Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of Swanton during CMS and state inspections, most recent first.
A resident with cognitive impairment and continuous bowel and bladder incontinence did not receive incontinence care consistent with the care plan and facility policy. The care plan called for incontinence care every two hours and as needed, and the facility’s perineal care policy required care to promote cleanliness and prevent skin issues. During observed care, staff found the resident wearing two briefs, with the inner brief saturated with urine while the outer brief appeared dry. A CNA reported that her two-hour checks involved only assessing the outer brief and that she was unaware of the second brief, despite facility rules prohibiting double briefing and requiring a physician order for any additional incontinence products, which was not present for this resident.
A resident receiving hospice care with chronic respiratory failure, emphysema, and rheumatoid arthritis experienced repeated medication errors when morphine orders were incorrectly transcribed and administered at significantly lower doses than prescribed. Hospice orders for oral morphine solution were written for specific mg doses based on a 20 mg per 1 mL concentration, but staff entered them on the MAR using a 20 mg per 5 mL concentration, resulting in under-dosing. The pharmacy label initially reflected the correct dose, but the dose on the label was altered by hand, and the resident was repeatedly given 1 mg instead of 5 mg and later 2 mg instead of 10 mg over multiple administrations. An RN documented the incorrect dosing, and the DON confirmed the errors, which were not consistent with the facility’s medication administration policy.
A resident with multiple medical conditions, including surgical aftercare needs and cognitive impairment, required daily abdominal wound care per physician orders. During an observed dressing change, an LPN removed a soiled dressing and cleansed the wound but did not change gloves before applying a clean dressing, and used scissors to cut alginate without disinfecting them beforehand. The LPN later confirmed these actions, while the DON stated that gloves should be changed between dirty and clean steps and scissors disinfected before use, consistent with facility policies and CDC infection control protocols.
A resident admitted with severe cognitive impairment, total care dependency, and multiple serious diagnoses did not have a baseline care plan developed within 48 hours of admission, as required by facility policy. Staff confirmed that no baseline care plan was in place to guide immediate care for this resident.
The facility failed to conduct quarterly care plan conferences for three residents, despite their complex medical conditions and cognitive impairments. Interviews confirmed the absence of required care conferences, and the facility's policy mandates were not followed.
Failure to Provide Timely and Policy-Compliant Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate incontinence care in accordance with its policy for a resident who was always incontinent of bowel and bladder. The resident, admitted with diagnoses including Lewy body dementia, hypertension, anxiety, muscle weakness, and abnormal posture, had an MDS indicating cognitive impairment and continuous incontinence. The resident’s care plan included an intervention for incontinence care every two hours and as needed, and the facility’s perineal care policy stated that perineal care would be provided to promote cleanliness, prevent infection, and prevent skin breakdown. Review of the physician’s orders showed there was no order for brief liners. During an observation of incontinence care, surveyors noted the resident appeared to have a dry brief, but further inspection revealed the resident was wearing two briefs, one on top of the other, with the brief next to the skin saturated with urine. The CNA providing care reported she had been performing every two-hour brief checks since the start of her shift by checking only the outer brief and was unaware that a second brief was in place. She acknowledged that facility policy prohibited double briefing and that brief liners could only be used with a physician’s order. The DON confirmed that double briefing was not permitted, that brief liners required a physician’s order, and that this resident did not have such an order, demonstrating that the resident did not receive incontinence care consistent with facility policy.
Incorrect Transcription and Under-Dosing of Hospice Morphine Orders
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when hospice morphine orders were incorrectly transcribed and administered at doses lower than prescribed. A cognitively intact resident with chronic respiratory failure with hypoxia, emphysema, and rheumatoid arthritis was admitted on an identified date and had hospice physician orders dated 10/16/25 for 0.25 mL (5 mg) of morphine solution 20 mg per 1 mL to be given by mouth every four hours. The medication administration record for October 2025 showed this order was incorrectly entered as 0.25 mL of morphine solution 20 mg per 5 mL, resulting in a 1 mg dose instead of the ordered 5 mg. The controlled medication count sheet and pharmacy label indicated morphine solution 20 mg per 5 mL was dispensed with a printed dose of 1.25 mL (5 mg), but the dose on the label was altered by hand to 0.25 mL, and the resident received 0.25 mL (1 mg) on 14 occasions on 10/16/25, 10/17/25, and 10/18/25. The DON confirmed the resident was given 1 mg instead of 5 mg on these dates. A second hospice morphine order dated 10/18/25 directed 0.5 mL (10 mg) of morphine solution 20 mg per 1 mL to be administered by mouth every two hours. The October 2025 medication administration record showed this order was incorrectly entered as 0.5 mL of morphine solution 20 mg per 5 mL, resulting in a 2 mg dose instead of the ordered 10 mg. The controlled medication count sheet showed morphine solution 20 mg per 5 mL was dispensed and administered at 0.5 mL (2 mg) per dose on 14 occasions on 10/18/25, 10/19/25, and 10/20/25. A progress note dated 10/20/25 by an RN documented that the resident had been administered incorrect doses of morphine at 2 mg instead of 10 mg, and the DON confirmed the resident received 2 mg instead of 10 mg on those dates. The facility’s Medication Administration policy dated 08/22/22 stated that medications would be administered as ordered by the physician, which was not followed in these instances. This deficiency was investigated under Complaint Number 2647291.
Failure to Maintain Infection Control Practices During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices during wound care for one resident. The resident was admitted with diagnoses including surgical aftercare on the respiratory system, pulmonary embolism, and traumatic subdural hemorrhage, and was documented as cognitively impaired, bedbound, and dependent on staff for all care. A physician’s order directed that the resident’s distal midline abdominal wound be cleansed with normal saline, patted dry, covered with alginate, and then covered with an absorbent silicone dressing once daily and as needed. During an observed dressing change, an LPN removed the soiled dressing and cleansed the abdominal wound but did not change gloves before applying the clean dressing. The LPN also used scissors to cut the alginate without disinfecting the scissors prior to use. In a subsequent interview, the LPN confirmed she had not changed gloves between handling the soiled dressing and applying the clean dressing, and had not disinfected the scissors before cutting the alginate and placing it in the wound bed. The DON stated that gloves should be changed after removing a soiled dressing and before applying a clean dressing, and that scissors should be disinfected prior to cutting dressing items. Facility policies on wound treatment management and infection prevention and control, as well as CDC protocols, required adherence to current standards of practice, including cleaning reusable equipment and changing gloves when moving from a dirty site to a clean site.
Failure to Initiate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to initiate a baseline care plan for a resident within 48 hours of admission, as required by facility policy. Medical record review showed that the resident was admitted with diagnoses including intracranial hemorrhage, respiratory failure, and COPD, and was assessed as severely cognitively impaired, dependent for all care, and at risk for pressure ulcers. Despite these significant care needs, there was no baseline care plan developed or implemented for the resident. This was confirmed during staff interview with the Regional Registered Nurse, who verified the absence of a baseline care plan upon admission. The facility's policy states that a baseline care plan must be developed within 48 hours to provide effective and person-centered care.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to conduct quarterly care plan conferences as required, affecting three residents. Resident #12, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease and bipolar disorder, had no care conferences completed despite being moderately cognitively impaired. Similarly, Resident #24, with conditions such as acute and chronic respiratory failure and atrial fibrillation, had only one care conference since admission, missing the required quarterly reviews. Interviews with Social Services confirmed these deficiencies. Resident #32, admitted with diagnoses including chronic obstructive pulmonary disease and anxiety disorder, also had no care conferences completed. Although the resident was cognitively intact, there were no documented refusals for attending care conferences, and Social Services reported a lack of interest from the resident and their representatives. The facility's policy mandates that comprehensive care plans be prepared and reviewed by an interdisciplinary team, including the resident and their representative, after each comprehensive and quarterly MDS assessment, which was not adhered to in these cases.
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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 Swanton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Swanton Valley Rehabilitation And Healthcare Cente | 0.2 mi | ★★★★★ | 2 | 0 |
| Whitehouse Country Manor | 6.4 mi | ★★★★★ | 0 | 0 |
| Elizabeth Scott Community | 8.6 mi | ★★★★★ | 0 | 0 |
| Addison Heights Health And Rehabilitation Center | 9.5 mi | ★★★★★ | 42 | 0 |
| Otterbein Monclova | 9.5 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.