 2025
Visit Reason
This visit was conducted for the investigation of Complaints IN00455899 and IN00456040.
Findings
No deficiencies related to the allegations in Complaints IN00455899 and IN00456040 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 complaints.
Complaint Details
Investigation of Complaints IN00455899 and IN00456040 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 74
Census Bed Type - SNF: 4
Total Census: 78
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 11
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 2
Feb 3, 2025
Visit Reason
This visit was conducted for the investigation of two complaints, IN00451002 and IN00451712, related to allegations of verbal abuse and misappropriation of resident property at the facility.
Findings
The facility was found to have failed to ensure residents were free from verbal abuse and misappropriation of property. Verbal abuse was identified involving a Certified Nurse Aid and one resident, and misappropriation of controlled medications by a Licensed Practical Nurse was identified involving four residents. Both deficient practices were corrected prior to the survey date.
Complaint Details
Complaint IN00451002 related to misappropriation of resident property was substantiated with deficiencies cited at F602. Complaint IN00451712 related to verbal abuse was substantiated with deficiencies cited at F600.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were free from verbal abuse for 1 of 3 residents reviewed (Resident J). | SS=D |
| Facility failed to ensure residents were free from misappropriation of property for 4 of 4 residents reviewed (Residents K, L, M, and N). | SS=E |
Report Facts
Residents reviewed for verbal abuse: 3
Residents reviewed for misappropriation: 4
Total residents present: 72
SNF beds: 4
SNF/NF beds: 68
Medicare residents: 8
Medicaid residents: 57
Other payor residents: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aid (CNA 8) | Named as involved in verbal abuse incident against Resident J. | |
| Licensed Practical Nurse 5 (LPN 5) | Involved in misappropriation of controlled medications for multiple residents; suspended following investigation. | |
| Administrator | Interviewed regarding verbal abuse and medication discrepancies; involved in investigation and reporting. | |
| Director of Nursing (DON) | Conducted compliance audits, interviewed, provided facility policies, and involved in investigation of misappropriation. | |
| Licensed Practical Nurse 7 (LPN 7) | Reported medication discrepancy involving LPN 5. |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Jan 10, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00449987, IN00450692, and IN00450727.
Findings
No deficiencies related to the allegations in complaints IN00449987, IN00450692, and IN00450727 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaints IN00449987, IN00450692, and IN00450727 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 72
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 8
Inspection Report
Re-Inspection
Census: 74
Capacity: 100
Deficiencies: 0
Jan 7, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the PSR from 12/09/24 for the Life Safety Code Recertification and State Licensure Survey conducted on 10/10/24 by the Indiana Department of Health.
Findings
At this PSR survey, The Waters of Lagrange Skilled Nursing Facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and applicable state and NFPA codes. The facility was fully sprinklered with appropriate smoke detection systems and had no deficiencies noted.
Report Facts
Facility capacity: 100
Census: 74
Inspection Report
Re-Inspection
Census: 78
Capacity: 100
Deficiencies: 5
Dec 9, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code Recertification surveys that exited on 10/10/24.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements, including fire alarm system maintenance, fire alarm system out of service policy, sprinkler system out of service policy, electrical receptacle testing, and improper use of flexible cords. Corrective actions and plans of correction were implemented with a compliance date of 12/23/24.
Severity Breakdown
SS=F: 2
SS=C: 2
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure fire alarm system was maintained in accordance with LSC 9.6.1.3; smoke detectors in NW Lounge kitchenette and Alzheimer dining hall failed sensitivity testing. | SS=F |
| Failed to provide a complete written policy for protection of residents when fire alarm system is out of service for four hours or more in a 24-hour period. | SS=C |
| Failed to provide correct written policies for automatic sprinkler system out of service for 10 hours or more in a 24-hour period. | SS=C |
| Failed to ensure non-hospital grade electrical receptacles in 95 resident sleeping rooms were tested at least annually with proper documentation. | SS=F |
| Failed to ensure flexible cords were not used as a substitute for fixed wiring; observed blue extension cord used improperly. | SS=E |
Report Facts
Facility capacity: 100
Census: 78
Number of resident rooms with electrical receptacles tested: 95
Number of extension cords observed: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Hunter | Administrator | Named in relation to findings and plan of correction |
| Maintenance Director | Interviewed regarding fire alarm and electrical system deficiencies | |
| Maintenance Supervisor/Designee | Responsible for corrective actions and monitoring preventive maintenance |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Nov 15, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00444791 and IN00445945.
Findings
No deficiencies related to the allegations in complaints IN00444791 and IN00445945 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00444791 and Complaint IN00445945 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type: 75
Census Bed Type: 3
Census Total: 78
Census Payor Type: 1
Census Payor Type: 65
Census Payor Type: 12
Inspection Report
Re-Inspection
Census: 81
Capacity: 81
Deficiencies: 0
Oct 23, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00440946 completed on 09/04/24, conducted in conjunction with a PSR to the Recertification and State Licensure Survey and Complaints IN00443025, IN00443527, IN00443716, and IN00443976 completed on 10/1/24.
Findings
Waters of Lagrange Skilled Nursing Facility 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 Investigation of Complaint IN00440946.
Complaint Details
Complaint IN00440946 was corrected as of this visit.
Report Facts
Census SNF/NF: 81
Total Capacity: 81
Census Payor Type Medicare: 5
Census Payor Type Medicaid: 67
Census Payor Type Other: 9
Inspection Report
Re-Inspection
Census: 81
Capacity: 81
Deficiencies: 0
Oct 23, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Complaints IN00443025, IN00443527, IN00443716, and IN00443976 completed on 10/1/24, done in conjunction with a PSR to Complaint IN00440946 completed on 09/04/24.
Findings
The Waters of Lagrange Skilled Nursing Facility 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. All referenced complaints were corrected.
Complaint Details
Complaints IN00443025, IN00443527, IN00443716, and IN00443976 were corrected as of this visit.
Report Facts
Medicare census: 5
Medicaid census: 67
Other payor census: 9
Inspection Report
Annual Inspection
Census: 79
Capacity: 100
Deficiencies: 10
Oct 10, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare/Medicaid participation requirements and safety codes.
Findings
The facility was found not in compliance with emergency preparedness requirements including failure to conduct required emergency plan exercises and generator testing, deficiencies in fire safety systems such as kitchen fire suppression inspection, fire alarm system testing and policies, sprinkler system out-of-service procedures, combustible decorations in resident rooms, electrical receptacle testing, generator load testing, and improper use of extension cords and power strips.
Severity Breakdown
SS=F: 5
SS=E: 3
SS=C: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=F |
| Failed to implement emergency power system requirements including missing annual load bank and fuel testing of the emergency generator. | SS=F |
| Failed to ensure kitchen fire suppression system was inspected semiannually. | SS=E |
| Failed to maintain fire alarm system including missing smoke detector sensitivity testing and annual functional inspection of all devices. | SS=F |
| Failed to provide complete written policy for fire alarm system out-of-service procedures including required notification methods. | SS=C |
| Failed to provide correct written policies for sprinkler system out-of-service procedures including required notification methods. | SS=C |
| Maintained combustible decorations (candles with wicks) in resident room. | SS=E |
| Failed to test non-hospital grade electrical receptacles in resident rooms at least annually with required testing beyond visual inspection. | SS=F |
| Failed to exercise diesel powered generator monthly with required load and perform annual fuel quality test. | SS=F |
| Used flexible cords and extension cords as substitutes for fixed wiring and used power strips improperly to power high current equipment. | SS=E |
Report Facts
Facility capacity: 100
Census: 79
Deficiencies cited: 10
Completion date for corrective actions: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Hunter | Administrator | Named in relation to exit conference and verification of corrective actions |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions | |
| Maintenance Supervisor | Responsible for corrective actions and monitoring compliance |
Inspection Report
Annual Inspection
Census: 82
Capacity: 100
Deficiencies: 13
Oct 1, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including investigation of multiple complaints.
Findings
The facility was found deficient in multiple areas including advance directive accuracy, family notification of resident incidents, privacy violations, abuse prevention, incident reporting, elopement investigation, shower provision, supervision and seizure precautions, staffing sufficiency, dementia care, and quality assurance processes.
Complaint Details
Complaints investigated included IN00443025, IN00443527, IN0043716, IN00443976, and IN00444459. Deficiencies were cited in all except IN00444459 where no deficiencies related to allegations were cited.
Severity Breakdown
SS=D: 8
SS=E: 1
SS=F: 2
SS=C: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure an advance directive (code status) was accurate for 1 of 7 residents reviewed. | SS=D |
| Failed to ensure family notification of an episode of resident-to-resident contact for 1 of 2 residents reviewed. | SS=D |
| Failed to ensure contents of a urinary catheter bag were not visible from the hallway for 1 of 2 residents reviewed. | SS=D |
| Failed to prevent abuse for 1 of 2 residents reviewed. | SS=D |
| Failed to ensure unusual incidents were reported to the appropriate agencies for 2 of 2 residents reviewed. | SS=D |
| Failed to ensure the elopement of a resident was investigated for 1 of 2 residents reviewed. | SS=D |
| Failed to ensure showers were consistently offered for 1 of 6 residents reviewed. | SS=D |
| Failed to ensure supervision and maintain seizure precautions for 2 of 6 residents reviewed. | SS=D |
| Failed to ensure adequate supervision to prevent resident elopement, falls and ensure safe smoking for 4 of 6 residents reviewed. | SS=E |
| Failed to ensure specific resident behaviors were identified, investigated and communicated with individualized interventions for a resident with dementia. | SS=D |
| Failed to ensure a process was in place to identify and correct deficiencies from re-occurring for 82 residents. | SS=F |
| Failed to ensure nursing staffing numbers were posted in an area accessible to residents and visitors. | SS=C |
| Failed to ensure in-service training for dementia for 2 of 5 staff reviewed and failed to ensure 2-step tuberculosis skin testing for 6 of 9 staff reviewed. | — |
Report Facts
Census: 82
Total licensed beds: 100
Staffing hours - CNA Day Shift: 60
Staffing hours - CNA Evening Shift: 45
Staffing hours - CNA Night Shift: 22.5
Staffing hours worked: 38
Staffing hours worked: 20.25
Staffing hours worked: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eric Hunter | Administrator | Signed report and involved in staffing and QAPI interviews |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 2
Sep 3, 2024
Visit Reason
This visit was for the investigation of Complaint IN00440946 regarding allegations of deficiencies related to wound care and pain management.
Findings
The facility failed to ensure effective identification, treatment, and prevention of pressure ulcers and skin tears for Resident J, resulting in a stage three pressure injury with infection requiring sharp debridement. Additionally, the facility failed to provide effective pain management for Resident L, who experienced pain related to an unstageable pressure ulcer and other conditions.
Complaint Details
Complaint IN00440946 - Federal/State deficiencies related to the allegations are cited at F686 (Treatment/Services to Prevent/Heal Pressure Ulcer) and F697 (Pain Management).
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure staff effectively identified skin impairment and provided appropriate treatment and physician orders for pressure ulcers and skin tears (Resident J). | SS=G |
| Failed to provide effective pain management for Resident L experiencing pain related to an unstageable pressure ulcer and other conditions. | SS=D |
Report Facts
Census: 80
Total Capacity: 80
Pain medication dosage: 50
Wound measurements: 3.5
Wound measurements: 2
Wound measurements: 1
Pain scale: 9
Pain medication dosage: 325
Pain medication dosage: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 3 | Administered pain medication and involved in wound care for Resident J | |
| Wound Nurse Practitioner (NP) | Performed wound assessments and treatments for Resident J and Resident L | |
| Regional Nurse Consultant | Interviewed regarding wound care policies and documentation |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Aug 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439417 at the Waters of Lagrange Skilled Nursing Facility.
Findings
No deficiencies related to the allegations in Complaint IN00439417 were cited. The facility was found to be in compliance with applicable federal and state regulations.
Complaint Details
Complaint IN00439417 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 79
Total Capacity: 79
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 61
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 18, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00438589 and IN00436738.
Findings
The Waters 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.
Complaint Details
Investigation of Complaints IN00438589 and IN00436738 completed on July 18, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 2
Jul 16, 2024
Visit Reason
This visit was for the investigation of complaints IN00436738, IN00437887, and IN00438589. Complaints IN00436738 and IN00438589 resulted in federal/state deficiencies related to the allegations.
Findings
The facility failed to develop and implement an effective behavior management plan for a resident with a history of alcohol abuse, resulting in resident to staff altercations and other residents fearing for their safety. Additionally, the facility failed to ensure dementia care and services were provided to a resident on the memory care unit, including lack of timely medications, lack of activities, and inconsistent staffing.
Complaint Details
Complaint IN00436738 cited deficiencies related to behavior management and safety concerns. Complaint IN00437887 had no deficiencies cited. Complaint IN00438589 cited deficiencies related to dementia care and services.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop and implement an effective behavior management plan for a resident with a history of alcohol abuse, resulting in resident to staff altercations and fear among other residents. | SS=E |
| Failed to ensure dementia care and services were provided to a resident on the memory care unit, including lack of timely medications, lack of activities, and inconsistent staffing. | SS=D |
Report Facts
Census: 79
Total Capacity: 79
Deficiencies cited: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
May 1, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00431290 completed on April 2, 2024.
Findings
The Waters 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.
Complaint Details
Investigation of Complaint IN00431290 completed with findings of compliance.
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Apr 23, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431906.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00431906 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 81
Total Capacity: 81
Medicare Census: 3
Medicaid Census: 62
Other Payor Census: 16
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 3
Apr 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431290 regarding allegations of abuse and neglect at the facility.
Findings
The facility failed to ensure a resident's right to be free from abuse, timely reporting of alleged violations, and protection from abuse during an investigation. A CNA recorded a resident without permission, shared the video with staff, and was not suspended immediately. The facility also failed to report the incident timely to the Indiana Department of Health and allowed the involved CNA to continue providing care for several days.
Complaint Details
Complaint IN00431290 involved allegations of abuse related to a CNA recording a resident without permission and mistreatment allegations. The complaint was investigated and deficiencies were cited.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure a resident's right to be free from abuse for 1 of 3 residents reviewed (Resident Q) related to unauthorized video recording and mistreatment allegations. | SS=D |
| Failed to ensure timely reporting of alleged abuse to the appropriate authorities for 1 of 3 residents reviewed (Resident Q). | SS=D |
| Failed to ensure protection from abuse for residents while an investigation was conducted for 1 of 3 residents reviewed (Resident Q). | SS=D |
Report Facts
Census: 79
Total Capacity: 79
Residents with BIM score 12 or less: Facility-wide skin sweep conducted on residents with BIM score 12 or less
Residents with BIM score 13 or higher: Abuse questionnaires completed on residents with BIM score 13 or higher
Date of alleged compliance: Apr 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 5 | Certified Nurse Aid | Recorded resident without permission and reported alleged mistreatment |
| CNA 7 | Certified Nurse Aid | Alleged mistreatment of resident; was suspended pending investigation |
| Charlie SYer | Asmin | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Nursing (DON) | Provided interviews and information about the investigation and corrective actions | |
| Social Service Director | Completed psycho-social follow up for affected resident | |
| Regional Director of Operations | Provided facility policy and education on abuse prevention |
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 0
Mar 25, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430013 and IN00430812 and included a COVID-19 infection control survey.
Findings
No deficiencies related to the allegations in complaints IN00430013 and IN00430812 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00430013 and Complaint IN00430812 were investigated with no deficiencies related to the allegations cited.
Report Facts
Census Bed Type - SNF/NF: 75
Census Bed Type - SNF: 4
Total Census: 79
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 63
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Feb 28, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00427545 and IN00429053.
Findings
No deficiencies related to the allegations in Complaints IN00427545 and IN00429053 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00427545 - No deficiencies related to the allegations are cited. Complaint IN00429053 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type - SNF/NF: 75
Census Bed Type - SNF: 5
Total Census: 80
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 14
Inspection Report
Follow-Up
Census: 77
Capacity: 100
Deficiencies: 0
Feb 20, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 12/27/23.
Findings
The Waters of Lagrange Skilled Nursing Facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is fully sprinklered with a fire alarm system and smoke detectors, and has a capacity of 100 with a census of 77 at the time of survey.
Report Facts
Facility capacity: 100
Census: 77
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Feb 19, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00453441 and IN00453602.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be compliant with applicable federal and state regulations.
Complaint Details
Investigation of Complaint IN00453441 and IN00453602 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 72
Census Bed Type - SNF: 4
Total Census: 76
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 13
Total Capacity: 76
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 8, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
The Waters of LaGrange Skilled Nursing Facility 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
Routine
Census: 80
Capacity: 100
Deficiencies: 11
Dec 27, 2023
Visit Reason
A routine Emergency Preparedness and Life Safety Code survey was conducted by the Indiana Department of Health to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Emergency Preparedness training and testing requirements, Life Safety Code requirements including exit door functionality, hazardous area protections, smoke barrier penetrations, corridor door closures, combustible decorations, fire alarm system maintenance, generator inspection documentation, and staff training on oxygen transfilling procedures.
Severity Breakdown
SS=F: 3
SS=E: 5
SS=D: 1
SS=C: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to conduct annual Emergency Preparedness Program training and demonstrate staff knowledge. | SS=F |
| Failed to provide complete documentation for the second Emergency Preparedness exercise of choice. | SS=F |
| One exit discharge door was not free of impediments and required excessive force to open. | SS=E |
| Soiled utility room door did not latch due to gloves shoved into crash plate. | SS=E |
| Fire alarm system had a trouble light flashing due to a faulty cable not yet repaired. | SS=F |
| Reception office pass-through window greater than 20 square inches was not protected by an electrically supervised smoke detector. | SS=E |
| Three resident room corridor doors would not completely close or latch due to obstructions or door issues. | SS=E |
| Penetrations through smoke barrier walls were not sealed to maintain smoke resistance. | SS=E |
| Corridor door decorations exceeded 30% of door surface area. | SS=D |
| Failed to maintain written records of weekly generator inspections for one week. | SS=C |
| Staff were not properly trained on oxygen transfilling procedures in the oxygen storage room. | SS=E |
Report Facts
Facility capacity: 100
Census: 80
Deficiencies cited: 11
Resident rooms with door issues: 3
Percentage of door covered by decoration: 45
Pass-through window opening size: 360
Gap size in smoke barrier wall: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Charlie Syer | Administrator | Named in relation to findings and exit conference |
Inspection Report
Recertification
Census: 76
Capacity: 76
Deficiencies: 8
Dec 1, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00420496.
Findings
The facility was cited for multiple deficiencies including failure to report and investigate an episode of attempted self-harm, failure to provide services for communication deficits and activities of daily living, failure to follow care plans for pressure ulcers and accident prevention, insufficient staffing for mechanical lifts, and failure to investigate and identify underlying causes of dementia-related behaviors.
Complaint Details
Complaint IN00420496 involved allegations of abuse related to failure to report and investigate an episode of attempted self-harm by Resident 34. The complaint was substantiated with federal/state deficiencies cited.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to report an episode of attempted self-harm for Resident 34. | SS=D |
| Failed to investigate an episode of attempted self-harm for Resident 34. | SS=D |
| Failed to ensure services were provided for communication deficits and activities of daily living for Residents 34 and 16. | SS=D |
| Failed to follow care planned interventions for pressure ulcers for Resident 35. | SS=D |
| Failed to follow care planned interventions to prevent accidents for Residents 3 and 74. | SS=D |
| Failed to maintain minimum staffing levels to ensure safety with 2 staff members to transfer 22 residents requiring mechanical lifts. | SS=E |
| Failed to investigate and identify underlying causes of dementia-related behaviors for Resident 34. | SS=D |
| Failed to provide medically-related social services to identify and track abnormal behaviors for Resident 34. | SS=D |
Report Facts
Census: 76
Total Capacity: 76
Residents requiring mechanical lift: 22
Minimum CNA hours required: 135
CNA hours worked: 98.75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Griffith | FNP | Assessed Resident 34 for suicidal ideation on 12/20/23. |
| Charlie Syer | Administrator | Facility Administrator signing report. |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Oct 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418401.
Findings
No deficiencies related to the allegations in Complaint IN00418401 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00418401 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 74
Census Payor Type: 74
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 12, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00415319 completed on August 16, 2023.
Findings
The facility, Waters of LaGrange Skilled Nursing Facility, 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00415319 completed on August 16, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 0
Aug 31, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00415511 and IN00416120 at the Waters of Lagrange Skilled Nursing Facility.
Findings
No deficiencies related to the allegations in complaints IN00415511 and IN00416120 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00415511 and IN00416120 found no deficiencies related to the allegations.
Report Facts
Census Bed Type: 81
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 20
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 1
Aug 16, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413928 and IN00415319. Complaint IN00413928 had no deficiencies related to the allegations, while Complaint IN00415319 resulted in federal/state deficiencies cited at F550.
Findings
The facility failed to ensure that one of three residents was treated with respect and dignity during non-care related interactions. Specifically, an activity aide showed inappropriate nude photographs on her personal cell phone to a resident, which led to the aide's suspension and monitoring of the resident for psychosocial distress.
Complaint Details
Complaint IN00413928 had no deficiencies related to the allegations. Complaint IN00415319 was substantiated with federal/state deficiencies cited at F550 related to resident rights violations involving inappropriate behavior by an activity aide.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident was treated with respect and dignity during non-care related interactions when an activity aide showed inappropriate nude photographs on her personal cell phone. | SS=D |
Report Facts
Census: 80
Total Capacity: 80
Residents interviewed weekly: 10
Residents interviewed weekly: 5
Residents interviewed monthly: 5
Date of alleged compliance: Sep 1, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident L | Resident | Resident involved in the complaint and interview |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and facility policies |
| Activity Director | Activity Director | Interviewed regarding the incident and investigation |
| Social Services Director | Social Services Director | Interviewed regarding the incident and resident monitoring |
Inspection Report
Complaint Investigation
Census: 72
Deficiencies: 0
Jun 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409718.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Complaint Details
Complaint IN00409718 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 72
Census Payor Type Total: 72
Medicare Census: 5
Medicaid Census: 53
Other Payor Census: 14
Inspection Report
Deficiencies: 0
Feb 9, 2023
Visit Reason
The inspection was conducted to assess paper compliance with the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey.
Findings
The Waters of Lagrange Skilled Nursing Facility was found in compliance with the Medicare/Medicaid Emergency Preparedness Requirements and Life Safety Code requirements.
Inspection Report
Routine
Census: 69
Capacity: 100
Deficiencies: 4
Jan 12, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with Medicare and Medicaid participation requirements, emergency preparedness, and fire safety standards.
Findings
The facility was found not in compliance with emergency preparedness requirements due to failure to conduct required emergency plan exercises at least twice per year. Additionally, deficiencies were found in life safety code compliance including outdated battery-operated smoke alarms in resident rooms, lack of self-closing door on a hazardous PPE storage room, and overdue annual fire door inspections.
Severity Breakdown
SS=F: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures. | — |
| Battery-operated smoke alarms in 54 resident rooms were not replaced according to manufacturer's instructions and were older than 10 years. | SS=F |
| PPE storage room with large amounts of combustible storage and greater than 50 square feet was not protected as a hazardous area due to lack of self-closing door. | SS=E |
| Annual inspection and testing of 9 fire door assemblies were not completed within the last 12 months as required by NFPA 80. | SS=F |
Report Facts
Facility capacity: 100
Census: 69
Battery-operated smoke alarms: 54
Fire door assemblies: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myrna Thomas | Administrator | Named in relation to emergency preparedness survey and life safety code survey findings |
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 10, 2023
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey was conducted.
Findings
The Waters of LaGrange Skilled Nursing Facility 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
Annual Inspection
Deficiencies: 2
Dec 19, 2022
Visit Reason
The inspection was conducted as part of the facility's most recent annual survey to assess compliance with behavioral health services and sanitation regulations.
Findings
The facility failed to ensure resident-specific behavioral health care for 3 residents by not identifying or adequately addressing behavioral symptoms, including exit seeking, suicidal ideations, hallucinations, and trauma history. Additionally, the facility failed to maintain sanitation of the outside trash storage area, with an open dumpster lid and spillage not cleaned promptly.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to identify and address behavioral symptoms for 3 residents, including lack of thorough assessment, documentation, and care plan updates. | SS=D |
| Failure to maintain sanitation of the outside trash storage area, including an open dumpster lid and spillage on the ground. | SS=D |
Report Facts
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Myrna Thomas | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Nursing | Interviewed regarding resident behavioral history and care plan | |
| Social Service Director | Interviewed regarding behavioral assessments and care plan revisions | |
| Dietary Manager | Interviewed regarding dumpster sanitation and observed open dumpster lid | |
| Maintenance Director | Interviewed regarding dumpster lid issues and sanitation responsibilities | |
| Administrator | Interviewed regarding dumpster lid and sanitation awareness | |
| Nurse Practitioner 1 | Provided progress notes on residents' behavioral symptoms |
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 0
Dec 5, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00395103.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00395103 was substantiated; however, no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 66
Medicare Census: 4
Medicaid Census: 39
Other Payor Census: 23
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