Inspection Reports for
Smith Village

The complaint investigation found that resident R1 was transferred by one staff instead of two as required, causing a laceration that required hospital treatment. The investigation also revealed the bed frame was improperly adjusted, contributing to the injury. The facility had not implemented a system to ensure bed frame safety after the incident.

The facility failed to ensure that resident R1, who required two-person assistance for transfers, was transferred safely, resulting in a laceration requiring 18 sutures. Additionally, the bed frame was not properly adjusted to the mattress size, contributing to the injury. The facility lacked a system to monitor bed frame safety post-incident.

The facility was found deficient in multiple areas including failure to maintain resident dignity by not covering a urinary catheter drainage bag, incomplete controlled substance shift counts, failure to follow a resident's fluid restriction diet order, improper food labeling and storage, lack of temperature monitoring for residents' personal refrigerators, open garbage dumpster lids, and failure to implement enhanced barrier precautions for a resident with a chronic wound.

The complaint investigation found that R1, a severely cognitively impaired resident with multiple medical issues and high fall risk, fell in the bathroom and sustained a head injury requiring hospital care. The fall occurred shortly after the family member left the facility. The resident does not use the call light and requires constant supervision. Staff reported challenges in monitoring due to R1's combative behavior and inability to communicate needs. The facility had implemented fall prevention measures including a fall alert system and close monitoring, but the fall still occurred. The physician and staff agreed the fall was likely unavoidable given R1's impulsiveness and cognitive status.

The facility failed to provide adequate supervision for a confused, high fall risk resident (R1), resulting in a fall with head injury requiring hospital treatment and staples. Despite fall prevention measures including monitoring devices and staff supervision, R1 fell when left unattended briefly. Staff and family interviews confirmed the resident's high fall risk and need for constant supervision.

The complaint investigation found that the resident (R1) eloped from the facility on 11/17/2023. The resident was found outside in the courtyard after multiple alarms were triggered but not properly investigated. Staff and security failed to respond adequately to alarms and did not conduct thorough searches. Staffing shortages and lack of communication were noted. The resident was combative and refused assessment after being found. The facility's investigation confirmed the alarms were functional but staff disarmed alarms without proper investigation.

The facility failed to adequately supervise a confused resident (R1) who eloped from the facility, despite alarms and security measures in place. Staff failed to respond properly to alarms and did not conduct thorough searches, resulting in the resident being found outside in the courtyard. Staffing shortages and inadequate monitoring contributed to the incident.

The facility was found deficient in maintaining residents' dignity during meals and catheter care, ensuring safe respiratory care including proper labeling and storage of oxygen equipment, food safety practices including proper food labeling and storage, sanitation practices related to dumpster coverage, and infection prevention including proper use of PPE during medication administration.

The investigation substantiated that the resident fell out of bed reaching for the call light which was not within reach. The resident sustained a closed right hip fracture. Staff interviews indicated failure to maintain call light accessibility and inadequate rounding prior to the fall.

The facility failed to keep the call light within reach of a high fall-risk resident who requires extensive assistance, leading to the resident falling out of bed and sustaining a closed right hip fracture. Staff interviews and record reviews confirmed the call light was not in place, and there were issues with staff rounding and response times.

The complaint investigation found that the transfer of resident R2 was performed by only one staff member instead of the required two, increasing risk of injury to resident and staff. The complaint was substantiated by observation, interviews, and record review.

The facility failed to properly transfer resident R2 using a total body mechanical lift with the required two staff members present, posing a safety risk. The resident is cognitively impaired and at high risk for falls, and facility policies require two staff members for such transfers, which was not followed.

The complaint investigation was initiated due to allegations received on 2023-04-05 that the facility was not performing proper skin checks, resulting in a resident wound being present and staff being unaware. The investigation substantiated neglect related to skin assessments and care.

The facility failed to conduct scheduled bi-weekly skin assessments and showers for four sampled residents, failed to document skin impairments, and failed to timely notify physicians of changes in skin conditions. These failures resulted in a resident sustaining a 1.6 cm keratotic papule requiring surgical intervention. Other residents had undocumented or excluded skin assessments and bruises of unknown origin were not properly investigated.

The complaint investigation focused on issues including failure to document advance directives, inadequate supervision leading to falls, improper medication and supplement storage, and food safety violations. Substantiation status is not explicitly stated.

The facility failed to document full code status orders for residents, supervise cognitively impaired residents at high risk for falls resulting in injuries, maintain proper medication and supplement refrigerator temperature logs and discard expired supplements, and store food items properly off the floor in the kitchen.