Inspection Reports for Smithfield Woods

An unannounced complaint/incident investigation survey was conducted from 10/27/2025 through 10/28/2025 to determine compliance with state regulations.

The facility failed to provide care and services in accordance with the prevailing community standard of care related to medication administration for Resident ID #1, who received propranolol outside of prescribed blood pressure parameters on multiple occasions.

The complaint investigation was substantiated as a deficiency was identified related to medication administration errors for Resident ID #1, including administration of propranolol when systolic blood pressure was below the prescribed threshold.

An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations following allegations of a resident eloping from the facility.

The facility failed to provide a secure distinct living environment for a resident with Alzheimer's disease, resulting in the resident eloping through an exterior door and being found outside after approximately two hours with heat exhaustion and a fall in the woods. Staff did not follow the facility's alarmed exit door policy, and supervision was lacking on the unit.

The complaint investigation was substantiated based on observations, record review, and staff interviews confirming the resident eloped through an exterior door at 6:25 PM and was found outside at 8:24 PM with heat exhaustion and a fall.

An unannounced complaint/incident investigation survey and a State Licensure survey were conducted at Smithfield Woods on 05/07/2025 following a complaint alleging medication errors related to Resident ID #1's readmission on 04/25/2025.

The facility failed to provide care and services in accordance with the prevailing community standard of care related to administering medications per physician's orders for Resident ID #1. Additionally, personnel records for three staff members lacked required documentation, resident records failed to include specific health problem information, medication administration and storage deficiencies were identified, and the facility failed to have a licensed physician, nurse practitioner, or physician assistant as a member of the Quality Improvement Committee.

The complaint investigation was substantiated based on record review and staff interviews indicating medication errors and failure to follow physician orders for Resident ID #1 during readmission on 04/25/2025.

An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations based on multiple complaint reference numbers.

The facility failed to provide care and services in accordance with community standards related to administering medications and oxygen orders for a resident. Specifically, the resident did not have an active physician's order for oxygen despite being on oxygen therapy, and assessments and service plans were not accurately reflecting the resident's condition or oxygen use.

The investigation was triggered by multiple complaint reference numbers (100484, 100402, 100303, 100147, 100221, 100222, 99904, 99866, and 99840). Deficiencies were identified as a result of this complaint investigation.

An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.

No deficiencies were identified during the investigation.

The investigation was based on ACTS reference numbers 99314, 99451, 99531, 99539, and 99621. No deficiencies were found.

An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.

No deficiencies were identified during the investigation.

The visit was triggered by an unannounced complaint/incident investigation with ACTS reference numbers 98999. No deficiencies were found.

An unannounced complaint/incident investigation survey was conducted on 11/4/2024 to determine compliance with state regulations based on ACTS reference numbers 98089, 98215, 98242, and 98277.

Deficiencies were identified related to failure to complete and update comprehensive resident assessments and service plans reflecting receipt of physical therapy, occupational therapy, and speech therapy services for two residents. The facility failed to update service plans when residents' conditions changed significantly.

The investigation was complaint-driven based on ACTS reference numbers 98089, 98215, 98242, and 98277. Deficiencies were substantiated related to resident assessments and service plan updates.

An unannounced complaint/incident investigation survey was conducted to determine compliance with state regulations.

No deficiencies were identified during the investigation. A follow-up to two previous surveys was conducted, and all prior deficiencies were corrected.

The investigation was related to complaint reference numbers 97854 and 97951 and found no deficiencies.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

The visit was complaint-related as an unannounced complaint/incident investigation survey; no deficiencies were found.

An unannounced complaint/incident investigation survey was conducted at Smithfield Woods to investigate allegations related to staff working without active licenses and medication administration errors.

The facility was found to have staff members working without active licenses and failures in medication administration, including administering medications outside scheduled times and missing medications in the secure medication cart. The facility also failed to update resident assessments timely and had medication reconciliation and documentation issues.

The investigation was triggered by complaints regarding staff working without active licenses and medication administration errors. Staff A and B were confirmed to be working without active licenses. Staff member A was terminated for giving medications outside scheduled times. Medication errors and documentation issues were substantiated.

An unannounced complaint/incident investigation survey was conducted at Smithfield Woods residence due to concerns about medication administration and resident care.

The facility failed to provide care and services in accordance with the prevailing community standard of care, specifically related to medication administration for Resident ID #1. The medication administration record (MAR) did not show evidence of administration of Losartan Potassium from 6/14/2024 to 6/26/2024, and the facility lacked a system to notify management of medication refill requests or missed medications. Additionally, deficiencies were found in residency requirements, resident assessments, service plans, and medication services documentation and oversight.

The investigation was triggered by a complaint/incident involving Resident ID #1 who was sent to the hospital for chest pain and diagnosed with a heart attack. The complaint was substantiated as the facility failed to administer prescribed medication and maintain accurate medication records.

An unannounced complaint/incident investigation survey was conducted at the facility on 6/12/2024 based on multiple ACTS reference numbers.

No deficiencies were identified during the investigation.

The investigation was unannounced and related to complaint/incident reference numbers 95818, 95819, 95955, 95954, 96096, and 96152. No deficiencies were found.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

The investigation was complaint-related and no deficiencies were found, indicating no substantiated issues.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the complaint investigation survey.

The complaint/incident investigation was unannounced and no deficiencies were found, indicating no substantiated issues.

An unannounced complaint/incident investigation survey was conducted at Smithfield Woods due to an allegation of abuse involving Resident ID #1.

The investigation found that the facility failed to report an alleged verbal abuse incident involving staff and Resident ID #1 within the required 24-hour timeframe. The incident occurred on 3/1/2024 but was not reported to the state agency until 3/21/2024. Staff acknowledged inappropriate behavior toward the resident.

The complaint was substantiated based on record review, staff interviews, and witness statements indicating verbal abuse by a Licensed Practical Nurse toward Resident ID #1. The facility did not report the incident to the state agency within the required timeframe.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

Unannounced complaint/incident investigation survey with no deficiencies identified.

An unannounced complaint/incident investigation survey was conducted at the facility based on ACTS reference number 92979 during the period 11/08/2023 to 11/15/2023.

No deficiencies were identified during the investigation.

Investigation was conducted as a complaint/incident investigation with ACTS reference number 92979. No deficiencies were found.

An unannounced complaint/incident investigation survey was conducted at Smithfield Woods to identify deficiencies related to medication services.

The investigation found deficiencies in medication administration, storage, documentation, and disposal practices, including failure to properly record medication administration and disposal, and errors in medication counts for a resident's Tramadol medication.

The visit was triggered by an unannounced complaint/incident investigation. The Regional Nurse was unable to provide evidence that the Tramadol medication was properly disposed of after discontinuation, indicating a medication error.

An unannounced biennial State Licensure survey and a complaint/incident investigation survey (ILP111, 05/01/2023) were conducted at Smithfield Woods to assess compliance with State Licensure requirements and investigate complaints.

The facility was found deficient in multiple areas including failure to establish a Safe Resident Handling program, inadequate in-service training for staff, incomplete personnel records, failure to update resident assessments and service plans, medication administration discrepancies, and deficiencies in fire safety drill documentation.

The visit included a complaint/incident investigation survey (ILP111) conducted on 05/01/2023. Specific substantiation status is not stated.

An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at the facility.

The investigation of ACTS #89720 found no deficiencies at the facility.

Complaint/incident investigation ACTS #89720 was investigated and found to have no deficiencies.

An unannounced complaint/incident investigation survey was conducted at the residence to investigate a medication administration error involving a resident.

The investigation found that the facility failed to provide care in accordance with community standards related to physician's orders for one resident. Medication errors were identified where medications were administered without physician orders, and the Director of Wellness acknowledged the errors.

The complaint investigation was substantiated by findings of medication administration errors and lack of physician orders for the medications administered to the resident.

An unannounced complaint/incident investigation survey was conducted at Smithfield Woods to investigate a deficiency identified related to management of services and resident care.

The facility failed to operate and provide services in accordance with the prevailing community standard of care for residents related to dementia. Specifically, wellness checks were not routinely performed as required by facility policy, resulting in a resident being found with injuries and subsequent hospitalization. The resident later passed away while in hospice care post hospitalization.

The complaint investigation found that the facility did not follow the policy for wellness checks on Resident ID #1, who was admitted with dementia and was found with injuries on multiple occasions. The resident was hospitalized and later passed away in hospice care. The Administrator and Director of Wellness acknowledged the failure to follow policy during the exit interview.

An unannounced complaint/incident investigation survey was conducted at this residence.

No deficiencies were identified during the investigation.

The investigation was unannounced and complaint/incident related; no deficiencies were found.

An unannounced complaint/incident investigation survey was conducted at the residence to investigate deficiencies related to discharge summaries and reporting of incidents.

Deficiencies were identified in the completion of discharge summaries for three closed resident records and in maintaining evidence that all reportable incidents were thoroughly investigated and reported to the Rhode Island Department of Health within five business days.

The complaint investigation found that discharge summaries were not completed as required for Residents #1, 2, and 3. Additionally, reportable incidents including resident-to-resident altercations, unwitnessed falls resulting in hospitalization, and unexpected or sudden deaths were not reported to RIDOH within the required timeframe.

An unannounced biennial State Licensure survey and a complaint/incident investigation survey were conducted at the residence on 03/23/2021 to assess compliance with state licensure requirements and investigate complaints.

Multiple deficiencies were identified related to personnel records, resident assessments and service plans, infection control, medication services, and limited health services license requirements. The facility failed to maintain required documentation, conduct timely nurse reviews, ensure proper infection control practices, and maintain appropriate health screenings and immunizations for staff.

The visit included a complaint/incident investigation component as part of the unannounced biennial survey. Specific complaint details are not explicitly stated, but deficiencies related to personnel records, resident care, infection control, and medication management were identified.

An unannounced complaint/incident investigation survey and a biennial State licensure survey were conducted at this residence on 03/23/2021.

No deficient practice was identified under the complaint investigation survey.

The complaint investigation survey found no deficient practice and no substantiated issues.

An unannounced focused survey was conducted related to COVID-19 infection control at the residence.

The facility failed to establish adequate infection control provisions for the mutual protection of residents, employees, and the public relative to COVID-19 standards. Observations included improper use of N95 masks by staff, empty and expired hand sanitizer dispensers, and lack of proper mask fitting and use.