Smithfield Manor: Fall Risk Violations Cause Actual Harm - NC
The November 2025 inspection, filed as a complaint investigation, resulted in a citation under F0689, the federal tag covering accident hazards and resident safety. Inspectors rated the level of harm as actual, not potential, and identified the violation as affecting a small number of residents.
The core problem was repositioning. When nursing assistants helped residents with incontinence care and other activities of daily living, they were not rolling residents toward them as required. Rolling a resident toward the staff member providing care is a basic safety technique, one that reduces the risk of falls, reduces the risk of the resident rolling off the bed, and gives the aide physical control of the movement. Doing it wrong, or not doing it at all, puts the person being cared for in a far more vulnerable position.
The facility's own corrective action plan, submitted as part of the inspection record, acknowledged the gap. Smithfield Manor scheduled an in-service training for nursing assistants and nurses on October 26, 2025, specifically covering the correct technique of rolling residents toward staff during care. The Director of Nursing and the Administrator were identified as responsible for addressing all areas of concern.
To track whether the retraining held, the facility put in place a structured audit schedule. Unit Managers, a Quality Assurance Nurse, and the Assistant Director of Nursing were assigned to use a Turning and Repositioning Audit Tool, monitoring ten residents per week for four weeks, then five residents per week for another four weeks, then one resident per week for the final four weeks. Monthly results were to go to the Executive QA Committee for three months so leadership could watch for patterns and decide whether additional steps were needed.
The facility set October 28, 2025 as the completion date for its corrective plan.
When inspectors returned on November 4, they reviewed the in-service records and questionnaires from October 26. They interviewed nurses and nursing assistants to confirm the training had actually taken place. They observed a nursing assistant, identified in the report as NA #2, performing incontinence care for the resident identified as Resident #1, and they watched how the repositioning was done. They also reviewed the first weekly audit, which had an end date of November 1, 2025.
Inspectors found no concerns in any of those reviews. The corrective action completion date was validated.
What the inspection record does not contain is a description of what the harm looked like for the residents who experienced it before the complaint was filed. The report, as released, begins mid-document on page four of four, and the earlier pages, which would have contained the full citation narrative describing what inspectors originally found, what happened to which residents, and how the violation was discovered, are not included in the available text. The finding that actual harm occurred is documented. The specifics of that harm are in the pages that precede this excerpt.
What is clear is that someone filed a complaint. Complaint investigations at nursing facilities are not routine surveys. They are triggered by a report, usually from a resident, a family member, or a staff member, that something specific went wrong. The inspection was completed November 4, 2025, the same day inspectors validated the facility's corrective plan, suggesting the complaint was filed sometime before late October and the facility moved quickly once the issue was formally raised.
Smithfield Manor is a rehabilitation and healthcare center, meaning a portion of its residents are there short-term, recovering from surgery or illness, while others are long-term residents with complex care needs. Both populations depend on nursing assistants for the kind of hands-on daily care where repositioning technique matters most.
The audit structure the facility put in place will run through early 2026. Whether the correction holds past the monitoring period, and whether the residents who were harmed before the complaint was filed have recovered, is not addressed in the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Smithfield Manor Rehabilitation and Healthcare Cen from 2025-11-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
Smithfield Manor Rehabilitation and Healthcare Cen in Smithfield, NC was cited for violations during a health inspection on November 4, 2025.
Inspectors rated the level of harm as actual, not potential, and identified the violation as affecting a small number of residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.