Grove of LaGrange Park: Resident Left Soiled for Hours - IL
It was the first time anyone had checked her that day.
The nursing assistant, identified in inspection records as V3, said she believed the resident, identified as R6, had last been changed around 5:00 AM by the overnight aide. That was roughly seven hours earlier. V3 told inspectors this was her first round of the day and that R6 had not been checked or changed before the meal tray arrived.
The inspection, conducted by complaint at The Grove of LaGrange Park, was documented on October 20, 2025.
A second nursing assistant, V6, told inspectors the following afternoon that she had not been present during the incident but confirmed that the facility's own protocol requires residents to be checked and changed every two hours, and before and after every meal. The Director of Nursing, identified as V2, said the same thing when interviewed at 2:15 PM on October 15. CNAs are expected to check and change residents at least every two hours and before and after meals, she said. All CNAs receive orientation, competence, and computer training when hired.
The facility's Incontinence and Perineal Care Policy, dated June 30, 2025, states that staff should do rounds at least every two hours to check for incontinence during a shift and provide perineal care to ensure cleanliness, comfort, and infection prevention. The General Care Policy, also dated June 30, 2025, states the facility will provide care to meet each resident's physical and psychosocial needs.
None of that happened for R6 on the morning of October 14.
Sitting in soiled bedding for hours is not a minor inconvenience. Prolonged contact with urine and feces breaks down skin, creating conditions for pressure injuries and infection. For a resident who cannot reposition or clean herself, the gap between a 5:00 AM change and a noon discovery is not an oversight in paperwork. It is hours of physical discomfort that the facility's own written policies were designed to prevent.
The inspection classified the harm level as minimal harm or potential for actual harm, and noted that some residents were affected. What the record shows is one woman, in bed, with a meal tray beside her and no one having checked on her since before dawn.
The Director of Nursing's response pointed to training. Orientation. Competence checks. Computer modules. What it did not explain was why, on that particular morning, no one came.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Grove of Lagrange Park, The from 2025-10-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
GROVE OF LAGRANGE PARK, THE in LA GRANGE PARK, IL was cited for violations during a health inspection on October 20, 2025.
It was the first time anyone had checked her that day.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.