Smithfield Manor Rehabilitation And Healthcare Cen
Smithfield Manor Rehabilitation and Healthcare Cen in Smithfield, NC — inspection on September 12, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
8/27/25.
The Maintenance Director conducted education and an initial return demonstration with the Transportation Driver, Director of Nursing and Administrator on 8/26/25 that included proper securement of the wheelchair and van anchors per manufacturer's instructions.
Outside Maintenance Director from a sister facility provided additional education to the Administrator, Maintenance Director and Transportation Driver regarding proper securement of the wheelchair and van anchors per manufacturer's instructions on 9/2/25.
On 8/27/25 the Administrator initiated 100% in-service with the Maintenance Director and Transportation Driver about proper securement of wheelchairs during transport per manufacturer's instructions.
The in-service was completed by 8/28/2025.
All newly hired Transport Drivers will be in-serviced by the Maintenance Director during orientation to include the skills check list.
The skills check list includes but is not limited to a competency validation of loading, securing and unloading a resident and a return demonstration.
The Maintenance Director sent the van out for inspection that included checking functional status of the wheelchair anchors that was completed on 8/27/25 with no concerns identified. 4.
Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
Include dates when corrective action will be completed. On 8/26/25 the facility initiated 10% audit of all residents being transported by the facility to be completed by the Maintenance Director weekly x 4 weeks then monthly x 2 months utilizing the Van Transport Audit Tool to ensure proper securing of the resident before leaving the facility and this was taken to Quality Assurance committee meeting on 8/26/25.
This audit is an observational audit to determine proper securement of the resident, wheelchair, and van anchors.
The results will be documented on the Van Transport Audit Tool.
All areas of concern will be addressed by the Administrator and/or Maintenance Director immediately.The Administrator will forward the results of the Van Transport Audit Tool to the Executive Quality Assurance Committee to include Administrator, Director of Nursing, Assistant Director of Nursing, Quality Assurance Nurse, Infection Control Preventionist/Staff Development Nurse, Activities Director, social workers, unit managers and unit coordinators, Maintenance Director, Minimum Data Set nurse, Dietary Manager, Medical Director and additional staff representatives monthly x 3 months for review to determine trends and / or issues that may need further interventions put into place and to determine the need for further and / or frequency of monitoring.
Completion date 9/3/25Onsite validation of the facility's corrective action plan was completed on 9/11/25.
The initial audit results were reviewed.
The in-service education records completed 9/2/25 were reviewed.
Interviews with the Transport Driver and Maintenance Director as well as observations of a demonstration of anchoring a wheelchair to a transport van by both staff members were completed.
The monitoring results were reviewed, and the Quality Assurance meeting minutes were reviewed.
The facility's immediate jeopardy removal date of 9/3/25 was validated.
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