Smith Medical Nursing Care CTR

In the surveyor’s words

From the most serious findings on record at Smith Medical Nursing Care CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 31, 2023

  Based on record review, review of the facility's policy Code Blue 911 Call, and staff interviews, the facility failed to activate Emergency Medical Services (EMS) and continue Cardio-Pulmonary Resuscitation (CPR) until more aggressive life sustaining treatment could be initiated for two residents (R#30 and R#232) of four residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing Services (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 9:22 a.m. […]

• Immediate jeopardy, isolatedF835Jan 31, 2023

  Based on record review, staff interviews and review of the Administrator and Director of Nursing Job Description, Administration failed to ensure that staff were following appropriate procedure when providing Cardiopulmonary Resuscitation (CPR) for two residents (R) (R#30 and R#232) of four residents reviewed for code status. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing Services (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 9:22 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. […]

• Actual harm, isolatedF689Apr 24, 2023

  Based on observation, staff interview, record review, and review of facility policy titled, Lifting Policy, and Policy on Hoyer Lift, the facility failed to ensure safe transfer for one resident (R) (#1) of eight residents requiring transfer using the mechanical list. Actual harm was identified to have occurred on 4/18/23 when R#1 suffered a five-centimeter (cm) laceration to her forehead above her left eye and a skull fracture. Findings include: Review of the undated policy titled, Fall Prevention-Lifting Policy, revealed it is the policy of this facility that all lifting of residents be done with a minimum of two employees. […]

• No harm, potential for more than minimal, widespreadF585Aug 7, 2025

  Based on observation, resident and staff interviews, and review of the facility's policy titled Grievance Policy, the facility failed to ensure information about the grievance process was posted and made available in visible areas of the facility. In addition, the facility failed to ensure three of 20 sampled residents (R) (R1, R38, and R3) were informed of the grievance process. The deficient practices had the potential to place the 44 residents residing in the facility at risk of not having the knowledge to file a grievance. Findings include:Review of the facility's undated policy titled Grievance Policy revealed the Procedure section included, 1. […]

• No harm, potential for more than minimal, widespreadF730Aug 7, 2025

  Based on staff interviews and record review, the facility failed to ensure 14 of 14 Certified Nurse Aides (CNA) reviewed received an annual performance evaluation. This deficient practice had the potential to place the 44 residents residing in the facility at risk of receiving care from incompetent staff. Findings include: Review of the facility's education and training records dated 8/23/2024 through 7/17/2025 revealed no record of annual performance review for CNAs.During an interview on 8/7/25 at 9:45 am, CNA AA stated evaluations were done verbally and with observations, and she cannot recall having a written evaluation since her hire date of 3/29/2024.During an interview on 8/7/2025 at 10:06 am, CNA KK reports not having had a written performance evaluation since her start date of… […]