Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Smithfield Manor Rehabilitation And Healthcare Cen during CMS and state inspections, most recent first.
The facility failed to ensure adequate washcloths and towels were available for residents’ ADL care, resulting in multiple cognitively intact residents on two halls reporting difficulty obtaining linens for bathing, missed baths, and the need to purchase their own washcloths. Staff across all shifts described an ongoing linen shortage over many months, stating that residents sometimes did not receive scheduled showers or bed baths and that they resorted to using sheets, pillowcases, cut-up blankets, clothing protectors, wipes, and paper towels instead of proper linens. Observations of linen rooms repeatedly showed no or very few towels and no washcloths despite high resident census. Environmental services and laundry staff reported stocking limited numbers of washcloths and towels based only on scheduled shower days, having no system to track soiled linens returned, no emergency stock, and no total inventory count. Nursing and supervisory staff stated they frequently reported the shortages to administration, while leadership acknowledged awareness of the problem but continued to provide insufficient quantities of linens to the halls.
Surveyors found that kitchen equipment and food contact surfaces were not maintained in a clean, sanitary condition. Shelves under two steam tables were covered with dried, sticky food particles, door handles on two reach-in refrigerators and a hot box/warmer had dried food debris, and a three-cylinder pellet plate warmer contained dried food particles in all cylinders. These unsanitary conditions were observed on multiple days despite written cleaning schedules requiring thorough cleaning of the steam tables and pellet warmer, and expectations that staff wipe down steam tables after each meal and clean door handles and the plate warmer daily.
A cognitively intact resident with chronic ankle pain had a PRN order for Oxycodone 5 mg, and pharmacy records showed that two narcotic cards (88 tablets total) were delivered and placed on a med cart with corresponding narcotic sheets. A nurse on second shift confirmed receiving and counting both cards, and subsequent nurses on night and day shifts reported correct narcotic counts, though one did not recall how many Oxycodone cards were present. During a later shift-change count, a nurse discovered that one full Oxycodone card (44 tablets) and its associated shift-change count sheet and narcotic countdown sheet were missing, and the medication could not be located, resulting in misappropriation of the resident’s narcotic medication.
A resident with COPD, heart failure, dementia, lower extremity limitations, and a high fall risk, who required substantial assistance for bed mobility and incontinence care, rolled off the bed during incontinence care when an agency NA raised the bed, unfastened the brief, and partially cleaned the resident. While the resident used an overhead trapeze bar to turn, the NA, unfamiliar with the resident and working a double shift, took her hands and eyes off the resident to prepare a clean brief, and the resident rolled off the opposite side of the bed onto the floor. The DON later confirmed that staff were expected to prevent residents from rolling off the bed and that the NA had not been observing or maintaining contact with the resident at the time of the fall.
Surveyors found expired and improperly dated medications on one of four medication carts, including an open bottle of zinc sulfate with a past manufacturer’s expiration date and illegible open date, and two open multi-dose insulin pens (lispro and glargine) with handwritten open dates but no documented discard dates. The insulin pens were stored in a clear plastic bag labeled by the pharmacy with a later expiration date, which an RN relied upon instead of discarding the pens 28 days after opening. The RN reported only checking floor stock medication expirations when administering, not routinely reviewing all stock, while the pharmacist confirmed the 28-day discard requirement and the DON and Administrator stated their expectation that nursing staff and medication aides check carts daily and remove expired medications.
Accurate resident assessment was not maintained when two MDS assessments were coded incorrectly. One resident with dementia and schizoaffective disorder had a psych provider note stating a GDR of psychotropic meds was clinically contraindicated, but the MDS was marked as if it had not been documented. Another resident with obstructive uropathy had a urostomy, yet the admission MDS incorrectly coded both an indwelling catheter and an ostomy; staff confirmed the catheter code was in error.
A resident with multiple chronic conditions and a medication regimen including anticoagulant, beta blocker, diuretic, thyroid replacement, psychotropics, and opioid pain medication had a cup of pills found unattended on her bed. The resident was blind and stated she did not know the medication was there, while an RN and the DON said staff should not leave meds in a resident room and that the resident was not coded for self-administration. The facility could not determine when or by whom the pills were left or whether they were the resident’s medications.
Urinary Catheter Bag Left on Floor: A resident with an indwelling urinary catheter and intact cognition had the drainage bag repeatedly observed with the bottom resting on the floor while hanging from the bed frame. Staff interviews showed one NA did not know the bag should not touch the floor, another NA acknowledged it should not be on the floor due to infection control concerns, and an RN stated it should not touch the floor; the DON confirmed urinary drainage bags were not to be touching or placed on the floor to prevent contamination.
Agency staff were not adequately trained or competency-checked before providing resident care. An agency NA stated she was working with a resident for the first time, did not know the resident was not on her assignment until told by another aide, and had not received facility training on fall prevention or post-fall procedures. The DON and Administrator confirmed that agency nurses and nurse aides had not received in-service training or verified competencies for required policies and procedures.
Daily nurse staffing sheets were posted with a single Licensed Nursing Staff column that did not separately total RN and LPN hours or counts, affecting all 33 days reviewed. The Staffing Coordinator, Nurse Supervisor, DON, and Administrator each described the process used to complete and review the sheets, and both the Staffing Coordinator and Nurse Supervisor stated they were unaware that RNs and LPNs had to be totaled separately.
A resident with osteoporosis and dementia, requiring two-person assistance for ADLs, fell and sustained a leg fracture when only one nurse aide provided incontinence care and rolled the resident away from herself. The aide did not follow the care guide, and a discrepancy existed between therapy recommendations and the care plan, leading to the resident not receiving the required assistance and resulting in injury.
A resident with multiple comorbidities, including neuropathy and a left leg amputation, was injured when her wheelchair tipped backward in a facility van due to improper securement by the Transport Driver, who attached all four anchor straps to the rear wheels instead of the wheelchair frame. The resident suffered neck and back pain, a tongue laceration, and a hand abrasion, requiring hospital evaluation before returning to the facility.
The facility failed to provide opportunities for residents to formulate advance directives and maintain accurate documentation. Several residents lacked documentation of advance directive education, and one resident's care plan inaccurately reflected their code status. Staff interviews revealed assumptions about discussions that were not documented, highlighting systemic issues in communication and documentation of residents' wishes.
A facility failed to accurately code MDS assessments for several residents, leading to deficiencies in skin conditions, bowel and bladder, nutritional status, and discharge. A resident with a surgical wound was not coded for wound care, another with a urostomy was incorrectly coded for catheters, a cognitively impaired resident receiving tube feeding was not coded for a gastrostomy tube, and a resident's discharge was inaccurately recorded. Staff interviews confirmed these errors.
The facility failed to update nutritional care plans for three residents experiencing weight loss, despite physician orders and dietary recommendations. The care plans did not address the risk of decreased nutritional status, and staff interviews revealed that the Dietary Manager had not completed the necessary updates.
A resident receiving oxygen therapy was at risk due to the application of petroleum jelly, a flammable substance, on their lips. Despite the known risks, the facility continued this practice as per a physician's order. Interviews with staff revealed a lack of awareness about the potential hazard, leading to a deficiency in accident prevention.
A resident with hypoxia was prescribed 1L of oxygen via nasal cannula, but observations revealed the oxygen concentrator was set at 2L. Despite the incorrect setting, the resident showed no distress. Staff interviews confirmed the discrepancy, and the Medical Director noted no harm occurred from the higher oxygen level.
A medication cart was found unlocked and unattended in a hallway near an entrance, with no staff or residents nearby. A nurse later acknowledged the cart should have been locked when unattended, but did not provide a reason for the oversight. The DON confirmed the expectation for the cart to be locked at all times when not attended.
A resident with multiple medical comorbidities and on blood thinning medication was left unattended by a Nursing Assistant (NA) during Activities of Daily Living (ADL) care, despite requiring 2 person assistance. The resident fell from the bed, resulting in a closed fracture of the left distal femur and a small skin tear to the left elbow. The injury led to complications and the resident's subsequent death. The incident highlighted the facility's failure to adhere to the care plan and ensure proper supervision, resulting in Immediate Jeopardy.
A dependent resident with multiple comorbidities, including chronic atrial fibrillation, heart failure, diabetes mellitus, and peripheral artery disease, required two-person assistance for bed mobility, incontinence care, and bathing. Despite this, a Nursing Assistant (NA) provided care independently, resulting in the resident falling from the bed and sustaining a closed fracture of the left distal femur and a skin tear to the left elbow. The incident occurred when the NA left the resident unattended to retrieve a washcloth. The resident's care plan had clearly indicated the need for two-person assistance due to impaired mobility and other risk factors.
Failure to Provide Adequate Washcloths and Towels for Resident ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate washcloths and towels for residents and staff to complete Activities of Daily Living (ADL) care, resulting in residents going without regular showers or bed baths and staff resorting to inappropriate substitutes. On multiple observations of the East and [NAME] Halls’ linen rooms, surveyors found no towels or washcloths available, or only a very limited number of towels and no washcloths, despite census counts of approximately 56 and 53 residents on those halls. Residents reported ongoing difficulty obtaining basic linens for bathing and personal hygiene, with some stating they had to purchase their own washcloths and could not bathe when they wished. Staff interviews consistently described a chronic shortage of washcloths and towels beginning around March–May 2025, leading to missed baths and the use of items such as sheets, pillowcases, blankets, clothing protectors, paper towels, and disposable wipes in place of proper linens. Several cognitively intact residents who required varying levels of assistance with bathing and toileting reported specific impacts from the linen shortages. One resident on [NAME] Hall, who was frequently incontinent of urine and always incontinent of bowel and required substantial/maximal assistance with bathing and toileting, had ADL documentation over nearly three months showing only two showers and seven bed baths despite scheduled shower days twice weekly. She stated she was unable to shower or bathe daily due to lack of washcloths and towels and had purchased her own washcloths. Another resident on [NAME] Hall, who required set-up or clean-up assistance and was occasionally incontinent, reported trouble getting washcloths and said she used disposable wipes or paper towels when linens were unavailable and had also bought her own washcloths. On East Hall, multiple residents who were incontinent and required partial to maximal assistance with bathing and toileting reported missing baths, receiving only one washcloth and no towel for ADL care, or being unable to clean up when they wanted, with one resident stating the problem had existed since admission and another stating she purchased and labeled her own washcloths. Nursing and nurse aide staff across all shifts described routine shortages of washcloths and towels and the resulting care limitations. NAs reported that on a typical assignment of about 12 residents, they would normally use two washcloths and one towel per resident, but when supplies were short, they limited showers/bed baths to scheduled days only, used one towel for both washing and drying, or substituted sheets, pillowcases, cut-up blankets, clothing protectors, wipes, or paper towels. Some NAs stated that residents missed scheduled baths or showers because there were no washcloths or towels available. Nurses and nurse supervisors reported that staff frequently informed them there were no clean linens, that residents were told they had to wait for laundry to be done, and that some residents and staff purchased their own washcloths. Supervisory staff acknowledged that residents had gone without showers/bed baths due to lack of linens and that concerns were reported to administration repeatedly. The Environmental Services Director and laundry staff described a linen process that did not ensure sufficient washcloths and towels were available for all residents’ daily ADL needs. Laundry staff began work at 6:30 AM, collected soiled linens, and stocked three linen rooms at set times during the day, but there was no system to count soiled washcloths and towels returned to laundry, and no total inventory count of available linens. Documentation showed that East and [NAME] Halls received on average only about 30 washcloths and 16 towels each, based on scheduled shower days rather than the full census of residents. The Environmental Services Director stated he followed administration’s guidance to provide enough linens for residents scheduled for showers, acknowledged there was no emergency stock, and confirmed awareness that staff were cutting up blankets and using pillowcases for care. He also reported seeing soiled washcloths and towels discarded in trash cans and stated he informed the Administrator of the need for more linens. The DON stated she did not know the exact timing of linen cart deliveries, was unaware of residents missing showers/bed baths due to linen shortages, and indicated she would need linen counts and census information to address the issue. The Administrator acknowledged hearing about washcloth and towel shortages from staff, was aware of current concerns about lack of linens for daily showers/bed baths, and confirmed that additional towels and washcloths kept in her office were only accessible when she was present, while the overall linen distribution to the halls remained insufficient for the number of residents.
Failure to Maintain Sanitary Kitchen Equipment and Food Contact Surfaces
Penalty
Summary
The deficiency involves the facility’s failure to maintain kitchen equipment in a clean and sanitary condition as required by professional standards and the facility’s own cleaning schedules. Surveyors observed that both 5-foot shelves under two steam tables were covered with dark, dried food particles and were sticky to the touch. The door handles of two reach-in refrigerators and one hot box/warmer were also noted to have dried food particles. In addition, the three-cylinder pellet plate warmer dispenser contained dried food particles in the bottom of all three cylinders. These conditions were identified during a kitchen tour with the Clinical Registered Dietitian. On a subsequent observation two days later, the same unsanitary conditions persisted: the shelves under the steam tables remained dirty, the reach-in refrigerator and hot box/warmer door handles still had dried food particles, and the pellet plate warmer cylinders continued to contain dried food debris. Review of the undated morning cleaning schedule showed that staff were expected to clean under both steam tables thoroughly, including the legs, on Mondays, and the dietary aide daily cleaning schedule required cleaning and polishing of the pellet warmer on Mondays. In interviews, the morning dietary staff member stated they were training new staff and did not get to clean the steam table, while the Certified Dietary Manager and the Administrator both acknowledged that staff were expected to wipe down the steam tables after every meal and clean the door handles and plate warmer daily.
Misappropriation and Loss of Resident’s Oxycodone and Narcotic Documentation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property by preventing the misappropriation of a controlled narcotic medication, Oxycodone 5 mg, prescribed PRN for ankle pain. The resident was cognitively intact and had a physician’s order for Oxycodone 5 mg every 6 hours as needed. Pharmacy packing slips showed that two medication cards, each containing 44 tablets (total 88 tablets), were delivered and accepted on the same date by a nurse supervisor. The narcotic countdown sheet labeled as card #2 of 2 documented receipt of 44 tablets and was verified by two nurses, but the narcotic countdown sheet for card #1 of 2 was missing. According to staff interviews and records, the two Oxycodone cards were initially added to the medication cart and the corresponding narcotic sheets were placed in the narcotic book. A nurse on the second shift reported that the narcotic count was correct at the end of his shift when he received and placed both cards in the cart. The night-shift nurse who followed stated her narcotic count was correct at the end of her shift but did not recall how many Oxycodone cards were present. Another nurse working the first shift the next day recalled seeing only one Oxycodone card for the resident and stated there was nothing to alert her that a second card should have been present if the narcotic countdown sheet was not on the cart. During a subsequent shift-change narcotic count between first and second shift nurses two days after delivery, the second-shift nurse identified that one Oxycodone card containing 44 tablets was missing, along with the associated shift change count sheet and narcotic countdown sheet. This nurse recognized the discrepancy because he had personally received and placed both Oxycodone cards in the cart earlier. Other nurses who worked intervening shifts reported that their narcotic counts were correct and that they maintained possession of the medication cart keys while on duty. Despite these accounts, the facility was unable to locate the missing Oxycodone card or the related documentation, resulting in an unresolved loss of the resident’s narcotic medication and associated records.
Resident Falls From Bed During Incontinence Care Due to Lack of Supervision
Penalty
Summary
The facility failed to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided during incontinence care, resulting in the resident rolling off the bed onto the floor. The resident had COPD, heart failure, atherosclerotic heart disease, dementia, functional limitations in both lower extremities, and was identified as high risk for falls. A recent MDS showed moderate cognitive impairment and dependence on staff for toileting and substantial/maximal assistance for rolling in bed. The care plan required staff assistance with repositioning and incontinence care. On the night of the incident, an agency nursing assistant, unfamiliar with the resident’s care needs and working a double shift, raised the bed to about three feet from the floor to provide incontinence care, unfastened the resident’s brief, and partially cleaned the resident. During this care, the resident, lying on her back in the center of the bed, used an overhead trapeze bar to begin turning from her back to her right side. The nursing assistant was positioned near the head of the bed on the left side and took both her hands and eyes off the resident to prepare the clean brief, which was within reach. While the assistant was looking down and not maintaining observation or physical contact, the resident rolled off the opposite side of the bed onto the floor. The assistant reported she did not know how or why the resident rolled off because she was not watching the resident at that moment. Another nursing assistant, who regularly worked with the resident, confirmed the presence of the trapeze bar used by the resident to turn for incontinence care. The DON stated that staff were expected to provide care so residents did not roll off the bed and confirmed that the assistant had taken her eyes off the resident and had no hands on the resident when the resident used the trapeze bar and rolled off the bed.
Expired Medications and Improper Dating on Medication Cart
Penalty
Summary
The deficiency involves failure to ensure medications were properly labeled and stored, specifically related to expired and improperly dated drugs on one of four medication carts (Upper East Medication Cart). During an observation of this cart with a nurse, surveyors found an open bottle of floor stock zinc sulfate 50 mg tablets with a manufacturer’s expiration date of 2/2026 circled in red and an illegible handwritten open date on the bottle. They also found one open insulin lispro injector pen with a handwritten open date of 3/8/26 and no handwritten expiration date, and one open insulin glargine injector pen with a handwritten open date of 3/5/26 and no handwritten expiration date. Both insulin pens had manufacturer’s expiration dates in 2027 and were stored together in a clear plastic bag with a pharmacy label on the outside listing an expiration date of 4/10/27. During the observation, the nurse stated she checked expiration dates of floor stock medications only when pulling them to administer and did not check all floor stock medications for expiration dates, acknowledging she did not know the zinc sulfate was expired. She also stated she relied on the expiration date on the outside of the pharmacy bag for the insulin pens instead of following the handwritten opened dates on the pens and discarding them after 28 days. The pharmacist confirmed that the insulin pens should have been discarded 28 days after opening and that the zinc sulfate should have been discarded after 2/2026. In a separate interview, the DON and Administrator stated that nurses were responsible for checking medication carts daily for expired medications and discarding any expired medications, and that their expectation was that nursing staff, including medication aides, would check the carts daily and ensure there were no expired medications present.
Inaccurate MDS Coding for Psychotropic GDR and Bowel/Bladder Appliances
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to accurately code physician-documented information on two Minimum Data Set (MDS) assessments. For one resident with diagnoses including dementia and schizoaffective disorder, a psychiatric provider note documented that an attempted reduction in the psychotropic regimen was likely to impair function and worsen underlying psychiatric conditions, but the quarterly MDS indicated that a gradual dose reduction had not been documented by the physician as clinically contraindicated. The MDS nurse stated this was an error and that it should have been marked yes because the physician had documented the contraindication. For another resident with obstructive uropathy, the record showed a physician order for a urostomy, and the care plan identified an urostomy related to the condition. However, the admission MDS coded both an indwelling catheter and an ostomy. Staff interviews confirmed the resident had a urostomy since admission and had never had an indwelling catheter, and the MDS nurse stated the indwelling catheter entry was coded in error. The administrator stated the MDS assessment should have been coded accurately.
Unattended Medication Cup Found at Resident Bedside
Penalty
Summary
The facility failed to ensure medications were observed being taken during medication administration when a cup containing approximately twelve pills was found unattended on Resident #83’s bed. Resident #83 was admitted with diagnoses including peripheral vascular disease, atrial fibrillation, hypertension, chronic pain syndrome, hypothyroidism, hyperlipidemia, generalized anxiety disorder, and bipolar disorder with a history of depression. Her medication regimen included Apixaban, Metoprolol, Furosemide, Levothyroxine, Sertraline, Aripiprazole, Alprazolam, Oxycodone, and other medications for constipation, electrolyte balance, and nutritional supplementation. Her care plan addressed medication management and psychotropic use, and a quarterly MDS identified her as cognitively intact. During observation, the medication cup was sitting on the resident’s bed with no staff present. The resident stated she did not know the medication was there and explained that she was blind and slept in a recliner next to her bed, saying she may have been asleep or in the bathroom when the nurse left the medication. Nurse #10 stated the pills were not the resident’s morning medications and believed they may have been from the prior night. Nurse Supervisor #5 stated staff should not leave medication unattended in a resident’s room and believed the medication was from the previous shift. The DON stated the resident had not been coded for self-administration, that facility policy required the nurse to observe the resident take medications, and that there was no way to tell when or who left the cup of medication on the bed or whether it was the resident’s medication.
Urinary Catheter Bag Left on Floor
Penalty
Summary
The facility failed to keep a urinary catheter drainage bag from touching the floor for one resident with an indwelling urinary catheter. The resident was admitted with diagnoses including retention of urine and obstructive uropathy, and his annual MDS assessment indicated he was cognitively intact. He was coded for an indwelling urinary catheter. During multiple observations, the resident’s catheter drainage bag was seen hanging off the bed frame with the bottom of the bag resting on the floor. This was observed first at 5:40 am, again at 6:07 am and 6:23 am, and later at 9:35 am. A nurse aide stated she did not know the bag was not supposed to touch the floor and did not know why, while another nurse aide stated she was unaware the bag was on the floor but acknowledged it should not be placed there due to infection control concerns. The hall nurse stated the bag should not touch the floor and thought it may have ended up there because the bed was in a low position. The DON stated urinary drainage bags were not to be touching or placed on the floor to prevent contamination.
Agency Staff Not Trained or Competent Before Providing Care
Penalty
Summary
The facility failed to ensure agency personnel were adequately trained and competent before providing care to residents, affecting Nursing Assistant #9. Record review and staff interviews showed that the facility did not provide training or verify competencies for agency nurses and nurse aides, and did not have a system in place at the time of the incident to ensure staff were competent in required post-fall procedures. The Administrator stated that staff should receive in-service training regarding fall prevention, accidents, and abuse upon hire and annually, and acknowledged that this training was not completed for NA #9. This deficiency was cross referenced to an incident involving Resident #121, who rolled off the bed and onto the floor during incontinence care. NA #9 stated that this was her first time working with Resident #121, that she was not aware the resident was not on her assignment until another aide told her, and that she had not received any facility training on fall prevention or what to do after a fall. The DON stated that the NA and nurse working the hall that night were agency staff and had not received any training or in-service about facility policies or procedures.
Daily nurse staffing sheets did not separate RN and LPN hours
Penalty
Summary
The facility failed to ensure daily nurse staffing sheets were accurate for 33 of 33 days reviewed for posted staffing. Review of the staffing sheets dated 3/20/26 through 4/21/26, which were posted for resident and visitor view, showed that the total number and actual hours worked by RNs and LPNs directly responsible for resident care per shift were not categorized separately. Instead, there was one column labeled Licensed Nursing Staff that did not distinguish between RNs and LPNs. During interviews, the Staffing Coordinator stated she completed the staffing sheets by confirming census, reviewing staffing for the day, filling out the sheet, and posting it in the front lobby, and she said she was unaware that RNs and LPNs had to be totaled separately. The Nurse Supervisor who trained her stated the licensed nurses were written in one section and nurse aides in another, and she also was unaware of the requirement to separate RNs and LPNs. The DON stated she knew the regulation required licensed nurses to be separated by license type and said she should have been reviewing the staffing sheets for accuracy. The Administrator stated the sheets were completed based on the staff schedule and census by the Staffing Coordinator on weekdays and a Nurse Supervisor on weekends, and that the form in use was the form already at the facility when she came onboard.
Failure to Provide Required Assistance During Bed Mobility Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with osteoporosis, atrial fibrillation, and dementia sustained a left distal tibia and fibula fracture after rolling out of bed during incontinence care. The resident was on an anticoagulant and had a care plan indicating the need for assistance from two staff members for activities of daily living (ADLs) due to impaired mobility, poor safety awareness, and impulsiveness. However, at the time of the incident, only one nurse aide was providing care, and the resident was rolled away from the aide, resulting in the resident sliding off the bed and falling to the floor. The nurse aide involved did not request assistance from another staff member, despite the care guide indicating a two-person assist was required for ADLs. The aide also rolled the resident away from herself, rather than towards herself, which contributed to the resident's fall. The bed was raised to the aide's waist height, and the resident was positioned in the middle of the bed before care began, but during the process, the resident attempted to assist and rolled too far, leading to the fall. At the time of the incident, there was a discrepancy between the physical therapy discharge summary, which indicated the resident required supervision/touch assistance from one staff member for bed mobility, and the care plan and care guide, which still required two-person assistance. The therapy department had notified nursing of the change, but the care plan and care guide had not yet been updated. This lack of timely communication and failure to follow the existing care plan resulted in the resident not receiving the required level of assistance, directly leading to the accident and injury.
Failure to Properly Secure Wheelchair During Transport Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to follow the manufacturer's instructions for securing a wheelchair in the facility's transportation van. The Transport Driver incorrectly anchored all four securement straps to the rear wheels of the wheelchair, leaving the front of the wheelchair unsecured. According to the manufacturer's instructions, tie-down hooks should be attached to solid frame members near seat level and not to wheels, plastic, or removable parts. This improper anchoring allowed the wheelchair to tip backward during vehicle acceleration. The incident involved a resident with multiple medical conditions, including neuropathy, chronic ischemic heart disease, osteomyelitis, diabetes, and a left leg above-knee amputation. The resident was cognitively intact, dependent on staff for transfers, and required assistance with wheelchair mobility. During transport to a dental appointment, the resident's wheelchair tipped backward when the van accelerated from a stop, causing her to fall and strike her head and back on the floor of the van. The resident was wearing a seatbelt at the time of the incident. As a result of the fall, the resident experienced posterior neck and upper back pain, a superficial laceration on the tongue, paraspinal tenderness in the upper thoracic region, and a superficial abrasion on the right hand. She was transported to the hospital, where CT scans showed no evidence of hemorrhage or acute fracture, and she was discharged back to the facility later that evening. The investigation confirmed that the Transport Driver had attached both front and rear anchor straps to the rear wheels, leaving the wheelchair frame free to rotate and tip over during transport.
Removal Plan
- Resident #1's wheelchair tipped backwards in the facility transportation van due to the transportation driver failing to follow manufacturer's instructions for wheelchair securement. The driver had improperly anchored both left and right front and rear straps to the rear wheels, leaving the front of the wheelchair unsecured. When the vehicle accelerated, the wheelchair tipped backwards, causing Resident #1's head and back to strike the floor of the van. Emergency services were called, and Resident #1 was transported to the hospital where she was treated for posterior neck pain, upper back pain, a superficial tongue laceration, paraspinal tenderness, and a superficial abrasion to her right hand. A CT scan revealed no evidence of hemorrhage or acute fracture, and the resident was discharged back to the facility.
- The transportation driver was removed from driving duties pending retraining and competency validation.
- The facility conducted a 100% audit of progress notes, transport log and interview with the Transportation Driver of in-house facility residents' transports for the past 90 days by the Assistant Director of Nursing, with no concerns identified.
- The Assistant Director of Nursing reviewed the transport log to identify any resident that would potentially be transported with facility van. No residents were to be transported until investigation and retraining completed.
- All scheduled appointments were scheduled by the Transportation Driver with a contracted outside transportation company.
- The facility has two employees who drive the transportation van. The Transportation Driver is the primary driver and the Maintenance Director is the back up driver.
- The Administrator audited the transport employee files: audit to include training, valid driver's license, van maintenance checklist to include proper alignment of the wheelchair between the tie down straps, attaching the rear tie down straps to the rear frame, front tie down straps to the front frame, ensuring tightness on both the front and rear tie downs, and securing seatbelt around resident, and employee vehicle policy to include but not limited to vehicle purpose, driver licensing, maintenance of company van, proof of insurance on company van, traffic violations, usage of cellular phone, accidents involving company vehicle, theft of company vehicle and driver responsibilities in regards to operation of vehicle, use of seatbelts and securement devices and reporting requirements with no concerns identified.
- The Maintenance Director did the initial education for the Transportation Driver on site of incident and return demonstration.
- The Administrator reviewed the manufacturer's video and training documents provided by the facility and re-educated post incident.
- The Maintenance Director conducted education and an initial return demonstration with the Transportation Driver, Director of Nursing and Administrator that included proper securement of the wheelchair and van anchors per manufacturer's instructions.
- Outside Maintenance Director from a sister facility provided additional education to the Administrator, Maintenance Director and Transportation Driver regarding proper securement of the wheelchair and van anchors per manufacturer's instructions.
- The Administrator initiated 100% in-service with the Maintenance Director and Transportation Driver about proper securement of wheelchairs during transport per manufacturer's instructions. The in-service was completed.
- All newly hired Transport Drivers will be in-serviced by the Maintenance Director during orientation to include the skills check list. The skills check list includes but is not limited to a competency validation of loading, securing and unloading a resident and a return demonstration.
- The Maintenance Director sent the van out for inspection that included checking functional status of the wheelchair anchors with no concerns identified.
- The facility initiated 10% audit of all residents being transported by the facility to be completed by the Maintenance Director weekly then monthly utilizing the Van Transport Audit Tool to ensure proper securing of the resident before leaving the facility and this was taken to Quality Assurance committee meeting. This audit is an observational audit to determine proper securement of the resident, wheelchair, and van anchors. The results will be documented on the Van Transport Audit Tool. All areas of concern will be addressed by the Administrator and/or Maintenance Director immediately.
- The Administrator will forward the results of the Van Transport Audit Tool to the Executive Quality Assurance Committee to include Administrator, Director of Nursing, Assistant Director of Nursing, Quality Assurance Nurse, Infection Control Preventionist/Staff Development Nurse, Activities Director, social workers, unit managers and unit coordinators, Maintenance Director, Minimum Data Set nurse, Dietary Manager, Medical Director and additional staff representatives monthly for review to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring.
Deficiency in Advance Directive Documentation and Code Status Accuracy
Penalty
Summary
The facility failed to provide an opportunity for residents to formulate advance directives and maintain accurate documentation of these directives in the medical records. Specifically, for five residents reviewed, there was no documentation indicating that education regarding advance directives was offered. This included residents with various medical conditions such as spinal cord disease, chronic obstructive pulmonary disease, pyothorax, chronic ischemic heart disease, and type 2 diabetes mellitus. Interviews with staff revealed that discussions about advance directives were assumed to occur but were not documented, leading to a lack of evidence that residents were informed about their rights to formulate these directives. Additionally, there was a discrepancy in the documentation of a resident's code status. One resident, who was severely cognitively impaired, had a care plan indicating a full code status, despite having a documented preference for Do Not Resuscitate (DNR) in their hard chart and physician's orders. This error was acknowledged by the MDS Nurse responsible for updating the care plan, who admitted to entering the incorrect code status by mistake. The Director of Nursing confirmed that care plans should accurately reflect the resident's wishes, and this discrepancy was discussed in morning meetings. The report highlights a systemic issue within the facility regarding the documentation and communication of advance directives and code status. Staff interviews revealed a lack of consistent procedures for discussing and documenting these critical aspects of resident care, leading to potential confusion and misalignment with residents' wishes. The facility's failure to ensure accurate and complete documentation of advance directives and code status represents a significant deficiency in meeting residents' rights and care needs.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the areas of skin conditions, bowel and bladder, nutritional status, and discharge. Resident #129, who was readmitted with a transmetatarsal amputation and a surgical wound treated with a wound vacuum, was inaccurately coded on the MDS as having no surgical wound or receiving wound care. The MDS Coordinator acknowledged the error, stating the data was not reviewed for accuracy before transmission. Resident #31, who had a urostomy due to bladder cancer, was incorrectly coded on the MDS as having an indwelling and external urinary catheter, despite nursing documentation and staff interviews confirming the presence of only a urostomy. The MDS Coordinator admitted the coding error, noting that the resident should not have been coded for catheters they did not have. Resident #5, who was severely cognitively impaired and receiving tube feeding, was not coded for having a gastrostomy tube on the MDS. The Food Service Director, responsible for coding the nutrition section, admitted the oversight. Additionally, Resident #134's discharge MDS was inaccurately coded as discharged to an acute hospital, while progress notes indicated a discharge to an assisted living facility. The MDS Coordinator confirmed the incorrect coding, and the Director of Nursing emphasized the need for accurate MDS coding.
Failure to Update Nutritional Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized, person-centered care plans addressing the nutritional needs of three residents, leading to deficiencies in their care. Resident #67, who was admitted with a diagnosis of diabetes mellitus, experienced significant weight loss over several months. Despite physician orders for dietary interventions and recommendations from a registered dietician, Resident #67's care plan did not address the risk of decreased nutritional status or weight loss. The care plan was last reviewed on December 10, 2024, but did not include necessary updates to reflect the resident's nutritional needs. Resident #122, admitted with a diagnosis of depression, also experienced weight loss and required dietary modifications due to dysphagia. Although dietary notes and physician orders indicated the need for nutritional supplements and a change in diet consistency, Resident #122's care plan was not updated to address the risk of decreased nutritional status or weight loss. The care plan was last reviewed on December 5, 2024, but failed to incorporate the necessary interventions to support the resident's nutritional health. Resident #19, with diagnoses including diabetes mellitus, dementia, and depression, showed a pattern of weight loss over several months. Despite physician orders for dietary supplements and monitoring, the care plan did not address the risk of decreased nutritional status or weight loss. The care plan was last reviewed on December 3, 2024, without necessary updates. Interviews with facility staff revealed that the Dietary Manager was responsible for updating care plans but had not completed the task, leading to the deficiencies identified in the residents' care plans.
Use of Petroleum Jelly on Resident with Oxygen Therapy
Penalty
Summary
The facility failed to protect a resident from a potential flammable hazard by using petroleum jelly on a resident receiving oxygen therapy. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was prescribed oxygen therapy to manage hypoxia. Despite the known risks associated with using petroleum-based products in conjunction with oxygen therapy, the facility continued to apply white petroleum jelly to the resident's lips as per a physician's order. Interviews with various staff members, including a nurse, the Director of Nursing, the Pharmacist Consultant, and the Medical Director, revealed a lack of awareness and understanding of the potential hazard posed by petroleum jelly in this context. The Sales Representative from an oxygen concentrator repair company also acknowledged the risk, albeit small, associated with the use of petroleum jelly. The facility's failure to recognize and address this risk resulted in a deficiency related to accident hazards and inadequate supervision to prevent accidents.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to provide supplemental oxygen as ordered by the physician for a resident diagnosed with hypoxia. The resident was readmitted to the facility with a care plan that included oxygen therapy at 1 liter via nasal cannula to maintain oxygen saturation rates greater than 94%. However, observations revealed that the resident's in-room oxygen concentrator was set at 2 liters instead of the prescribed 1 liter. Despite the incorrect setting, the resident showed no signs or symptoms of respiratory distress during the observations. Interviews with staff, including a nurse, the Quality Coordinator, and the Director of Nursing, confirmed that the oxygen setting was not in accordance with the physician's order. The nurse verified the order for 1 liter of oxygen and acknowledged that nurses should check the oxygen concentrators every shift to ensure the correct setting. The Quality Coordinator suggested that the knob might have been accidentally bumped, and the Director of Nursing reiterated the importance of daily checks. The Medical Director confirmed that the oxygen should have been set at the ordered liter, although there was no harm to the resident from the higher oxygen level.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to secure residents' medications in a locked medication cart, as observed on the 200-hall upper west medication cart. On the morning of January 24, 2025, the medication cart was found unlocked and unattended outside the nurse's station, approximately 15 feet from an unlocked entrance to the facility. No staff or residents were present in the vicinity of the cart at that time. Shortly after, a nurse was seen exiting a resident's room and walking towards the unlocked cart. During an interview, the nurse acknowledged that the cart should have been locked when unattended but did not provide a reason for the oversight. The Director of Nursing confirmed that the cart was expected to be locked at all times when not attended by the nurse.
Failure to Provide Required Assistance Leads to Resident Injury and Death
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, as evidenced by an incident involving Resident #1. On 3/4/24, Nursing Assistant (NA) #1 neglected to provide the required 2 person assistance with Activities of Daily Living (ADL) care to Resident #1, who had multiple medical comorbidities and was on a blood thinning medication, making him vulnerable to injury. During care, NA #1 left Resident #1 unattended on his right side on the bed at waist height, resulting in the resident rolling off the bed and sustaining a closed fracture of the left distal femur and a small skin tear to the left elbow. The resident's vulnerability and the failure to adhere to the care plan led to serious harm, ultimately resulting in the resident's death due to complications of the left femur fracture. The neglect incident was brought to light when the Director of Nursing (DON) became aware of Resident #1's allegation of neglect, which occurred on 3/4/24 during a bath where the aide turned away from the bed, leading to the resident's fall. The investigation report revealed that NA #1 was aware of the 2 person ADL care requirement for Resident #1 but chose to provide care independently, resulting in the fall and serious bodily injury to the resident. The facility was notified of Immediate Jeopardy on 4/17/24, highlighting the severity of the deficiency in providing safe and appropriate care to vulnerable residents. The deficiency was further emphasized by the facility's failure to ensure proper supervision to prevent accidents for Resident #1, who required 2 person assistance with ADL care. The lack of adherence to the care plan, coupled with the resident's high risk for injury, led to the immediate jeopardy situation on 3/4/24.
Failure to Provide Adequate ADL Assistance Leads to Resident Injury
Penalty
Summary
The deficiency identified in the report pertains to a failure in providing safe Activities of Daily Living (ADL) care to a dependent resident, resulting in a serious adverse outcome. Resident #1, a heavy-set individual with multiple comorbidities including chronic atrial fibrillation, heart failure, diabetes mellitus, and peripheral artery disease, was assessed as dependent for bed mobility, incontinence care, and bathing. Despite being designated as a two-person assist for ADL care due to impaired mobility and other risk factors, Resident #1 experienced a fall while being cared for by Nursing Assistant (NA) #1 on 3/4/24. The resident rolled off the bed, sustaining a closed fracture of the left distal femur and a small skin tear to the left elbow. The incident occurred when NA #1 left Resident #1 positioned on his right side with the bed at waist height to retrieve a washcloth, failing to provide the required level of supervision to prevent accidents. The report highlights that Resident #1's care plan clearly indicated the need for two-person assistance with ADL care, which was initiated on 11/01/22 due to the resident's condition and risk factors. Despite this, NA #1 proceeded to provide care independently on the day of the incident, citing a busy environment and familiarity with the resident as reasons for not seeking assistance. Interviews with NA #1, other nursing staff, and the Unit Manager Nurse revealed that Resident #1 was known to require extensive assistance and was considered a two-person assist due to his size and mobility limitations. The subsequent investigations and interviews with medical staff, including the Nurse Practitioner and Medical Doctor, shed light on the series of events following the fall, including subsequent hospital visits for chest pain, facial droop, and acute chest pain, ultimately leading to the resident's transfer to an inpatient hospice facility and eventual passing due to complications from the femur fracture.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 86 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Smithfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Barbour Court Nursing And Rehabilitation Center | 2.4 mi | ★★★★★ | 6 | 0 |
| Springbrook Nursing And Rehabilitation Center | 10.5 mi | ★★★★★ | 0 | 0 |
| Clayton Rehabilitation And Healthcare Center | 11.5 mi | ★★★★★ | 19 | 1 |
| Liberty Commons Nursing & Rehabilitation Center Of | 14.4 mi | ★★★★★ | 12 | 0 |
| O'berry Neuro-medical Treatment Center | 18.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Smithfield Manor Rehabilitation And Healthcare Cen.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.