Smyrna Care Center

In the surveyor’s words

From the most serious findings on record at Smyrna Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF656Nov 4, 2022

  44447 Based on facility policy review, medical record review, observations, and interviews, the facility failed to implement a care plan for risk of elopement for 3 of 14 sampled residents (Resident #5, Resident #6, and Resident #7) reviewed for elopement. The facility also failed to implement a care plan for 2 of 16 sampled residents (Resident #9 and Resident #18) reviewed for safe smoking/tobacco use, and failed to implement interventions on care plans for 3 of 16 sampled residents (Resident #5, Resident #10, and Resident #12) reviewed for safe smoking. […]

• Immediate jeopardy, widespreadF689Nov 4, 2022

  Based on facility policy review, Facility Reported Incident (FRI) review, medical record review, observation, and interview, the facility failed to ensure 1 of 14 sampled residents (Resident #4) received adequate supervision to prevent an avoidable accident. The facility failed to ensure safe smoking for 6 of 17 sampled residents (Resident #5, Resident #8, Resident #9, Resident #10, Resident #12, and Resident #18) reviewed for tobacco product use. The facility failed to ensure igniting materials (lighters/matches) were secured in a safe manner for 3 of 17 sampled residents (Resident #8, Resident #9, and Resident #10) reviewed for smoking. […]

• Immediate jeopardy, widespreadF835Nov 4, 2022

  Based on the job description review and interview, Administration failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain the highest practicable well being of the residents. Administration failed to provide oversight, ensure a safe environment, complete a thorough investigation of resident elopement, and conduct an ad hoc Quality Assurance and Performance Improvement (QAPI) Committee meeting that identified the appropriate root cause of an elopement to implement appropriate interventions. […]

• Immediate jeopardy, widespreadF867Nov 4, 2022

  Based on facility policy review, Facility Reported Incident (FRI) review, medical record review, interviews, and observations, the facility's Quality Assurance Performance Improvement (QAPI) failed to identify the root cause of an avoidable accident, and failed to implement a plan of action interventions for an elopement. The facility's QAPI Committee also failed to recognize unsafe smoking practices and storage of igniting materials.The facility's failure to identify the root cause of an avoidable accident and implement plan of action interventions, and failure to recognize and prevent unsafe smoking and storage of igniting materials, placed all 92 residents residing in the facility in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of… […]

• Immediate jeopardy, isolatedF686Jun 26, 2026

  Based on American College of Physicians (ACP) article review, facility policy review, Quick Glance Skin Integrity and Wounds procedure form, medical record review, observation, and interview, the facility failed to ensure residents received the necessary treatment and services consistent with professional standards of practice to promote wound healing, prevent new wounds from developing, and complete wound assessments on residents determined to be at risk of skin breakdown for 4 of 5 (Residents #4, #47, #62 and #66) sampled residents reviewed for pressure wounds. Resident #4 was admitted to the facility on [DATE]. On 5/19/2026, a pressure wound was identified as a Stage 3 (pressure wounds are staged from 1 - 4 to measure tissue damage with 4 being the most tissue damage). […]