F0689

D

Failure to Ensure Smoking Safety and Correct Tripping Hazards in Resident Hallway

Lagrange, Indiana Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately assess and evaluate smoking safety for two residents and to maintain an environment free from accident hazards. One resident with Alzheimer’s disease, moderately impaired cognition, impaired vision, and a history of nicotine dependence experienced a fall while smoking outside the facility entrance, resulting in facial fractures and a traumatic hematoma to the right knee. Her MDS and quarterly smoking evaluations documented that she did not use smoking or tobacco products, and her care plan stated she did not smoke at the facility, only occasionally with family on outings. Despite this, she reported routinely going across the parking lot to a nearby church to smoke and, on the day of the fall, chose to smoke near the facility entrance due to windy conditions, sitting on her rolling walker and falling when her coat pocket caught on the walker handle. A pack of cigarettes was observed at her bedside, and her revised care plan did not address that she was an everyday smoker, her safety in ambulating off the property to smoke, staff interventions to ensure her safety off site, or ongoing observations for safe smoking given her cognitive and physical status.

A second resident with paralysis of the lower extremities was also not fully assessed and managed for smoking safety. His admission MDS and initial smoking evaluation indicated he did not use tobacco, but a subsequent significant change smoking evaluation documented that he used cigarettes and a vape pen. His care plan identified potential safety hazards and injury related to smoking and noted that the facility had a non‑smoking policy, with interventions to provide a copy of the policy and store smoking materials per facility policy. However, LOA sign in/out forms showed that beginning shortly after admission, he signed himself out multiple times per day for about 20 minutes each time to go smoke, and staff reported that residents who smoked would go across the parking lot to a neighboring church lot to smoke. Staff also stated that residents were to obtain smoking materials from the nurse and return them afterward, but sometimes did not return them. The facility’s smoking policy addressed only smoking in designated outdoor areas when permitted and staff monitoring of those areas, and did not address assessment of resident safety when leaving the property to smoke or where residents were permitted to smoke off site.

The facility also failed to ensure the environment was free of accident hazards by not correcting bunched‑up and uneven carpeting in a resident hallway. During observation, the carpeting in the middle of the northwest rehabilitation hallway was rippled and bunched from one resident room to another, creating a tripping hazard in an area where five short‑term stay rooms were occupied. Confidential interviews indicated the carpet had been in this condition for some time and that administration was aware of the problem. Interviewees reported that a resident had fallen in that hallway the previous year, causing severe injuries, that mechanical lifts were difficult to move down the hallway because of the uneven carpet, and that several people had tripped with near falls. Staff and visitors were observed walking in the hallway during the survey, confirming the ongoing presence of the hazard.