Smith Crossing

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Licensed Practical Nurse (LPN) had training/certification to infuse an intravenous (IV) medication. This applies to 1 of 1 resident (R1) reviewed for IV medication administration in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of an unstageable pressure ulcer for a resident at moderate risk for skin breakdown. This failure led to a resident requiring skin grafting. This applies to 1 of 4 residents (R59) reviewed for pressure ulcers in a sample of 21.

Inspectors wrote2. R13's progress notes show the following: On 12/30/24 at 9:14 PM at 6 PM, (R13) observed supine on floor near window. Limb shortening noted to LLE (Left Lower Extremity). (R13) complained of pain to RLE (Right Lower Extremity), but unable to rate pain using number scale. This nurse called 911 and notified dispatch of unwitnessed fall. Called Fire Department. EMT (Emergency Medical Technician) arrived. (R13) sent to hospital emergency room. On 12/30/24 at 11:14 PM, (R13) admitted to ICU (Intensive Care Unit) with a diagnosis of subdural hematoma. On 12/31/24 at 7:56 PM, (R13) returned from hospital with POA (Power of Attorney) at bedside via stretcher with ambulance services. On 3/21/25 at 10:12 PM, Writer was called to (R13)'s room by the CNA (Certified Nursing Assistant). Writer observed (R13) sitting on the side of the bed on the floor. (R13) was bleeding from her head. [...]

Inspectors wrote4. On 6/16/25, at 9:30 AM, R330 was resting on her bed and just had a bowel movement on the bed pan. V22 (CNA) provided peri-care with the assistance of V21 (Nurse). V22 cleaned R330's back perineum, removed the bed pan, emptied the stool into the toilet, returned to R330, and continued to clean R330's frontal perineum. V21 and V22 applied a clean incontinence brief and assisted to reposition R330. V22 changed her gloves in between all these tasks without performing hand hygiene. On 6/17/25, at 11:01 AM, V2 (DON) stated the staff must perform hand hygiene and change gloves in between tasks, such as dirty to clean tasks, to prevent cross contamination and spread of infection. Facility's Policy and Procedure for Hand Hygiene dated December 2024, shows: Policy: All staff will perform proper hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining experience. This applies to 1 resident (R26) reviewed for dignity in a sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's medical records were in agreement with his wishes for his advance directives. This applies to 1 of 6 residents reviewed for advance directives in a sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and homelike environment. This applies to 2 of 2 residents (R2, R22) reviewed for environment in a sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to meet the needs of the residents. This applies to 3 of 3 residents (R54, R59 & R60) reviewed for ADLs care in a sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide peri-care in a manner that would prevent urinary tract infection, and failed to ensure that urinary catheter drainage bags are not touching the floor. This applies to 4 of 4 residents (R59, R128, R227, R330) reviewed for peri-care and catheter care in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain orders for gastrostomy tube (g-tube) flushes. This applies to 2 of 2 residents (R64, R70) reviewed for gastrostomy tube in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were administered as prescribed by the physician. There were 26 medication opportunities with 5 errors, resulting to 19.23% error rate. This applies to 2 of the 5 residents (R19, R70) reviewed for medication administration in the sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to document complete assessments of pressure ulcers. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for pressure ulcers in the sample of 8.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a cognitively impaired resident received treatment and care in accordance with professional standards of practice for 1 of 4 residents (R2) reviewed for nursing care and services. This failure resulted in staff pulling on R2's contracted arm while turning resident in bed that caused R2 to experience moderate to severe pain to her left arm and was subsequently diagnosed with a fracture to the left humeral head (upper arm).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement effective fall interventions to minimize the risk of falls, failed to ensure current fall interventions were in place for a resident at risk for falls, and failed to provide adequate supervision to prevent repeated falls with or without significant injury for 3 of 4 residents (R1, R3, R4) reviewed for accidents and supervision in a sample size of 4. This failure resulted in R4, who is a high fall risk with repeated falls, being observed without current fall preventative interventions in place; and resulted in R1 and R3 who had repeated falls and subsequently were emergently transferred to the hospital after a fall incident for treatment of a cervical neck fracture and facial abrasion (R1) and closure of a head laceration with staples (R3).

Inspectors wroteBased on interviews and record review, the facility failed to recognize an injury of unknown origin as a suspected allegation of abuse and failed to report an allegation of abuse to the administrator. This failure applies to 1 of 1 resident (R2) reviewed for abuse in a sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen staff performed hand hygiene before handling clean dishes, and failed to ensure staff contained their hair during food preparation. This applies to 74 of 75 residents that consume food from the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide privacy during personal cares. This applies to 4 residents (R29, R45, R117, & R418) reviewed for privacy in a sample of 20.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to appropriately store medications and biologicals safely for 6 residents (R44, R15, R18, R45, R47, R6 and R418) in a sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post and follow isolation precautions for residents under isolation; failed to perform hand hygiene during meal service, toileting, wound care, and incontinence care; and failed to safely handle soiled linen. This applies to 8 of 8 residents (R23, R29, R43, R44, R45, R117, R167, R418) reviewed for infection control in a sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess whether a resident was able to administer medications independently. This applies to 1 of 1 resident (R419) reviewed for self-administration of medications in a sample of 20.

Inspectors wroteBased on interview and record review, the facility failed to provide the facility's bed hold and bed payment policy in writing to a resident and their representative before transferring to the hospital. This applies to 1 of 3 residents (R66) reviewed for discharge in a sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide wound dressing changes as per physician's order. This applies to 1 of 4 residents (R64) reviewed for skin conditions in a sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to store oxygen cylinders in a manner to prevent possible explosion hazards, and failed to transfer a resident using a gait belt. This applies to 4 of 4 residents (R25, R59, R64 and R418) reviewed for safety hazards in a sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received oxygen therapy consistent with how the device was designed to deliver it per physician orders. This applies to 1 of 4 residents (R15) reviewed for respiratory care in a sample of 20. On 6/25/24 at 12:14 PM, R15 was sitting at a table in the dining room with her nasal cannula crooked on her face; one nasal prong was in her right nostril and the other nasal prong was next to her right nostril on her right cheek. Her nasal cannula tubing was connected to a portable oxygen delivery device that was flashing orange with message no breathing detected, please check cannula. Surveyor counted R15's respiratory rate at 32 breaths per minute. Surveyor asked R15 if she was feeling and breathing okay and R15 did not answer. R15 was breathing fast, but she was not mouth breathing or gasping for air. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date medications after it was opened to determine expiration dates. This applies to 4 of 6 residents (R15, R57, R58, R59) reviewed for labeling and storage of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices regarding hand hygiene and changing of gloves during provisions of peri-care. This applies to 4 of 20 residents (R12, R32, R57, R67) reviewed for infection control in the sample of 20. 1. On 8/14/23 at 1:38 PM, V26 (Certified Nursing Assistant/CNA) rendered peri-care to R57. V26 cleaned R57's perineum from front to back and applied a new incontinence brief while wearing the same gloves. Afterwards, V26 changed her gloves without hand hygiene. She assisted to reposition R57 and R57's indwelling urinary catheter, then placed a blanket on top of R57. 2. On 8/15/23 at 1:04 PM, V27 and V28 (Both CNAs) rendered incontinence care to R12 who was wet with urine and had a bowel movement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent, identify, and manage a residents facility acquired pressure ulcer. This applies to 1 of 5 residents (R17) in the sample of 20.

Inspectors wroteBased on observation and interview the facility failed to ensure the correct placement of a gastrostomy tube before administering medication and fluids through it. This applies to 1 of 1 (R58) resident reviewed for gastrostomy tubes.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Peripherally Inserted Central Catheter (PICC) care. This applies to 1 of 1 resident (R42) in the sample of 20.

Inspectors wroteBased on observation and interview the facility failed to ensure that oxygen was delivered to a resident at the rate prescribed by the physician. This applies to 1 of 1 (R23) resident reviewed for oxygen therapy.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve pureed diet with the consistency as per policy guidance. This applies to 2 of 2 residents (R224 and R225) reviewed for pureed diets in the sample of 20.