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 August 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.
The facility failed to maintain Legionella monitoring measures for the nursing home, with documentation showing the environmental assessment addressed only the ALU and no records of required water flushing or quarterly shower head descaling. The facility also failed to use gown and gloves for a resident on EBP who had COPD, acute respiratory failure, a trach, PEG tube, dysphagia, aphasia, and severe cognitive impairment; two CNAs provided incontinence and trach-related care with gloves only, and an LPN confirmed PPE should have been worn.
Delayed Resident Fund Disbursement: The facility failed to timely reimburse resident funds after death or discharge for two residents. One resident with COPD, HTN, DM2, lymphedema, and major depressive disorder had an incorrect refund amount and required a second check after the representative reported the error, while another resident with HTN, seizures, and bipolar disorder did not receive funds payout within the required timeframe after discharge. The BOM cited a vacancy in the business office role and missing payment documentation as contributing factors.
Failure to provide adequate and timely oral care to a dependent resident with a tracheostomy, severe cognitive impairment, aphasia, dysphagia, and total ADL dependence. Staff observed a white object on the resident’s upper lip while CNAs were providing care, and the CNAs stated they had not completed oral care during their shift because they believed RT handled it. RT said it provided oral care once per shift, while RN staff said they did not provide oral care for residents with tracheostomies; the DON confirmed RT was assigned oral care, but CNAs, LPNs, and RNs were also to provide oral care as needed.
Pressure ulcer care was not accurately carried out or documented for two residents. One resident with multiple serious diagnoses had an admission skin finding of a coccyx pressure ulcer, but the wound was not assessed, measured, or staged on admission, and ordered wound care was later documented as completed even though an old dressing was still in place when the area was checked. Another resident with heart failure, anoxic brain injury, and contractures had an order for heel boots every shift, but the TAR showed the boots in place even though an RN observed the resident’s heels resting directly on the mattress with no boots on.
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.
Legionella Monitoring and EBP PPE Failures
Penalty
Summary
The facility failed to ensure monitoring of Legionella control measures were in place. Review of the Legionella Environmental Assessment Form dated 02/11/26 showed interventions to prevent Legionella were listed only for flushing the closed Assisted Living unit showers and bathrooms. The Director of Maintenance confirmed the form was specific only to the Assisted Living unit and did not include Legionella prevention measures for the nursing home. Review of the Environmental Monitoring policy dated 09/2018 showed Legionella prevention monitoring was to include flushing hot and cold water in rooms vacant for ten or more days, running the water for five minutes at a time for five different times, and quarterly removal and descaling of shower heads. The Director of Maintenance confirmed there was no documentation of flushing empty rooms in this manner and no documentation that shower heads were removed and descaled quarterly. The facility also failed to ensure proper PPE was worn for a resident on enhanced barrier precautions. Resident #67 was admitted with diagnoses including COPD, acute respiratory failure, traumatic subdural hemorrhage, aphasia, dysphagia, and tracheostomy, and the quarterly MDS showed a BIMS score of 00 with dependence for all ADLs. Physician orders required gloves and gown for dressing, bathing, hygiene, changing linens, changing briefs, and device care including tracheostomy and feeding tube care. The revised care plan indicated enhanced barrier precautions were in place. During observation, two CNAs entered the resident's room to provide incontinence care, cleansed mucous around the tracheostomy area, and repositioned the resident while wearing gloves only. Both CNAs stated they did not wear PPE and believed the EBP sign did not apply to the resident; an LPN confirmed PPE should have been worn.
Delayed Resident Fund Disbursement
Penalty
Summary
The facility failed to ensure resident funds were reimbursed timely after discharge for two residents. Resident #77 was admitted with diagnoses including COPD, hypertension, type II diabetes mellitus, lymphedema, and major depressive disorder, and later died while still admitted to the facility. Review of the funds disbursement check showed the first refund check was dated more than a month after the resident’s death, and the resident’s representative reported the amount was incorrect, resulting in a second check being issued later. The Business Office Manager stated the first amount was wrong because the representative had paid cash at the beginning of February at the daily rate, but there was no record of that payment. Resident #78 had diagnoses of hypertension, seizures, and bipolar disorder and was discharged to another LTC facility. Review of the funds disbursement check showed it was dated nearly three months after discharge. The Business Office Manager stated the Business Office Manager position had been vacant from approximately the end of December 2025 until she began at the end of January 2026, and confirmed the resident’s funds were not paid out within 30 days because of the vacancy and the process of learning the new role. The facility policy stated the personal needs account must be closed within 30 days of death or discharge.
Failure to Provide Timely Oral Care to Dependent Resident
Penalty
Summary
The facility failed to provide adequate and timely oral care to a dependent resident who was unable to perform activities of daily living independently. Resident #67 was admitted with diagnoses including COPD, acute respiratory failure, traumatic subdural hemorrhage, aphasia, dysphagia, and a tracheostomy. The quarterly MDS showed a BIMS score of 00, indicating severe cognitive deficit, and the resident was dependent on others for all ADL care. The care plan and physician orders directed staff to provide oral care every shift and as needed. During observation, a white object approximately two inches long was noted on the resident’s right upper lip while CNA #118 and CNA #180 were providing incontinence care and repositioning. Both CNAs stated they did not complete oral care at all during their overnight shift and believed oral care for a resident with a tracheostomy was provided by Respiratory Therapy. Interviews showed RT staff did complete oral care once a shift and as needed, while RN staff stated they did not provide oral care to residents with tracheostomies. The DON confirmed RT was assigned oral care once a shift and as needed, while CNAs, LPNs, and RNs were also to complete oral care as needed. Review of task documentation showed no specific oral care task beyond a dependent-care entry, and progress notes reflected RT completing oral care at least once a shift with no documentation from other disciplines.
Pressure ulcer assessments, treatments, and prevention devices were not accurately completed or documented
Penalty
Summary
The facility failed to ensure timely and accurate pressure ulcer wound assessments and failed to ensure wound treatments were completed and documented per physician orders for Resident #74. The resident was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, tracheostomy status, gastrostomy status, hypertension, abnormal weight loss, and type 2 diabetes mellitus. On admission, the resident was noted to have an existing buttock wound and was assessed as high risk for skin breakdown, but the admission skin assessment documented a coccyx pressure ulcer without any wound assessment, measurements, or staging. A physician order was entered for cleansing the coccyx and applying nystatin cream and zinc oxide cream every shift, and the TAR showed the treatment as completed on both shifts on 01/20/26. However, when the nurse checked the coccyx the next day, an old dressing dated 01/11/26 was found in place, redness was observed around the area, and the nurse then completed the ordered treatment. The DON stated staff should have removed the hospital dressing, assessed and measured the wound on admission, and obtained treatment orders, and also stated the nurses had incorrectly documented the treatment as completed. The facility also failed to ensure pressure ulcer prevention treatments were in place per physician orders for Resident #2. The resident had diagnoses including heart failure, anoxic brain injury, and contractures, and the MDS indicated the resident was never understood, dependent on staff for toileting, repositioning, and personal hygiene, and at risk for skin breakdown. The care plan included heel boots per physician orders and floating heels as tolerated, and a physician order required heel boots for protection every shift. The TAR documented the heel boots as in place, but during observation the resident had no heel boots on and the heels were resting directly on the mattress. RN #119 verified the boots were not in place and confirmed the documentation was incorrect.
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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What surveyors actually found near you
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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 | ★★★★★ | 3 | 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 | ★★★★★ | 16 | 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 August 2026) and official state health department websites.