Smithfield Manor Rehabilitation and Healthcare Cen

In the surveyor’s words

From the most serious findings on record at Smithfield Manor Rehabilitation and Healthcare Cen, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 12, 2025

  Based on observation, record review, and interviews with the resident, staff, and the Medical Director, the facility failed to follow the manufacturer's instructions for wheelchair securement in a transportation van. On August 26, 2025, the Transport Driver incorrectly anchored all four securement straps to the rear wheels of the wheelchair, leaving the front of the wheelchair unsecured. As the vehicle accelerated, the unsecured wheelchair tipped backward, causing Resident #1 to fall and strike her head and back on the floor of the van. […]

• Immediate jeopardy, isolatedF600Apr 19, 2024

  Based on observation, record review and interviews with staff, Nurse Practitioner, Medical Examiner and Physician, the facility failed to protect a resident's right to be free from neglect for 1 of 3 sampled residents reviewed for neglect (Resident #1). On 3/4/24, Nursing Assistant (NA) #1 disregarded Resident #1's physician orders and plan of care for the assessed need of 2 person assistance with Activities of Daily Living (ADL) care and provided care to the resident without assistance. During care, NA # left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. […]

• Immediate jeopardy, isolatedF689Apr 19, 2024

  Based on observation, record review, staff, Nurse Practitioner, Medical Examiner and Physician interviews, the facility failed to provide Activities of Daily Living (ADL) care safely to a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 3/4/24 Nursing Assistant (NA #1) began providing care to Resident #1 when he left the resident positioned on his right side with the bed at waist height and turned his back to get a washcloth. Resident #1 rolled off the bed, landing face down on the tile floor. Resident #1 was transferred to the emergency room where a Computerized Tomography (CT) scan revealed a closed fracture of the left distal femur (a break of the thigh bone just above the knee) and a small skin tear to the left elbow. […]

• Actual harm, isolatedF689Nov 4, 2025

  Based on observations, record review, and resident, staff and physician interviews, the facility failed to provide care in a safe manner on 10/26/25 when Resident #1 rolled out of bed while a nurse aide was providing care sustaining a left distal tibia and fibula fracture (two main bones in the lower leg). Resident #1 required surgical intervention to repair the fractures and was discharged back to the facility on [DATE] with a splint applied to her left leg. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included osteoporosis (a disease that makes bones weak and brittle increasing the risk of fractures from falls), vitamin D deficiency, atrial fibrillation… […]

• No harm, potential for more than minimal, patternF584Apr 23, 2026

  Based on observation, record review, and resident and staff interviews, the facility failed to provide staff and residents with washcloths and towels to complete Activities of Daily Living (ADL) care. This occurred for 5 of 5 residents residing on 2 of 4 halls reviewed for linens (East and [NAME] Halls). The findings included:Review of the facility's census dated 4/22/2026 revealed the East Hall census was 56 residents and the [NAME] Hall census was 53 residents.a. Resident #134 was admitted to the facility on [DATE] and was housed on the [NAME] Hall. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #134 was cognitively intact and had no rejection of care documented. The MDS documented Resident #134 required substantial/maximal assistance with bathing and toileting. […]