Lagrange Trails of Journey LLC

Inspectors wroteBased 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. Following use, the nurse cleaned only the strip insertion area of the glucometer with an alcohol swab rather than disinfecting the entire device according to facility policy. [...]

Inspectors wroteBased 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 carbonate), give 600 milligrams(mg) one time a day. [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled Catheter Care, the facility failed to ensure privacy was maintained for two of six residents (R) (R94 and R54) with an indwelling urinary catheter. This deficient practice had the potential to place R94 and R54 at risk of a diminished quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Routine Bathroom Cleaning, the facility failed to ensure resident bathrooms were maintained in a clean and sanitary manner in three of seven resident restrooms. This deficient practice placed the residents residing in the rooms at risk of living in an unsanitary environment.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Bed Hold Notice, the facility failed to provide bed hold information, in writing, at the time of transfer or within 24 hours, for one of 43 sampled residents (R) (R82). This failure had the potential to contribute to possible denial of re-admission and loss of the residents' home following a hospitalization for residents transferred to the hospital.

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility policy titled Appropriate Use of Indwelling Catheters, the facility failed to transcribe a physician's order for an indwelling urinary catheter for one of six residents (R) (R94) with an indwelling urinary catheter.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Oxygen Administration, the facility failed to ensure oxygen (O2) therapy was administered according to the physician's order and respiratory equipment was maintained in a sanitary manner for one of 23 residents (R) (R6) receiving O2 therapy. The deficient practices had the potential to place R6 at risk of respiratory distress and a diminished quality of life.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure that physician-ordered medications were obtained from the pharmacy to be administered at the designated time for three of 43 sampled residents (R) (R93, R64, and R24). This deficient practice had the potential to place R93, R64, and R24 at risk of unmet needs and medical complications. Findings Include: 1. Review of R93's admission Record revealed R93 was admitted to the facility on [DATE] with diagnoses including, but not limited to, essential hypertension and hyperlipidemia. Review of R93's Physician Orders revealed an order dated 5/6/2025 for amlodipine besylate (a medication used to treat high blood pressure, chronic stable chest pain, and coronary artery disease) oral tablet 5 milligrams (mg), give one by mouth one time a day for blood pressure, hold if systolic blood pressure is less than 110. [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure a medication error rate of less than five percent. There were three errors of 30 opportunities for two of six residents (R) (R93 and R24) observed for a medication error rate of 10 percent. This deficient practice had the potential to result in medication not being given in accordance with the physician's orders and the potential to adversely affect R93 and R24's clinical conditions.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled, Antipsychotic Medication Use, the facility failed to ensure that behavior monitoring was documented for one of four residents (R) (R17). The deficient practice had the potential to inhibit nursing staff from monitoring side affects and or adverse reactions for R17 while consuming antipsychotic medications and reporting the findings to the physician.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility policies titled, Obtaining a Fingerstick Glucose Level and Hand Hygiene Policy and Procedures, the facility failed to ensure infection control procedures were followed during Glucose finger stick monitoring for three of five Residents (R) (R57, R49, and R12). The deficient practice had the potential to increase the probability of the spread of infection between residents R57, R49, and R12 while monitoring their blood glucose levels.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, staff interviews, record review and review of policies titled Self-Administration of Medications and Administering Medications, the facility failed to ensure one of 22 sampled residents (R) (#134) was assessed to self-administer medications.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable, homelike environment related to dusty air intake vents, missing tiles, and disrepair of sinks on one of six halls (100 hall).

Inspectors wroteBased on observations, record review, and review of policy titled Oxygen Administration, the facility failed to obtain a physician's order to administer oxygen to one resident (R) (#41) of ten residents receiving oxygen therapy.

Inspectors wroteBased on observation, record review, resident and staff interview and policy review titled Hemodialysis Access Care, the facility failed to ensure the dialysis access site was monitored for one resident (R) (#59) receiving dialysis.

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance for four resident rooms (102A, 102B, 106A and 106B) on one of six halls (100 hall).