Smith Village

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate discharge for one resident reviewed for discharge practices by discharging the resident despite abnormal laboratory results indicative of dehydration. This deficient practice affected one (R1) of two residents reviewed for discharge. As a result, R1 was readmitted to the hospital within 48 hours of discharge with diagnoses of acute metabolic encephalopathy, likely secondary to a combination of dementia, dehydration, and urinary tract infection (UTI). Failure to ensure the resident was medically stable prior to discharge had the potential to result in worsening dehydration, delayed medical treatment, increased risk for hospitalization, and adverse health outcomes related to unresolved clinical conditions. R1 was admitted to the facility on [DATE] and discharged home on 2/18/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and residents' representatives when new treatments were initiated and failed to notify the physician of abnormal laboratory results for three (R1, R2 and R3) of three residents reviewed for notification of changes. This deficient practice had the potential to delay medical evaluation and treatment, limit resident and representative participation in care planning and informed decision-making, and place residents at risk for worsening conditions, avoidable hospitalization, and adverse health outcomes. R1 was admitted to the facility on [DATE] and discharged home on 2/18/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse protocol for one resident (R1) out of four residents reviewed for abuse. This failure resulted in an employee cashing several of R1's personal checks without his knowledge/permission. Findings Include:R1's 7/26/2025, 19:12 admission Details reads: Arrived by other. admission mode: wheelchair. Living situation prior to admission: Other residential facility / assisted living / group home. Mental Status: Alert & Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking. R1's 9/4/2025 18:26 Health Status Note Text reads: Resident actively transitioning. Family visiting through shift. Hospice RN made aware and was coming to facility. Resident resting in bed. Oncoming shift aware to monitor. R1's 9/4/2025 19:20 Health Status Note Text reads: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 7 residents prescribed controlled substances on the 3J medication cart and 5 residents prescribed controlled substances on the 2J medication cart.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that kitchen staff perform proper hand hygiene; failed to label and date dry storage food and left-over prepared foods; and failed to discard foods past their discard date. These failures have the potential to affect 60 residents consuming oral diets from the facility kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene before and after performing direct care to residents; failed to perform hand hygiene during dining; and failed to conduct proper respiratory etiquette during dining while feeding a resident. These failures affected three residents (R1, R5, and R27) in a total sample size of 36, and has the potential to affect all 23 residents that reside on the 3rd floor.

Inspectors wroteBased on interview and record review the facility failed to ensure that proper number of staff were used in transferring one of four residents (R1) to prevent accidental hazard in the sample who requires two persons assist in transfers from chair to bed or bed to chair. This failure affected R1 who was transferred from chair to bed by one staff instead of two. As a result, R1 sustained laceration of left lower leg, was sent to the hospital and the laceration required eighteen (18) sutures to be repaired. This has a potential to affect all 70-residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the bed frame is locked to the size of the mattress for the safety of one resident (R1) reviewed for injury. As a result, R1's left lower leg made contact with the loose bed frame during transfer into bed causing a laceration. R1 was sent to the hospital and the laceration was repaired with 18 sutures. This has the potential to affect all 70 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure foods were labeled, dated and maintained to prevent the spread of foodborne illness to all residents receiving oral nutrition. This failure has the potential to affect all residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the garbage dumpster lids were closed. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility staff failed to complete the controlled substance shift to shift count form which is utilized to complete a shift-to-shift count for controlled substances. This failure has the potential to affect all 27 residents on the second floor and all 16 residents on the first floor.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident (R21) with a chronic wound was placed on Enhanced Barrier Precautions (EBP). This failure has the potential to affect all 27 residents on the second floor.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one resident's (R11) urinary catheter drainage bag was covered with a privacy cover. This failure affected one resident (R11) in a sample of 44 residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow a resident's diet order for fluid restriction. This failure affected one resident (R37) out of 44 residents in the sample.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain temperature logs and provide thermometers for resident's personal refrigerators for two residents R1 and R29 to ensure the safety of the residents. This failure has the potential to affect all three residents (R1, R14 and R29) with personal refrigerators.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide adequate supervision for 1 confused resident [R1] who is a high fall risk out of 3 [R1, R2, R3] residents reviewed for falls. This failure resulted in R1 being found on the bathroom floor bleeding to the back of the head. R1 was transferred to the hospital and R1 received laceration repair with staples. Findings Include: R1's clinical record indicates in part the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise and prevent a demented and confused resident from eloping from the facility. This failure affects one of three residents (R1) reviewed for supervision in a total sample of three residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food items were properly labeled, dated, and stored; failed to ensure raw food and cooked/ready to eat foods stored properly on the same storage rack using top-to-bottom system per facility policy; and failed to ensure staff performed appropriate hand hygiene in between handling dirty plate ware and clean plate ware. This deficient practice has the potential to affect all 70 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dumpsters were covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 70 residents who reside in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain residents' dignity during meals (R8, R12, R42, R68) and while using a urinary catheter drainage bag (a device in which urine drains into) for one resident (R43) in a sample of 37 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to label/date 3 (R25, R32, R56) of 3 residents oxygen tubing, failed to properly store 2 (R32, R56) of 2 residents oxygen tubing and 1 (R32) nebulizer set up to prevent contamination, failed to change R56's oxygen humidifier bottle, and failed to have an oxygen in use signage posted for 1 (R42) resident reviewed for oxygen therapy in a sample of 18. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff wore the proper PPE (Personal Protective Equipment) during medication administration for 1 (R27) resident. This failure has the potential to affect 28 residents residing on the third floor.