Smiths Mill Health Campus

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to properly store drugs and biologicals in the medication storage rooms and ensure all medications were properly stored in a secured location. This affected two of two medication rooms reviewed for medication storage. This affected Resident #31 and had the potential to affect all 49 residents in the facility.

Inspectors wroteBased on interview, medical record review, and review of facility policy, the facility failed to conduct care plan conferences at regular intervals for residents. This affected four (Residents #19, #50, #61, and #62) of four residents reviewed for care planning. The facility census was 49 residents.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the call light was in reach for residents. This affected three (Resident #9, #27, and #50) of five residents reviewed for environment. The facility census was 49 residents.

Inspectors wroteBased on interview, medical record review, and review of facility policy, the facility failed to report an allegation of injury of unknown origin. This affected one (Resident #27) of two residents reviewed for abuse. The facility census was 49 residents.

Inspectors wroteBased on interview, medical record review, and review of facility policy, the facility failed to investigate an allegation of injury of unknown origin for Resident #27. This affected one (Resident #27) of two residents reviewed for abuse. The facility census was 49 residents.

Inspectors wroteBased on review of medical records, staff interviews and review of facility policy, the facility failed to issue a bed hold letter for a resident upon discharging to the hospital. Additionally, the facility failed to notify the Ombudsman of the discharge status of two residents. This affected two residents (#64 and 66) out of two residents reviewed for discharge. The facility census was 49 residents.

Inspectors wroteBased on review of resident medical record, review of resident hospital records, and staff interviews, the facility failed to accurately transcribe a diet order for a resident. This affected one resident (#67) out of four residents reviewed for food. The facility census was 49 residents.

Inspectors wroteBased on observation, staff interview, medical record review, and review of facility policy, the facility failed to change oxygen tubing as ordered by the physician and facility policy. This affected one (Resident #30) of two residents reviewed for oxygen services. The facility census was 49.

Inspectors wroteBased on medical record review, review of the monthly pharmacy recommendations, staff interviews, and review of facility policy, the facility failed to address pharmacy recommendations in a timely manner for the residents. This affected three (#11, #27, and #54) of five residents reviewed for unnecessary medications. The facility census was 49.

Inspectors wroteBased on interview, medical record review, and review of facility policy, the facility failed to implement non-pharmacological interventions in the management of a resident's pain. This affected one (Resident #27) of five residents reviewed for unnecessary medications. The facility census was 49.

Inspectors wroteBased on medical record review, observation, staff interview and review of facility policy, the facility failed to maintain a proper containment system for soiled personal protective equipment for a resident. This affected one (Resident #26) of five residents reviewed for infection control. The facility census was 49.

Inspectors wroteBased on observation, medical record review and interviews, the facility failed to ensure one resident who was dependent on staff for eating was provided a dignified dining experience when his meal tray was left for an extended period of time before staff returned to feed him. This affected one resident (#22) of six sampled residents. The facility census was 49. Findings Include:Review of the medical record for Resident #22 revealed an initial admission date of 02/06/25 with the diagnoses including but not limited to Guillain-Barre syndrome, dysphagia, retention of urine, diabetes mellitus, hyperlipidemia, hypertension and functional quadriplegia. Review of the plan of care dated 02/20/25 revealed the resident required staff dependence to complete self-care and mobility functional tasks completely and safely. [...]

Inspectors wroteBased on observation, open and closed medical record review, hospital record review, and interview, the facility failed to ensure physician ordered treatments were provided to non-pressure skin impairments. Additionally, the facility failed to identify a change in condition timely. This affected one resident (#19) of three residents reviewed for skin breakdown and one resident (#50) of three residents reviewed for change in condition. The facility census was 49. Findings Include:1. [...]

Inspectors wroteBased on medical record review, interview, hospital summary review, review of staffing schedules and facility policy review, the facility failed to provide adequate supervision and /or assistive devices to prevent falls and/or injury for those residents with a cognitive deficit. Additionally, the facility failed to ensure one resident was assisted in bed mobility in a manner to prevent falls from bed. This affected three residents (#19, #50 and #51) of three residents reviewed for falls. The facility census was 49. Findings Include:1. [...]

Inspectors wroteBased on observation, medical record review, interview and daily assignment sheet review, the facility failed to ensure sufficient levels of staffing to supervise to prevent falls. This affected one resident (#50) of three residents reviewed for falls. The facility census was 49. Findings Include:. Review of the closed medical record for Resident #50 revealed an initial admission date of 01/29/26 with the diagnoses including but not limited to displaced subtrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, effusion of right knee, anemia, cerebral ischemia, retention of urine, Alzheimer's disease, dementia, unspecified fall, adult failure to thrive, constipation, osteoarthritis, other specified disorder of right middle ear and mastoid and personal history of malignant neoplasm of prostate and tongue. [...]

Inspectors wroteBased on medical record review, interview and review of after care summary, the facility failed to ensure physician orders were implemented in a timely manner. This affected one resident (#19) of six sampled residents. The facility census was 49. Findings Include:Review of the medical record for Resident #19 revealed an initial admission date of 02/01/26 with the diagnoses including but not limited to infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, toxic encephalopathy, cellulitis of right lower limb, myositis, right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, retention of urine, cardiac arrythmia, left below the knee amputation, dementia, insomnia, chronic pain syndrome, benign prostatic hyperplasia and hypothyroidism. [...]

Inspectors wroteBased on medical record review, interview and facility policy review, the facility failed to ensure a complete and accurate electronic medical record (EMR). This affected two residents (#19 and #50) of six sampled residents. The facility census was 49. Findings Include:1. Review of the medical record for Resident #19 revealed an initial admission date of 02/01/26 with the diagnoses including but not limited to infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, toxic encephalopathy, cellulitis of right lower limb, myositis, right thigh, peripheral vascular disease, anemia, atrial fibrillation, hypertension, congestive heart failure, retention of urine, cardiac arrythmia, left below the knee amputation, dementia, insomnia, chronic pain syndrome, benign prostatic hyperplasia and hypothyroidism. [...]

Inspectors wroteBased on observation, medical record review, interview and facility policy review, the facility failed to maintain appropriate infection control practices to prevent the potential spread of infection during a pressure ulcer dressing change. This affected one resident (#16) of three residents reviewed for skin breakdown. The facility census was 49. Findings Include:Review of the medical record for Resident #16 revealed an initial admission date of 11/19/25 with the diagnoses including but not limited to sepsis, urinary tract infection, osteomyelitis of vertebra, stage four pressure ulcer to sacral region, moderate protein calorie malnutrition, hypertension, congestive heart failure, encounter for palliative care, neuromuscular dysfunction of bladder, dementia, hyperlipidemia, hypothyroidism, cerebral infarction, adult failure to thrive and dysphagia. [...]

Inspectors wroteBased on staff interview, record review, review of facility policy and review of drug labels, the facility failed to have appropriate diagnoses to support the use of an antipsychotic medication. This affected one (Resident #10) out of three residents reviewed for antipsychotic medication administration. The facility census was 44. Findings Include:Review of the medical record for Resident #10 revealed an admission date of 03/17/24, with diagnoses including Parkinson's disease and dementia (without behavioral, psychotic, mood, or anxiety disturbances), altered mental status, and depression. Review of the care plan dated 10/16/24 revealed Resident #10 exhibited altered behaviors, including hallucinations. Interventions included identifying behavioral triggers, notifying the physician of changes, redirecting the resident when needed, and administering medications as ordered. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and review of facility policy, the facility failed to ensure residents who had recent weight loss received their nutritional supplements and weighed according to physician orders. This affected one (Resident #18) of three residents reviewed for weight loss. The facility census was 39.

Inspectors wroteBased on record review and staff interviews, the facility failed to staff a registered nurse eight hours a day, seven days a week. The facility census was 42.

Inspectors wroteBased on record review, resident interview, staff interview and policy review, the facility failed to provide transportation to a scheduled medical appointment. The affected one Resident ( #17), of three residents reviewed for transportation to medical appointments. The facility census was 42.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to keep one, Resident (#23), of three reviewed for fall risk, free from a fall during care. The facility census was 42. Findings Include: Resident #23 was admitted [DATE] with the most recent re-admission date of 12/07/24, diagnoses included metabolic encephalopathy, dysphagia, severe protein-calorie malnutrition, hyperosmolality and hypernatremia, hypokalemia, adult failure to thrive, low back pain, major depressive disorder, anxiety disorder, neurocognitive disorder with Lewy bodies, Vitamin D deficiency, and hallucinations. Review of the admission minimum data set (MDS) 3.0 dated 11/11/24 revealed the resident was unable to be interviewed, Resident #23 is rarely understood. Staff reported Resident #23 had both short-term and long-term memory problems. [...]

Inspectors wroteBased on medical records review, shower sheet review, and staff interview, this facility failed to ensure residents received a bath or shower as scheduled and failed to provided supporting documents for provided shower sheets. This affected one (Resident #49) of the five residents reviewed for hygiene care. The facility census was 46.

Inspectors wroteBased on medical record review, wound clinic order review, and staff interview, this facility failed to ensure orders for lymphedema pumps were implemented as ordered. This affected one (Resident #49) of the five residents reviewed for physician orders. The facility summary was 46.

Inspectors wroteBased on medical records review, incident investigation review, and staff interview, this facility failed to ensure residents were free from injury when receiving assistance and transportation from facility staff. This affected one (Resident #49) of the five residents reviewed for accidents and injuries. The facility census was 46.

Inspectors wroteBased on medical record review, staff interview, and review of the resident assessment instrument (RAI) guidelines, the facility failed to ensure that minimum data set assessment (MDS) were completed within required timeframe's. This affected eight (Resident #1, #4, #19, #20,#30, #31, #44 and #299. The census was 41.

Inspectors wroteBased on medical record review, review of the medication administration record, staff interview, and facility policy review, the facility failed to ensure medications were available to be administered for one (Resident #20) resident and failed to ensure medication was administered timely as prescribed for four (Resident #12,#20,#30, and #22) residents. This affected four (Resident #12,#20,#30, and #22) residents out of 19 residents reviewed for medications. The facility census was 41.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure proper parameters were identified for anticoagulant, as needed (PRN) pain, and blood pressure medications. The deficient practice affected five residents (Residents #12, 28, 96, 98, and 146) of eight residents reviewed for unnecessary medications. The facility census was 41. Findings Include: 1. Review of the medical record for Resident #96 revealed an admission date on 09/14/24 and a discharge date on 10/01/24. Medical diagnoses included displaced intertrochanteric fracture of right femur, periprosthetic fracture around internal prosthetic right hip joint, paroxysmal atrial fibrillation, unspecified cirrhosis of liver, and anxiety disorder. Review of the census revealed Resident #96 was hospitalized from [DATE] to 09/25/24. [...]

Inspectors wroteBased on record review, resident representative and staff interviews, and facility policy review, the facility failed to timely notify one resident's representative (Resident #34) and certified nurse practitioner (CNP) of changes in condition. The deficient practice affected one resident (Resident #34) of three reviewed for changes in condition. The facility census was 41. Findings Include: Review of the medical record for Resident #34 revealed an admission date on 06/13/24 and a discharge date on 09/27/24 with return to the facility expected. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to provide written notice of transfer to a hospital to one resident (Resident #34) and/or the resident's representative. The deficient practice affected one resident (Resident #34) of three reviewed for transfer and discharge. The facility census was 41. Findings Include: Review of the medical record for Resident #34 revealed an admission date on 06/13/24 and a discharge date on 09/27/24 with return to the facility expected. Medical diagnoses included abdominal aortic aneurysm without rupture, urinary tract infection (UTI), severe protein-calorie malnutrition, complication of surgical and medical care of abdominal wound, acute posthemorrhagic anemia, acute kidney failure, dysphagia, bacteremia, colostomy, peripheral vascular disease, and pressure ulcers of sacral region, buttock, and heel. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to provide a written notice of discharge to one resident (Resident #34) or the resident's representative prior to discharging the resident from the facility. The deficient practice affected one resident (Resident #34) of three reviewed for transfer and discharge. The facility census was 41. Findings Include: Review of the medical record for Resident #34 revealed an admission date on 06/13/24 and a discharge date on 09/27/24 with return to the facility expected. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure minimum data set (MDS) assessments were completed accurately. This affected one resident (Resident #22) out of nine residents reviewed for MDS assessments. The facility census was 41.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #299 received timely treatment for a urinary tract infection. This affected one resident (#299) of 21 residents reviewed for medication administration. The facility census was 41.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the residents PTSD and minimize triggers and/or re-traumatization. This affected one resident (#147) identified by the facility as having PTSD/trauma. The facility census was 41.

Inspectors wroteBased on record review, staff interviews, and facility policy review, the facility failed to ensure two residents (Residents #20 and #98) were free from significant medication errors. The deficient practice affected two residents (Residents #20 and #98) of two reviewed for medication errors. The facility census was 41. Findings Include: 1. Review of the medical record for Resident #98 revealed an admission date on 09/13/24 and a discharge date on 10/02/24. Medical diagnoses included unspecified cirrhosis of the liver, celiac disease, chronic kidney disease, and charcot's joint for unspecified foot and ankle. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #98 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #98 received daily insulin injections. [...]

Inspectors wroteBased on staff and resident interview and review of facility arbitration agreement the facility failed to fully explain the arbitration agreement and the right to rescind the agreement within 30 days of signing. This affected two residents (#297 and #150) of three residents whose arbitration agreements were reviewed. The facility census was 41.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were followed during gastric-tube medication administration. This affected one resident (Resident #11) out of one resident observed for medication administration via a gastric - tube. The facility census was 41.

Inspectors wroteBased on observation, medical record review, staffing schedule review, review of the facility assessment, and family, resident, and staff interviews, the facility failed to ensure there was adequate staffing to provide activities of daily living (ADL) care for Residents #5, #12, #19, and #39. This affected four residents (#5, #12, #19, and #39) of seven residents reviewed for ADL care with the potential to affect all 46 residents. The facility census was 46.

Inspectors wroteBased on observation, record review, family interview, resident interview, and staff interviews, the facility failed to provide residents that required assistance from staff with activity of daily living (ADL) with the care and services with nail hygiene and dressing. This affected four (Residents #5, #12, #19, and #39) of seven residents reviewed for ADL care. The facility census was 46.

Inspectors wroteBased on observations, resident and staff interviews, medical record review, review of shower sheets, and facility policy review, the facility failed to provide showers as scheduled for one resident (Resident #29). This affected one resident (Resident #29) of three reviewed for showers. The facility census was 46. Findings Include: Review of the medical record for Resident #29 revealed an admission date on 04/28/24. Medical diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic kidney disease stage III, adjustment disorder, depression, legal blindness, unsteadiness on feet, abnormalities of gait and mobility, and need for assistance with personal care. [...]

Inspectors wroteBased on record review, interview and facility policy review the facility failed to ensure residents were free from significant medication errors. This affected two residents (#8, #19) of three residents reviewed for medication errors. The facility census was 46. Findings Include: Review of Resident #8 revealed Resident #8 was admitted on [DATE] with the diagnoses including Alzheimer's Disease, depressive disorder, anxiety disorder, and high blood pressure. Resident #8 required extensive assistance from staff for activities of daily living (ADL) tasks including medication administration. Resident #8 had severely impaired cognition and was receiving hospice services for end stage Alzheimer's Disease. Review of Resident #8's progress notes dated 05/11/24 at 11:00 P.M. authored by the Director of Health Services (DHS) revealed Resident #8 had been administered the wrong medication. [...]

Inspectors wroteBased on observation, medical record review, interview, and review of the manufacture guidelines the facility failed to ensure the glucometer was properly disinfected after use. This affected one resident (Resident #4) of five residents observed for medication administration. The facility census was 46.

Inspectors wroteBased on observation, medical record, review, staffing schedule review, review of the Centers for Medicare and Medicaid Census and Condition (CMS) Form 672, review of the facility assessment, and interviews, the facility failed to ensure there was adequate staffing to provide bathing for residents. This affected five residents (Residents #3, #23, #26, #87, and #187) of six residents reviewed for bathing with the potential to affect all 36 residents. The facility census was 36.

Inspectors wroteBased on observation, medical record, review, review of the Centers for Medicare and Medicaid Census and Condition (CMS) Form 672, policy review, and interviews, the facility failed to ensure residents unable to carry out activities of daily living including bathing received the necessary services. This affected five residents (Residents #87, #187, #26, #3, and #23) of six residents reviewed for bathing.

Inspectors wroteBased on interview, medical record review, and policy review, the facility failed to notify the physician and families of significant weight changes for Residents #3 and #27. This affected two residents (#3 and #27) of four residents reviewed for nutrition. The facility census was 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activities were provided for one resident (#3). This affected one resident (#3) of two residents reviewed for activities. The facility census was 36.

Inspectors wroteBased on observation, interview, medical record review, and policy review, the facility failed to ensure fall interventions were in place for one resident (#23) who was at risk for falling. This affected one resident (#23) of four reviewed for accidents. The facility census was 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure supplements were provided as ordered and weights were obtained as ordered for Residents #3 and Resident #23. This affected two residents (#3 and #23) of four reviewed for nutrition. The facility census was 36.

Inspectors wroteBased on interview and record review the facility failed to ensure pharmacy recommendations were followed for Resident #23. This affected one resident (#23) of five residents reviewed for unnecessary medications. The facility census was 36.

Inspectors wroteBased on interview and record review the facility failed to ensure as needed psychotropics were limited to 14 days or that the physician documented a rationale for extending the use and provided a duration for use for Resident #9 and Resident #23 and failed to ensure a psychotropic had an indication of use for Resident #9. This affected two residents (#9 and #23) of five residents reviewed for unnecessary medications. The facility census was 36.