Waters of LaGrange: Smoking Safety Failures, Tripping Hazard - IN
That finding was at the center of a March 30 complaint inspection at Waters of LaGrange Skilled Nursing Facility. Inspectors also found a stretch of hallway carpet in the rehabilitation wing that had been bunched and rippled for long enough that, according to staff interviewed during the survey, it had already put one resident in the hospital with severe injuries.
The resident identified in the report as Resident H had a care plan in place since March 14 noting he was a smoker and that the facility had a non-smoking policy. The goal was that he would not injure himself or others. The intervention was to give him a copy of the smoking policy and store his materials per policy. Every time inspectors observed him during the survey, he smelled of cigarette smoke.
Leave of absence sign-in and sign-out forms showed he had been leaving the building multiple times per day since March 10, each time for roughly 20 minutes, to go smoke.
A certified nursing assistant interviewed that afternoon explained the arrangement plainly. There were three residents on her hallway who smoked. Because the facility was non-smoking, those residents went across the parking lot to the church next door. They were supposed to sign themselves in and out, get their cigarettes from the nurse before leaving, and return them when they came back. Sometimes they didn't return the materials, and staff were supposed to report that to the nurse.
When the Social Services Director and Director of Nursing were asked how residents were assessed for safety before leaving the property to smoke alone, neither answered.
The facility's own smoking policy, provided by the Director of Nursing during the inspection, said nothing about residents leaving the property. It addressed designated outdoor smoking areas, required staff to be assigned to monitor those areas, and stated that staff were to light cigarettes for residents and remain present throughout. There was no provision for a resident signing himself out, crossing a parking lot, and smoking unsupervised at a neighboring property.
A second resident, identified as Resident F, had not received a smoking evaluation after a fall until March 29, the day before inspectors arrived. The Social Services Director confirmed that. Smoking contract agreements for both Resident F and Resident H were completed on March 27, three days before the inspection concluded.
The carpet problem was in some ways simpler, and in some ways harder to explain.
On March 27, inspectors walking the northwest rehabilitation hallway found carpeting bunched in the middle of the floor, running from one room to another across a span covering five occupied short-term stay rooms. The carpet was rippled, uneven, raised off the floor in a way that created a clear tripping hazard.
Staff and visitors were observed walking through the hallway. No residents were seen in the corridor during that observation.
Confidential interviews told a different story about how long this had been going on. Multiple people told inspectors the carpet had been bunched up for some time and that administration knew about it. Someone had already fallen in that exact stretch of hallway the previous year and suffered severe injuries. Mechanical lifts were hard to maneuver through the area because of the uneven surface. Several people had tripped and had near-falls.
There was a plan to replace the carpet, staff said. But the front entrance was being done first.
The administrator, interviewed that afternoon, said they had plans to replace the carpet but couldn't do all the proposed renovations at once. He said he was not aware of any falls in the area with the bunched carpet. He said he would look into having the carpet stretched in the meantime.
The staff who spoke confidentially knew about the fall. The administrator said he didn't.
At least five short-term rehabilitation residents were living in rooms along that hallway.
The smoking situation points to something that often gets lost in the gap between a written policy and how a facility actually runs. Waters of LaGrange had a non-smoking policy and a care plan for a resident who smoked. What it didn't have was any process for what happened when that resident left the building on his own and lit up across the parking lot. Nobody had assessed whether that was safe. Nobody was watching. He just went, multiple times a day, and came back smelling like cigarettes.
Whether he ever came back with his lighter still in his pocket, the inspection report doesn't say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Lagrange Skilled Nursing Facility, The from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
WATERS OF LAGRANGE SKILLED NURSING FACILITY, THE in LAGRANGE, IN was cited for violations during a health inspection on March 30, 2026.
That finding was at the center of a March 30 complaint inspection at Waters of LaGrange Skilled Nursing Facility.
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.