Smith Crossing

In the surveyor’s words

From the most serious findings on record at Smith Crossing, in the surveyor’s own words.

• Actual harm, patternF600Aug 10, 2023

  Based on observation, interview and record review trained facility staff neglected to provide safe transfer assistance resulting in resident injuries and falls. This applies to 5 of 9 residents (R1-R5) reviewed for transfers in a sample of 9. This failure resulted in R1 incurring a fracture of the right femur and R3 incurring a fracture of her right humerus. Findings include: The policy Safe Resident Handling dated May 2022 documents staff participating in resident handling and movement shall always practice safer resident handling techniques. This policy further documents gait belts are required for all transfers and the use of a mechanical lift or stand assist lift requires 2 staff to perform the transfer. 1. […]

• Actual harm, patternF689Aug 10, 2023

  Based on observation, interview and record review the facility failed to provide safe transfer assistance. This applies to 5 of 9 residents (R1-R5) reviewed for transfers in a sample of 9. This failure resulted in R1 incurring a fracture of the right femur and R3 incurring a fracture of her right humerus. Findings include: 1. R1's Face Sheet dated 8/9/2023 documents R1 as a [AGE] year old with diagnoses to include a right periprosthetic fracture around an artificial knee joint, Vascular Dementia and History of a Stroke. On 8/4/2023 12:15 PM V28 (R1's Daughter) stated she was at the facility on 7/9/2023. After lunch R1 had to use the bathroom and was transferred using a stand assist mechanical lift by V9 (Former Nursing Assistant). […]

• Actual harm, isolatedF686Jun 18, 2025

  Based on observation, interview, and record review, the facility failed to prevent the development of an unstageable pressure ulcer for a resident at moderate risk for skin breakdown. This failure led to a resident requiring skin grafting. This applies to 1 of 4 residents (R59) reviewed for pressure ulcers in a sample of 21. The findings include: On 06/17/25 at 10:14 AM, a bright-red, quarter-sized, open wound was present on R59's sacrum. R59 had an indwelling urinary catheter. R59's electronic health records showed that he was admitted on [DATE], with R59's first pressure ulcer risk assessment completed on 3/4/2025. The assessment showed R59 was at moderate risk for skin breakdown. On 06/17/25 at 10:14 AM, V27 (Wound Nurse) stated that R59 had a stage 4 pressure ulcer. […]

• Actual harm, isolatedF684Apr 30, 2025

  Based on interviews and record review, the facility failed to ensure that a cognitively impaired resident received treatment and care in accordance with professional standards of practice for 1 of 4 residents (R2) reviewed for nursing care and services. This failure resulted in staff pulling on R2's contracted arm while turning resident in bed that caused R2 to experience moderate to severe pain to her left arm and was subsequently diagnosed with a fracture to the left humeral head (upper arm). […]

• Actual harm, isolatedF689Apr 30, 2025

  Based on observation, interviews, and record review, the facility failed to implement effective fall interventions to minimize the risk of falls, failed to ensure current fall interventions were in place for a resident at risk for falls, and failed to provide adequate supervision to prevent repeated falls with or without significant injury for 3 of 4 residents (R1, R3, R4) reviewed for accidents and supervision in a sample size of 4. This failure resulted in R4, who is a high fall risk with repeated falls, being observed without current fall preventative interventions in place; and resulted in R1 and R3 who had repeated falls and subsequently were emergently transferred to the hospital after a fall incident for treatment of a cervical neck fracture and facial abrasion (R1) and closure of a… […]