Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Inaccurate MDS assessments were completed for multiple residents. Several BIMS/cognition sections were left blank or marked inconsistently despite diagnoses such as dementia, Alzheimer's disease, schizoaffective disorder, and anoxic brain injury, one resident was incorrectly coded as having teeth when observation showed no teeth, and another resident was incorrectly coded as not using tobacco despite a smoking agreement, care plan for supervised smoking, and inclusion on the facility smoking list.
Meal components were not served as ordered for residents on modified diets. During noon meal observation, a resident on a mechanical soft diet, a resident on a pureed diet, and a resident on a minced and moist diet received only part of the meal and did not get salad, bread, or diet-appropriate substitutes. Staff confirmed that residents on these diets were only given penne pasta with meat sauce or two unidentified pureed bowls, and that no bread was served during another meal despite being on the menu.
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.
Failure to provide timely Medicare non-coverage notice. A resident with acute kidney failure, CKD, and type II DM was given a Notice of Medicare Non-Coverage on the same day skilled services ended, rather than at least 48 hours before the end of the Medicare-covered stay. The resident was later discharged home, and the DON verified the timing of the notice and service end date.
Compression stockings were not applied as ordered for a resident with impaired cognition, bilateral lower-extremity edema, AFib, HTN, DM2, and CKD stage 3. Although the TAR showed the stockings were administered and there was no note of refusal, an LPN observed the resident without the stockings and verified the documentation was incorrect; the regional RN stated the facility had no policy for applying compression stockings.
The facility failed to ensure vision services were provided to two residents. One resident with ESRD, DM2, AFib, and HTN reported trouble seeing and needing an eye doctor, but there was no documentation of vision services, no admission agreement for ancillary services, and no vision-service interventions in the care plan. Another resident with anoxic brain injury, dysphagia, HTN, cerebellar ataxia, and cardiomyopathy received prescription eyeglasses but later reported blurry vision; the SW verified the concern was emailed to the vision provider, no response was received, and no further follow-up or reassessment occurred.
Failure to maintain an ordered urinary catheter securement device for a resident with an indwelling catheter. The resident had significant medical issues, including heart failure, anoxic brain injury, and contractures, and was dependent on staff for toileting and personal hygiene. During catheter care, an RN and LPN observed that no securement device was in place, and the RN confirmed the TAR had been inaccurately documented. The DON verified staff should have ensured the device was in place.
Missing Dialysis Communication Documentation: A resident with ESRD receiving dialysis had multiple missed dialysis communication forms and several forms without returned communication from the dialysis center. The resident’s care plan called for staff to communicate with the dialysis unit about the plan of care, lab values, and diet/fluid restrictions, but the DON verified the missing documentation and lack of response on several forms.
Failure to Provide Dental Services: Two residents did not receive ordered or planned dental services. One resident with ESRD, DM2, AFib, and HTN reported no teeth and ill-fitting dentures, but the record showed no signed admission agreement or documentation of dental care. Another resident with anoxic brain injury, dysphagia, HTN, cerebellar ataxia, and cardiomyopathy had consented to dental services, yet both the resident and SW confirmed routine dental care had not been provided.
Failure to Provide Ordered Adaptive Eating Equipment: Two residents with neurologic and cognitive conditions did not receive ordered mealtime adaptive equipment. One resident with parkinsonism, dementia, and MS was observed using standard utensils and an uncovered drink despite orders for built-up utensils, a scoop dish/individual bowls, and cups with lids. Another resident with Alzheimer’s disease and parkinsonism was observed with a regular cup instead of the ordered sippy cup during meals, and staff confirmed the mismatch.
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.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for seven residents. For Resident #6, who had parkinsonism, dementia, and multiple sclerosis, a quarterly MDS dated 02/15/26 indicated the Brief Interview for Mental Status (BIMS) should be conducted, but each BIMS item was entered as a dash, showing cognition was not assessed. For Resident #7, who had chronic respiratory failure with hypoxia, ventilator dependence, and seizures, the quarterly MDS dated 01/15/26 showed intact cognition, but the annual MDS dated 04/17/26 indicated BIMS should be conducted with each BIMS item entered as a dash, so cognition was not assessed. Resident #12, who had Alzheimer's disease, neuralgia, and parkinsonism, also had a quarterly MDS dated 02/03/26 that indicated BIMS should be conducted, yet each BIMS item was entered as a dash. The DON and Regional RN stated the MDS Coordinator worked remotely. Additional inaccuracies were identified in other assessments. Resident #44, with diagnoses including schizoaffective disorder, CHF, anemia, dementia, manic episode, and psychosis, had an annual MDS in which Section C was not assessed, and the DON confirmed cognition was not assessed. Resident #54, who had anoxic brain injury, dysphagia, HTN, cerebellar ataxia, and cardiomyopathy, had a quarterly MDS showing intact cognition, while a significant change MDS showed cognition status was not assessed; the Regional RN verified the cognitive assessment was not accurately completed and stated the RAI manual guidelines were used. Resident #22, who had ESRD, type 2 DM, atrial fibrillation, and HTN, was assessed as not edentulous on the quarterly MDS even though observation and resident interview showed no teeth. Resident #46, with COPD, alcoholic cirrhosis of the liver, and epilepsy, had an annual MDS stating the resident did not use tobacco, despite a smoking agreement, a care plan addressing smoking supervision, and inclusion on the facility's list of residents who smoke; the Regional RN confirmed the tobacco-use assessment was inaccurate.
Meal Components Not Served as Ordered
Penalty
Summary
The facility failed to ensure residents received all components of the meal. During observation of the noon meal, a resident with Parkinsonism, dementia, and multiple sclerosis who required partial/moderate assistance for eating and was ordered a mechanical soft diet with thin liquids received penne pasta but did not receive a salad or garlic bread. Another resident with Alzheimer's disease, neuralgia, and Parkinsonism who required supervision or touching assistance for eating and was ordered a pureed diet with thin liquids was served two pureed bowls of food, and staff could not identify the items in the bowls. A third resident with anoxic brain damage, dysphagia, and cerebellar ataxia who was dependent on staff for eating and ordered a minced and moist texture diet received only penne pasta and no salad or garlic bread. The posted menu for that meal included a salad, penne pasta with meat sauce, garlic bread, and marble cake. Follow-up interview with the Activities Recreation Director confirmed that residents on mechanical soft and minced and moist diets only received the penne pasta with meat sauce and did not receive other meal items such as salad, vegetable, or garlic bread, and that residents on a pureed diet only received two bowls of food. The Director of Food Services confirmed no vegetable or bread substitute was provided for residents on mechanical soft, minced and moist, or pureed diets. Review of the menu spreadsheet showed that residents on mechanical soft diets should have received shredded tossed salad and garlic bread, residents on minced and moist diets should have received minced and moist marinated green beans and pureed garlic toast, and residents on pureed diets should have received pureed soft marinated green beans and pureed garlic toast. In a separate observation, the noon menu called for chicken breast, sweet potatoes, peas and carrots, and wheat bread, but no bread was served to any residents, and staff confirmed bread was not given during the meal.
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 Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide a resident with a 48-hour notice of non-payment for services. Review of Former Resident #75's record showed an admission date of 12/24/25 and discharge to home on 01/01/26. The resident's diagnoses included acute kidney failure, chronic kidney disease, and type II diabetes mellitus. The Notice of Medicare Non-Coverage was dated 12/31/25 and stated that payment for skilled services would end on 12/31/25; it was signed that same day by the resident's guardian. The Director of Social Services verified that the resident's services ended on the same day the notification was provided. Facility policy stated that the notice should be given at least two days before the end of the Medicare-covered Part A stay or when Part B therapies are ending.
Compression Stockings Not Applied as Ordered
Penalty
Summary
The facility failed to ensure compression stockings were administered according to physician orders for one resident reviewed for edema. The resident had diagnoses including metabolic encephalopathy, atrial fibrillation, type 2 diabetes mellitus, hypertension, and chronic kidney disease stage three, and the quarterly MDS indicated impaired cognition and need for substantial to maximal assistance with lower body dressing and putting on and taking off footwear and socks. The care plan included applying compression stockings as ordered by the physician for altered or potential altered cardiac output related to atrial fibrillation, hypertension, and congestive heart failure. A physician order directed that compression stockings be worn daily, on in the morning and off at bedtime, for bilateral lower extremity edema. The TAR documented that the stockings had been administered, and the nurses' notes from the prior days contained no documentation that the resident refused them. However, during observation the resident had no compression stockings on and had pitting edema to both lower extremities. The LPN present verified the resident was not wearing the stockings and stated she had incorrectly documented that they had been administered. The regional RN stated the facility had no policy regarding the application of compression stockings.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure vision services were provided to two residents reviewed for vision care. Resident #22, admitted with end stage renal disease, type 2 diabetes mellitus, atrial fibrillation, and hypertension, had intact cognition and was identified on the vision care plan as being at risk for visual decline and undetected eye disease related to those conditions and aging. However, the care plan contained no interventions to arrange vision services, the medical record had no documentation that vision services were provided, and there was no signed admission agreement or documentation showing acceptance or refusal of ancillary services on admission. Although physician orders included an ophthalmology consult and optometrist as needed, the resident reported having glasses and needing to see an eye doctor because of trouble seeing, and stated she had told staff shortly after admission. Resident #54, admitted with anoxic brain injury, dysphagia, hypertension, cerebellar ataxia, and cardiomyopathy, also had intact cognition and had physician orders for ancillary services including vision services. The vision care plan included an intervention for staff to arrange eye appointments if increased visual deficits were noted, and the resident had consented to vision services. A vision provider note documented prescription eyeglasses, which the resident received in February 2026, but the resident later reported the glasses caused blurry vision and that he had not been seen by the eye care provider to correct them. The social worker verified concerns were emailed to the vision provider, no response was received, no further follow-up was attempted, and the resident was not further assessed for his vision or eyeglasses.
Failure to Maintain Ordered Urinary Catheter Securement Device
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter securement device was in place per physician order for one resident with an indwelling catheter. The resident was admitted with diagnoses including heart failure, anoxic brain injury, and contractures, and was documented as never understood and dependent on staff for toileting and personal hygiene. The resident’s care plan identified the indwelling urinary catheter as indicated due to a coccyx wound per hospice and included catheter care per facility policy, but it did not document an intervention for securing the catheter tubing. A physician order dated 05/13/26 included an order for a catheter securement device with instructions to ensure placement and replace as needed. During observation of urinary catheter care, the resident had no urinary catheter securement device in place. An RN verified the device was not in place and stated she had inaccurately documented in the TAR that the securement device was in place. The DON later verified the resident had an order for a urinary catheter securement device and staff should have ensured it was in place. The facility policy on catheter care stated residents with indwelling catheters would receive appropriate catheter care, but it did not include guidelines for securement devices.
Missing Dialysis Communication Documentation
Penalty
Summary
The facility failed to ensure ongoing communication with the dialysis center for a resident receiving dialysis services. Resident #22 was admitted with diagnoses including end stage renal disease, type 2 diabetes mellitus, atrial fibrillation, and hypertension. The quarterly MDS indicated the resident had intact cognition and was receiving dialysis services, and the care plan identified end stage renal disease requiring dialysis treatment. The care plan also included an intervention for staff to communicate with dialysis center staff regarding the resident’s plan of care, laboratory values, and diet/fluid restriction recommendations. Review of the dialysis communication forms showed multiple missed forms during April and May 2026, including several dates with no dialysis communication form present. In addition, several completed forms did not have returned communication from the dialysis center. During interview, the DON verified the missing dialysis communication forms and the forms lacking documentation of a response to treatment from the dialysis center. The facility policy stated there would be communication between the facility and the dialysis unit with each visit using the dialysis communication form, and if the dialysis unit failed to provide communication, staff would document that no communication was provided on the form.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to ensure dental services were provided to residents, affecting two of three residents reviewed for dental services. One resident was admitted with diagnoses including end stage renal disease, type 2 diabetes mellitus, atrial fibrillation, and hypertension, and had intact cognition on the quarterly MDS. The dental care plan called for staff to arrange periodic dental consults and follow-up visits, but the medical record contained no documentation that dental services were provided. The record also had no signed admission agreement and no documentation showing acceptance or refusal of ancillary services on admission. The resident stated she had no teeth, her old dentures no longer fit, and she told staff shortly after admission that she needed to see a dentist. The SW verified the resident had not been provided dental services since admission. The second resident was admitted with diagnoses including anoxic brain injury, dysphagia, hypertension, cerebellar ataxia, and cardiomyopathy, and had intact cognition on the quarterly MDS. A physician order included ancillary services such as dental services, the dental care plan directed staff to arrange periodic dental consults, and an ancillary services consent form showed the resident consented to dental services. However, the resident stated he had not been provided dental services in the last eight months, and the SW verified routine dental services had not been provided. The facility policy stated it would assist residents in obtaining routine and emergency ancillary services, including dental services.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to ensure adaptive eating equipment was provided during meals for two residents who had physician orders and care plan interventions for assistive devices. One resident with parkinsonism, dementia, and multiple sclerosis required partial/moderate assistance for eating and had orders for built-up utensils, a scoop dish or individual bowls as needed, and cups with lids. During lunch observation, the resident was seen using a standard fork while her arm shook, and she had an uncovered glass of red beverage; staff confirmed the meal was served on a standard plate with standard utensils and without the ordered lid or adaptive utensils. During breakfast the next day, the resident again received regular utensils, and built-up utensils were only provided after staff went to obtain them. A second resident with Alzheimer’s disease, neuralgia, and parkinsonism required supervision or touching assistance for eating and had a physician order to use a sippy cup with meals and snacks to prevent spilling. During lunch observation, the resident had two bowls of pureed food and an uncovered cup of chocolate milk, and CNA confirmed the drink was not in the ordered sippy cup. During breakfast the next day, the resident again had a regular cup with a red drink instead of the ordered sippy cup, and CNA confirmed the cup did not match the physician order.
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 | ★★★★★ | 7 | 0 |
| Whitehouse Country Manor | 6.4 mi | ★★★★★ | 0 | 0 |
| Elizabeth Scott Community | 8.6 mi | ★★★★★ | 2 | 0 |
| Addison Heights Health And Rehabilitation Center | 9.5 mi | ★★★★★ | 16 | 0 |
| Otterbein Monclova | 9.5 mi | ★★★★★ | 2 | 0 |
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