Smith Village

In the surveyor’s words

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

• Actual harm, isolatedF627May 16, 2026

  Based on interview and record review, the facility failed to ensure an appropriate discharge for one resident reviewed for discharge practices by discharging the resident despite abnormal laboratory results indicative of dehydration. This deficient practice affected one (R1) of two residents reviewed for discharge. As a result, R1 was readmitted to the hospital within 48 hours of discharge with diagnoses of acute metabolic encephalopathy, likely secondary to a combination of dementia, dehydration, and urinary tract infection (UTI).Failure to ensure the resident was medically stable prior to discharge had the potential to result in worsening dehydration, delayed medical treatment, increased risk for hospitalization, and adverse health outcomes related to unresolved clinical conditions.R1… […]

• Actual harm, isolatedF602Jan 21, 2026

  Based on interview and record review, the facility failed to follow their abuse protocol for one resident (R1) out of four residents reviewed for abuse. This failure resulted in an employee cashing several of R1's personal checks without his knowledge/permission. Findings Include:R1's 7/26/2025, 19:12 admission Details reads: Arrived by other. admission mode: wheelchair. Living situation prior to admission: Other residential facility / assisted living / group home. Mental Status: Alert & Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking.R1's 9/4/2025 18:26 Health Status Note Text reads: Resident actively transitioning. Family visiting through shift. Hospice RN made aware and was coming to facility. Resident resting in bed. […]

• Actual harm, isolatedF689Feb 13, 2025

  Based on interview and record review the facility failed to ensure that proper number of staff were used in transferring one of four residents (R1) to prevent accidental hazard in the sample who requires two persons assist in transfers from chair to bed or bed to chair. This failure affected R1 who was transferred from chair to bed by one staff instead of two. As a result, R1 sustained laceration of left lower leg, was sent to the hospital and the laceration required eighteen (18) sutures to be repaired. […]

• Actual harm, isolatedF909Feb 13, 2025

  Based on observation, interview, and record review the facility failed to ensure that the bed frame is locked to the size of the mattress for the safety of one resident (R1) reviewed for injury. As a result, R1's left lower leg made contact with the loose bed frame during transfer into bed causing a laceration. R1 was sent to the hospital and the laceration was repaired with 18 sutures. This has the potential to affect all 70 residents residing in the facility. Findings include: R1's medical record Admission Record showed that R1 was originally admitted to the facility on [DATE] and latest admitted was 08/26/24 with diagnosis list that includes but not limited to Unspecified intracapsular fracture of the left femur, subsequent encounter for closed fracture with routine healing, aftercare… […]

• Actual harm, isolatedF689Apr 7, 2024

  Based on interviews and record reviews, the facility failed to provide adequate supervision for 1 confused resident [R1] who is a high fall risk out of 3 [R1, R2, R3] residents reviewed for falls. This failure resulted in R1 being found on the bathroom floor bleeding to the back of the head. R1 was transferred to the hospital and R1 received laceration repair with staples. Findings Include: R1's clinical record indicates in part the following: R1 is a [AGE] year-old admitted to the facility on [DATE] with admitting medical diagnosis include but not limited to- right closed femur fracture, abnormal gait and mobility, weakness, cerebral infarction, aphasia following cerebral infarction, traumatic hemorrhage cerebral without the loss of consciousness, muscle wasting and atrophy, dementia… […]