Above average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Swannanoa Valley Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found expired yogurt and cottage cheese in one walk-in cooler and strawberries with visible mold in another. The DM acknowledged missing these items during routine checks and stated she was training staff to monitor food dates. The Administrator confirmed staff are expected to remove expired or spoiled food.
A resident with spinal stenosis who spent much of her time in bed was unable to reach the broken pull cord for her over-bed light, leaving her unable to independently control the room lighting. Despite routine maintenance checks, the cord remained inaccessible, and staff interviews confirmed the resident's needs were not accommodated in a timely manner.
A resident with end stage renal disease and chronic diarrhea missed 12 doses of a prescribed controlled antidiarrheal medication due to the facility's failure to maintain an effective system for timely reordering and communication. Staff were unclear on the process for reordering controlled substances, leading to delays and confusion, and the medication was not available for several days until a new provider order was obtained.
A Wound Nurse failed to follow infection control protocols by not changing gloves or performing hand hygiene between wound care tasks for two residents. The nurse handled multiple surfaces and assisted with personal care while wearing soiled gloves, only removing gloves and performing hand hygiene at the end of care. The nurse acknowledged awareness of the policy but did not realize the lapses during the incidents.
The facility failed to maintain a clean and safe environment, with dirty build-ups around commodes and broken window blinds with sharp edges in resident rooms. Observations and interviews revealed that these issues had been present for months, with staff aware but not addressing them promptly. The Maintenance Manager and Administrator were not fully informed, leading to unresolved safety hazards.
The facility failed to maintain an effective pest control program, resulting in a fly infestation in resident rooms, hallways, and the dining room. Observations and interviews revealed that flies were a persistent issue, with staff and residents noting an increase in their presence. The pest control service did not include fly control, and the facility's efforts, such as using fly lights, were insufficient to address the problem.
A cognitively intact resident physically assaulted a resident with severely impaired cognition who wandered into his room, resulting in a skin tear and bruising. The incident was reported as resident-to-resident abuse, but the facility's investigation deemed it unsubstantiated, citing defensive action. The facility failed to prevent the altercation and protect the resident with impaired cognition.
A resident at risk for falls fell from her bed during a bed bath due to inadequate supervision. Despite requiring two-person assistance, only one nurse aide was present, leading to the resident rolling off the bed and hitting her nose on an oxygen concentrator. The resident was sent to the hospital but returned with no injuries. Staff interviews confirmed the need for two-person assistance, which was not followed, resulting in the incident.
Expired and Spoiled Food Not Removed from Kitchen Coolers
Penalty
Summary
Surveyors observed that the facility failed to remove expired and spoiled food items from both walk-in coolers in the kitchen. Specifically, four unopened containers of vanilla low fat yogurt and one opened container of cottage cheese were found in walk-in cooler #1, all of which were past their 'best if used by' dates. In walk-in cooler #2, a container of fresh strawberries was found with two strawberries covered in grey and white fuzz. The Dietary Manager acknowledged during interviews that it was her responsibility to check for expired food and that the expired items were a visual oversight. She also stated she was training her team to check food dates before serving or using food from containers. The Administrator confirmed the expectation that kitchen staff should remove food past its use by date or showing signs of spoilage.
Failure to Ensure Resident Access to Light Switch
Penalty
Summary
A deficiency was identified when a resident with spinal stenosis, who was cognitively intact and used a wheelchair for mobility, was unable to access the light switch in her room. The over-bed light fixture's pull cord was broken, leaving only a 10-inch string that was positioned 3.5 feet from the floor and 3 feet from the bed, making it unreachable from the bed. The resident reported that she experienced frequent back pain and spent much of her time in bed, and stated she would like to use the light but could not reach the cord. She also mentioned that the cord had been broken for a long time and could not recall if she had notified staff when it first broke. Observations confirmed that the resident was unable to independently operate the light while in bed, and interviews with facility staff revealed that maintenance staff routinely repaired light cords throughout the facility but could not confirm if or when this particular cord had been fixed. Both the DON and the Administrator acknowledged that residents should be able to reach their light cords, with the Administrator adding that the resident could communicate her needs to staff if she wanted the light on. However, the lack of accessibility to the light switch for this resident was not addressed in a timely manner, resulting in a failure to reasonably accommodate her needs and preferences.
Failure to Ensure Timely Reordering and Availability of Controlled Antidiarrheal Medication
Penalty
Summary
The facility failed to implement an effective system to ensure that an antidiarrheal medication, diphenoxylate-atropine (Lomotil), was reordered and available for administration, resulting in 12 missed doses for a resident with incontinence, end stage renal disease, and end stage renal dialysis. The resident was cognitively intact and had a physician's order for Lomotil to be administered four times daily for diarrhea. According to the Medication Administration Record, the medication was administered as ordered until it was put on hold due to being out of stock, and the resident missed doses over several days. Multiple staff members, including medication aides and nurses, became aware that the medication was out of stock, but there was confusion and miscommunication regarding the process for reordering a controlled medication. Some staff believed the medication had been reordered through the electronic Medication Administration Record (eMAR), but as a controlled substance, a new provider order was required, which was not immediately obtained. The pharmacy confirmed that a refill request was received but could not be processed without a new script, and there was no record of follow-up calls from the facility to the pharmacy. The Director of Nursing and other staff acknowledged that the process for reordering controlled medications was not clearly understood or followed. During the period when the medication was unavailable, the resident did not report significant changes in his condition and was not experiencing diarrhea according to staff and the resident himself. The Medical Director and Nurse Practitioner were eventually notified and placed the medication on hold until a new order could be obtained. The deficiency was attributed to a lack of an effective system for ensuring timely reordering and availability of controlled medications, as well as inadequate communication among staff regarding the specific requirements for ordering such medications.
Failure to Follow Hand Hygiene and Glove Change Protocols During Wound Care
Penalty
Summary
The facility failed to implement its infection prevention and control hand hygiene policy during wound care for two residents. The Wound Nurse did not change gloves or perform hand hygiene after completing wound care on one resident's buttocks wound, and proceeded to assess and treat a new area, as well as touch multiple surfaces and personal items, all while wearing visibly soiled gloves. The nurse continued to handle the resident's socks, heel protectors, bedding, call bell, and other room items before finally removing gloves and performing hand hygiene only at the end of the care episode. A similar failure occurred during wound care for another resident, where the Wound Nurse touched her gown and scrub pockets with gloved hands, left the room to retrieve scissors, and upon returning, performed wound care on two separate wounds. After completing care on the second wound, the nurse failed to remove gloves and perform hand hygiene before assisting the resident with mobility and clothing, and handling the resident's walker. Hand hygiene and glove removal were only performed at the conclusion of the care process. Interviews with the Infection Preventionist and the Director of Nursing confirmed that the facility's policy requires glove changes and hand hygiene between wound care tasks and after removing soiled gloves. The Wound Nurse acknowledged understanding of the policy and attributed the lapses to nervousness, stating she did not realize she had failed to change gloves or perform hand hygiene before touching multiple surfaces.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the presence of dirty build-ups around the base of commodes in two resident bathrooms. Observations revealed that the caulking around the base of the commodes had fallen off, trapping dark-colored build-up, which residents reported had been accumulating for several months. Interviews with residents and staff indicated that the issue had been noticed but not addressed, with the Maintenance Manager unaware of the problem despite regular room inspections. Additionally, the facility did not replace broken window blinds with sharp edges in two resident rooms. Observations showed missing and broken slats, creating potential safety hazards. Residents reported that the blinds had been in disrepair for an extended period, and staff interviews confirmed that the Maintenance Manager was aware of the issue but had not yet resolved it. The Administrator was also unaware of the broken blinds in one of the rooms. The deficiencies highlight a lack of effective communication and timely response to maintenance issues within the facility. Despite staff noticing and reporting the problems, there was a failure to ensure that necessary repairs were completed promptly, compromising the residents' right to a safe and comfortable living environment.
Deficiency in Pest Control Program Due to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies in two of the four hallways, resident rooms, and the dining room. The pest control service specifications did not include fly control, and the facility's pest control records from May to September 2024 did not report any issues with flies. Observations by surveyors noted flies in specific rooms and common areas, including a fly landing on a surveyor's face in the dining room. Interviews with residents and staff revealed that flies had been a noticeable issue throughout the facility, with some attributing the presence of flies to unclean conditions, such as urine spills not being fully cleaned. Staff, including housekeepers and nurse aides, reported seeing flies in various areas and noted that the problem had worsened recently. The Maintenance Manager acknowledged the presence of flies and mentioned that fly lights were used, but he was uncertain about additional measures to control the flies. The Administrator and Maintenance Manager were aware of the fly issue and had ordered more fly lights. They also attempted to identify entry points for the flies but were unsuccessful. The Maintenance Manager suggested that the flies might be entering through the frequently used smoking door. Despite these efforts, the facility did not have a comprehensive plan to address the fly infestation, and the pest control technician did not provide specific details on fly control measures.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a cognitively intact resident hit a resident with severely impaired cognition. The incident involved a resident with dementia and traumatic brain injury who wandered into another resident's room asking for a cigarette. The resident with intact cognition responded by slapping and punching the resident with impaired cognition, resulting in a skin tear and bruising. The resident with impaired cognition was under hospice care and had a history of wandering and verbal behavioral symptoms. The resident with intact cognition had a history of depression and psychoactive substance dependence. The altercation occurred when the resident with impaired cognition entered the other resident's room and threw a cup of coffee, prompting the physical response. The facility's initial report to the Health Care Personnel Registry indicated it was a resident-to-resident abuse incident. The investigation report later deemed the allegation of abuse unsubstantiated, citing the resident with intact cognition acted defensively. However, the report highlights the facility's failure to prevent the altercation and protect the resident with impaired cognition from physical abuse.
Resident Falls Due to Inadequate Supervision During Bed Bath
Penalty
Summary
The facility failed to provide adequate supervision and care for a resident, leading to an accident. Resident #29, who was at risk for falls due to deconditioning, gait, and balance problems, fell from her bed during a bed bath. The resident required two-person assistance for bed baths, but on the day of the incident, only one nurse aide (NA #2) was present. During the bed bath, the resident rolled over and fell off the bed, hitting her nose on an oxygen concentrator before landing on the floor. The incident report and interviews revealed that NA #2 was aware of the requirement for two-person assistance, as it had been discussed during a huddle meeting earlier that day. However, NA #2 proceeded to provide care alone, which resulted in the resident's fall. The resident was sent to the hospital for evaluation, where no injuries were found, and she was discharged back to the facility the same day. The resident reported that she normally had two people assist her with bed baths and had not fallen from her bed before this incident. Interviews with the Director of Nursing (DON) and other staff confirmed that Resident #29 had experienced a decline and required two-person assistance for all care, including bed baths. The DON stated that NA #2 did not remember the need for two-person assistance, and education was provided to NA #2 following the incident. The facility's failure to ensure adequate supervision and adherence to the resident's care plan resulted in the resident's fall and subsequent hospital visit.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Swannanoa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Summit Ridge | 2.5 mi | ★★★★★ | 0 | 0 |
| Nc State Veterans Home - Black Mountain | 4.3 mi | ★★★★★ | 2 | 0 |
| Highland Farms | 5.2 mi | ★★★★★ | 3 | 0 |
| The Laurels Of Greentree Ridge | 5.5 mi | ★★★★★ | 0 | 0 |
| Bear Mountain Health And Rehabilitation | 6 mi | ★★★★★ | 2 | 0 |
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