Smithfield Manor Rehabilitation and Healthcare Cen

Inspectors wroteBased on record review and interviews with resident, staff, and pharmacist the facility failed to ensure communication between the pharmacy, facility staff, and provider occurred in order that a prescription be obtained for a controlled medication so that a new supply of the medication could be filled and dispensed, which in turn resulted in a resident missing 12 consecutive doses of an ordered medication. This was for one (Resident # 1) of one resident reviewed for pharmacy services.

Inspectors wroteBased on record review and staff interview the facility failed to ensure a resident's record was complete regarding measures taken when a change of status was initially noted. This was for one (Resident # 2) of three residents whose medical records were reviewed for change of status.

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to provide staff and residents with washcloths and towels to complete Activities of Daily Living (ADL) care. This occurred for 5 of 5 residents residing on 2 of 4 halls reviewed for linens (East and [NAME] Halls).

Inspectors wroteBased on observations, and staff interviews, the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent the potential for cross contamination of food by failing to clean the shelf under the steam table for 2 of 2 steam tables observed. In addition, failed to clean the door handles for 2 of 2 reach-in refrigerators and 1 of 1 hot box/warmer and to clean 1 of 1 pellet plate warmer observed. These practices had the potential to affect food served to residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic pain medication (Oxycodone) for 1 of 1 resident reviewed for misappropriation of property (Resident #60).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code the physician's documented clinical contraindication of a gradual dose reduction (GDR) of psychotropic medications (Resident #2) and appliances in the bowel and bladder section for 2 of 27 residents reviewed for Minimum Data Set (MDS) assessment accuracy (Resident #91).

Inspectors wroteBased on observations, and staff and Medical Director interviews, the facility failed to observe a resident to ensure they had taken their medications during medication administration which resulted in a cup of pills being found on the resident's bed for 1 of 1 resident observed with medications at the bedside (Resident #83).

Inspectors wroteBased on record review and staff interviews, the facility failed to provide care in a safe manner when the resident rolled off of the bed and onto the floor during incontinence care. This deficient practice affected 1 of 4 residents reviewed for accidents (Resident #121).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 2 residents reviewed with urinary catheters (Resident #123).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure agency personnel was adequately trained and competent before providing care of residents for 1 of 8 agency personnel reviewed for training requirements (Nursing Assistant #9).

Inspectors wroteBased on observations, manufacturer's instructions, and staff and Pharmacist interviews, the facility failed to remove one (1) open bottle of zinc sulfate, (1) multi-dose lispro insulin injector pen, and one (1) multi-dose glargine insulin injector pen that were expired in 1 of 4 medication carts reviewed for medication storage and labeling (Upper East Medication Cart).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure daily nurse staffing sheets were accurate for 33 of 33 days reviewed for posted staffing.

Inspectors wroteBased on observations, record review, and resident, staff and physician interviews, the facility failed to provide care in a safe manner on 10/26/25 when Resident #1 rolled out of bed while a nurse aide was providing care sustaining a left distal tibia and fibula fracture (two main bones in the lower leg). Resident #1 required surgical intervention to repair the fractures and was discharged back to the facility on [DATE] with a splint applied to her left leg. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1).

Inspectors wroteBased on observation, record review, and interviews with the resident, staff, and the Medical Director, the facility failed to follow the manufacturer's instructions for wheelchair securement in a transportation van. On August 26, 2025, the Transport Driver incorrectly anchored all four securement straps to the rear wheels of the wheelchair, leaving the front of the wheelchair unsecured. As the vehicle accelerated, the unsecured wheelchair tipped backward, causing Resident #1 to fall and strike her head and back on the floor of the van. She was transported to the hospital, where she was diagnosed with posterior (back) neck and upper back pain, a superficial laceration on the tip of her tongue, paraspinal (muscles located along the spine) tenderness in the upper thoracic (part of the body between the neck and the abdomen) region, and a superficial abrasion on her right hand. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to have a process that provided an opportunity to formulate an advance directive (Resident's #'s 292, 73, 287, 54) and have accurate advance directive documentation throughout the medical record (Resident #54) for 5 of 15 residents reviewed for advance directives.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of skin conditions (Resident #129), bowel and bladder (Resident #31), nutritional status (Resident #5) and discharge (Resident #134) for 4 of 36 residents whose MDS assessments were reviewed.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop and implement an individualized care person centered care plan in the area of nutrition for 3 of 36 residents reviewed for comprehensive care plans (Resident #67, Resident #122 and Resident #19).

Inspectors wroteBased on observation, record review, and Medical Director, Pharmacist Consultant, Sales Representative and staff interviews, the facility failed to protect the resident from a potential flammable hazard for 1 of 3 residents reviewed for accidents. (Resident #16)

Inspectors wroteBased on observations, record review, interviews with the Medical Director and staff, the facility failed to provide supplemental oxygen as ordered by the physician for 1 of 1 resident reviewed for respiratory care (Resident #16).

Inspectors wroteBased on observations and staff interviews, the facility failed to secure residents' medications in a locked medication cart for 1 of 6 medication carts observed (200-hall upper west medication cart).

Inspectors wroteBased on observation, record review and interviews with staff, Nurse Practitioner, Medical Examiner and Physician, the facility failed to protect a resident's right to be free from neglect for 1 of 3 sampled residents reviewed for neglect (Resident #1). On 3/4/24, Nursing Assistant (NA) #1 disregarded Resident #1's physician orders and plan of care for the assessed need of 2 person assistance with Activities of Daily Living (ADL) care and provided care to the resident without assistance. During care, NA # left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. [...]

Inspectors wroteBased on observation, record review, staff, Nurse Practitioner, Medical Examiner and Physician interviews, the facility failed to provide Activities of Daily Living (ADL) care safely to a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 3/4/24 Nursing Assistant (NA #1) began providing care to Resident #1 when he left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. Resident #1 was transferred to the emergency room where a Computerized Tomography (CT) scan revealed a closed fracture of the left distal femur (a break of the thigh bone just above the knee) and a small skin tear to the left elbow. [...]

Inspectors wroteBased on record review and facility staff and Dialysis staff interviews the facility failed to have a system in place to monitor for complications before and after dialysis treatments and to ensure there was ongoing communication, coordination, and collaboration between the nursing home and the dialysis staff for 1 of 1 residents reviewed for dialysis (Resident #46).