Below 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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Swanton Valley Rehabilitation And Healthcare Cente during CMS and state inspections, most recent first.
A resident with multiple comorbidities, moderately impaired cognition, wheelchair use, and high fall risk experienced repeated falls related to attempts to toilet independently. Although the care plan called for assistance with transfers and toileting and fall-prevention measures, post-fall interventions were limited to education, keeping items within reach, and non-skid footwear, without adding a toileting schedule or specific bathroom assistance despite the toileting-related nature of the falls. Documentation after the falls did not show what interventions were in place at the time, when the resident was last observed, or whether the call light was used. Observations later found the resident at the bedside and on a bedside commode without slip-resistant footwear, and an LPN reported being unaware the resident was up unsupervised, while the DON confirmed there were no implemented interventions to determine bowel/bladder habits or a toileting schedule and that key post-fall investigation details were missing.
A resident who was always incontinent of bowel and bladder, dependent for ADLs, and at risk for pressure ulcer development had a care plan that included assistance with toileting and peri-care after each incontinent episode but lacked any scheduled toileting or documented incontinence check frequency, despite an assessment indicating candidacy for scheduled toileting. On one morning, the resident reported being wet since an early-morning check, and the LPN who had assumed care several hours earlier acknowledged not checking for incontinence even though the resident was known to require q2h checks and had chronic buttock excoriation. When the RN and LPN finally provided incontinence care, the resident was found moderately wet with excoriated buttocks, and the DON confirmed there was no established toileting schedule and that the resident should have been asked if they needed to be checked or changed.
Two residents with chronic medical conditions were found to be using vape pens in their rooms, including while on oxygen therapy, in violation of facility policy. Staff were aware of the ongoing noncompliance, and vape pens were repeatedly found in resident rooms, but interventions and supervision were not effectively enforced to prevent these safety hazards.
The facility failed to ensure proper cleaning and storage of kitchenware, affecting 75 residents. Observations revealed no designated storage for clean dishes, with some items found with residue or improperly stored. The Corporate Dietary Manager confirmed these deficiencies, and unclean items were replaced during meal preparation.
The facility failed to maintain comfortable room temperatures for four residents with conditions like COPD and dementia. Observations showed residents bundled in blankets and wearing warm clothing, yet still feeling cold. The Maintenance Director confirmed the heating system was not activated, and room temperatures were below the facility's policy range of 71-81°F.
A facility failed to provide a dignified dining experience for a resident with severe cognitive impairment who required assistance with eating. A CNA was observed standing while assisting the resident, contrary to the facility's policy that requires staff to be seated at eye level. The CNA admitted to the oversight, and the DON confirmed the policy requirement.
A resident with a history of stroke and other medical conditions did not receive prescribed ROM exercises after being discharged from therapy. The resident's left extremities were immobile, and staff interviews revealed a lack of communication and implementation of the exercise regimen. The CNA was unaware of the specific exercises, and the Therapy Director confirmed that only one staff member was informed, with no documentation in the medical record.
The facility failed to administer oxygen therapy according to physician orders for three residents with respiratory issues. One resident with mild cognitive impairment had their oxygen set at three lpm instead of the ordered four lpm. Another resident, cognitively intact, had their oxygen set at two lpm instead of four lpm. A third resident with impaired cognition had their oxygen set at four lpm, contrary to the order of three lpm. These discrepancies were confirmed by LPNs, indicating a deficiency in the facility's respiratory care practices.
A resident with severe cognitive impairment and dental issues did not receive routine dental services as required. Despite consent for dental care and a care plan indicating dental problems, there was no record of a dental visit since admission. The facility's administrator confirmed the oversight, noting the dentist visits every three months.
A resident with severe cognitive impairment and hand tremors was not provided with the necessary adaptive eating equipment during meals, despite having a physician's order for a lidded cup with a straw. The resident was observed struggling to drink from a regular cup, leading to frustration. Facility policy requires adaptive devices for residents who need them, but this was not followed, resulting in a deficiency.
A facility failed to notify a resident's representative about the administration of PRN antipsychotic medications for behavior management. Despite the facility's policy requiring notification of changes in a resident's condition, staff interviews confirmed that the expected communication did not occur, resulting in a deficiency.
Failure to Implement Toileting-Related Fall Interventions and Complete Post-Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate fall interventions and conduct thorough post-fall investigations for a resident identified as high risk for falls. The resident had multiple serious medical diagnoses, including lung cancer, acute and chronic respiratory failure with hypoxia and hypercapnia, COPD, CHF, atrial fibrillation, diabetes, generalized anxiety, major depression, and chronic fatigue. The resident used a wheelchair, had moderately impaired cognition, required supervision/touching assistance for ADLs, partial to moderate assistance with toileting and transfers, and was always continent per the most recent MDS. Fall risk assessments on three separate dates identified the resident as high risk for falls. The care plan included one-person assist for transfers and toileting, assistance with toileting needs, evaluation of urination and incontinence patterns, and fall-risk interventions such as educating the resident to call for assistance, keeping items and call light within reach, monitoring mobility, and providing non-skid footwear. On one date, a fall occurrence evaluation documented that the resident was found on the floor by the bed, sitting on her buttocks, and reported attempting to use the bathroom when the fall occurred, with no injury noted. Interventions listed after this fall included education to call for assistance, keeping food/fluids within reach, and providing non-skid footwear, but did not include a toileting schedule or assistance to the bathroom, despite the fall being related to toileting. A post-fall risk evaluation noted the resident had previous falls, used assistive devices, and had a weak gait. On another date, a subsequent fall occurrence evaluation documented that staff found the resident scooting along the floor in the hall, with the resident stating she had been using the bathroom, became shaky, and sat on the floor to avoid injury. The bedside commode and walker were at the bedside, and a head-to-toe assessment showed no new injuries. The facility again initiated fall protocol with similar interventions (education, food/fluids within reach, non-skid footwear) but did not add a toileting schedule or specific assistance to the bathroom, and there was no documentation of what interventions were in place at the time of the fall, when the resident was last observed, or whether the call light was activated. Further observations showed the resident seated on the bedside with anti-embolism stockings on both lower extremities, with the stocking toes dangling and not securely in place, and no slip-resistant footwear applied. Another observation found the resident seated on a bedside commode without slip-resistant footwear. An LPN stated she was unaware the resident was up at the bedside without supervision and indicated the resident was supposed to be assisted by staff for transfers and not self-transfer. The DON confirmed that no interventions had been implemented to determine the resident’s bowel and bladder habits or a toileting schedule, and acknowledged that the resident’s falls were related to self-transferring to the toilet and bedside commode. The DON also verified that the fall investigation documentation for both falls lacked information on interventions in place at the time of the falls, when the resident was last observed, and whether the call light was activated, despite the facility’s fall policy requiring identification and adjustment of interventions based on resident-specific risks and causes.
Failure to Implement Scheduled Toileting and Timely Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement and provide timely incontinence care and scheduled toileting for a resident who was always incontinent of bowel and bladder. The resident had diagnoses including post-polio syndrome, Bell’s palsy, osteoarthritis, muscle weakness, and bilateral myopia, and was dependent on staff for activities of daily living. The most recent MDS documented intact cognition, frequent rejection of care, and a risk for pressure ulcer development. The nursing plan of care identified bladder and bowel incontinence related to generalized weakness, with interventions to assist with toileting needs, evaluate patterns of urination and incontinence, provide disposable incontinence products, and provide peri-care after each incontinent episode. However, there were no scheduled toileting times or documented frequency for incontinence checks in the medical record, despite a bowel and bladder assessment indicating the resident was a potential candidate for scheduled toileting. On the morning of the survey, the resident reported being incontinent of urine and stated the last incontinence check occurred at 4:30 A.M. The LPN acting as the resident’s CNA stated she assumed care at 5:00 A.M. and confirmed she had not checked the resident for incontinence, despite acknowledging the resident should be checked every two hours and had chronic excoriation to the buttocks. At 9:48 A.M., the RN and LPN went to provide incontinence care; the LPN verified she had not previously asked the resident if she needed to be checked. Upon removal of the incontinence brief, the resident was found to be incontinent of a moderate amount of urine, with bilateral buttocks showing excoriated tissue. The DON confirmed the resident frequently refused care, that no toileting schedule had been established as indicated by the bowel and bladder assessment, and that the resident should have been asked if she needed to be checked or changed that morning.
Failure to Prevent Vape Pen Use in Presence of Oxygen
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents related to the use of vape pens in the presence of oxygen. One resident with diagnoses including heart disease, chronic obstructive pulmonary disease, and chronic respiratory failure with hypoxia was observed and documented using a vape pen in her room while wearing oxygen. Despite being informed of the facility's smoking policy and signing an acknowledgment, the resident continued to use the vape pen in her room and did not remove her oxygen while vaping. Staff, including RNs, LPNs, and other personnel, were aware of the resident's noncompliance, and it was noted that the resident's husband would bring additional vape pens into the facility. The vape pen was repeatedly found in the resident's possession, and she admitted to using it in her room while on oxygen, in direct violation of facility policy and safety protocols. Another resident with multiple sclerosis and stroke was also found to have a vape pen in her room. This resident admitted to vaping in her room and was aware of the facility's policy but did not consistently return the vape pen to staff after use. Staff observed the vape pen on the resident's overbed table and reported the issue, but the resident was not fully aware of the requirement to return the vape pen to nursing staff. Both residents had care plans indicating noncompliance with the smoking policy and required supervision or interventions to ensure safety, but these interventions were not effectively enforced. Facility policy required that all smoking materials, including electronic smoking devices, be retained and distributed by staff during designated smoking times and that residents not smoke or vape while using oxygen or in areas where oxygen is present. Despite these policies, staff did not consistently enforce the rules, and residents were able to keep vape pens in their rooms and use them unsupervised. Multiple staff interviews confirmed awareness of the residents' noncompliance and the presence of vape pens in resident rooms, but actions taken were insufficient to prevent ongoing violations of the policy.
Improper Cleaning and Storage of Kitchenware
Penalty
Summary
The facility failed to ensure that dishes were cleaned and properly stored, which had the potential to affect 75 residents who received food from the kitchen. During an observation, it was noted that there was no designated storage area for clean cups, bowls, plates, or trays. Clean clear bowls and adaptive equipment were stored on a rack in the dish room, cups were stored on drink carts, trays were stored at the end of the steam table, and opaque soup bowls were stored in racks under the steam oven. On a subsequent observation, three coffee cups from a drink cart were found with a dried powdery residue inside, which could be easily removed by rubbing a finger across it. The Administrator confirmed that the cups appeared unclean. Further observations revealed that the kitchenware storage rack in the dishwashing room had two plates and a bowl with food residue, and clear bowls were stacked wet with the bowl facing up. The Corporate Dietary Manager verified that the dishes had food debris and were stored improperly. Additionally, during meal delivery preparation, two clear bowls on a serving cart were found with a brown substance on them and were unclean. The Corporate Dietary Manager confirmed the unclean condition and replaced them with clean bowls. Another observation showed that dishes appeared to be rewashed and were clean but were stacked wet, as verified by Dietary Staff.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to ensure comfortable room temperatures for residents, affecting four individuals with various medical conditions, including chronic obstructive pulmonary disease (COPD), diabetes mellitus, asthma, chronic respiratory failure, multiple sclerosis, and dementia. Observations and interviews revealed that these residents were experiencing discomfort due to cold room temperatures. Resident #57, who was cognitively intact, was observed wearing warm clothing and a blanket, yet still reported feeling cold. Similarly, Resident #19, also cognitively intact, was wrapped in blankets and complained about the cold room. Resident #34, with mild cognitive impairment, was found curled in a fetal position under blankets, expressing discomfort due to the cold. Resident #71, with mild cognitive impairment, was dressed in multiple layers and reported her room being cool. The Maintenance Director (MD) confirmed that the facility's heating system had not been turned on, despite the residents' complaints. Observations of room temperatures showed that all affected residents' rooms were below the facility's policy range of 71-81 degrees Fahrenheit, with temperatures recorded between 69.2 and 70.5 degrees Fahrenheit. The facility's policy, dated September 2021, mandates maintaining an acceptable temperature range to ensure residents' comfort and safety, which was not adhered to in this instance.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
The facility failed to ensure a dignified assisted dining experience for residents requiring staff assistance with eating. This deficiency was observed in the case of a resident with severe cognitive impairment and a self-care performance deficit, who required partial/moderate assistance with eating. During a meal service, a CNA was observed standing while assisting the resident with eating, rather than sitting at eye level as required by the facility's policy. The CNA acknowledged the oversight, attributing it to having just assisted another resident. The facility's policy, dated September 2021, mandates that residents who cannot feed themselves should be fed with attention to safety, comfort, and dignity. The Director of Nursing confirmed that staff should be seated at eye level with residents during meal assistance. This incident affected one resident directly observed and potentially impacted 12 additional residents identified by the facility as requiring similar assistance.
Failure to Provide ROM Exercises for Resident
Penalty
Summary
The facility failed to ensure that range of motion (ROM) exercises were provided to a resident, leading to a deficiency in care. Resident #46, who had a history of cerebrovascular disease, stroke, and other medical conditions, was observed with immobile left upper and lower extremities. The resident reported that after being discharged from therapy, staff did not apply the hand/wrist splint or assist with exercises, which were necessary to prevent further decline in ROM. Interviews with staff revealed a lack of communication and implementation of the prescribed exercise regimen. The Certified Nurse Assistant (CNA) responsible for the resident was not aware of the specific exercises or the functional maintenance program recommended by therapy. The Therapy Director confirmed that exercises were to be administered daily but acknowledged that only one staff member was informed, and no documentation was available in the resident's medical record to indicate that the ROM exercises were being provided.
Oxygen Therapy Not Administered Per Physician Orders
Penalty
Summary
The facility failed to administer oxygen therapy according to physician orders for three residents, all of whom had diagnoses related to respiratory issues such as chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. Resident #34, who had mild cognitive impairment, was observed with an oxygen concentrator set at three liters per minute (lpm) instead of the ordered four lpm. This discrepancy was confirmed by an LPN. Similarly, Resident #57, who was cognitively intact, had her oxygen concentrator set at two lpm, contrary to the physician's order of four lpm. This was also verified by the same LPN. Resident #5, who had impaired cognition and diagnoses including COPD and congestive heart failure, was found with her oxygen concentrator set at four lpm, while the physician's order specified three lpm. This was confirmed by an LPN/Unit Manager. The facility's policy on oxygen administration, dated September 2021, states that oxygen therapy should be administered as per physician orders to treat or prevent hypoxia. The failure to adhere to these orders indicates a deficiency in the facility's respiratory care practices.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that a resident received routine dental services, as required. The resident, who was admitted with diagnoses including dementia with psychotic disturbance and anxiety disorder, was severely cognitively impaired and required assistance with oral hygiene. Despite the care plan indicating dental problems related to poor nutrition and poor oral hygiene, and the representative's consent for dental services, there was no evidence in the medical record that the resident had been seen by a dentist since admission. An observation revealed the resident had significant dental issues, including one bottom tooth and brown, broken, or missing upper teeth. The resident, who was alert and oriented during the interview, could not recall the last dental visit and believed they had not seen a dentist since admission. The facility's administrator confirmed that the resident had not been seen by the dentist, who visited the facility every three months, and the resident would be scheduled for the next visit. The facility's policy stated that dental services were available for all residents requiring routine and emergency care, with Social Services responsible for making appointments.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive equipment to support a resident's independence during meals, affecting one of six residents reviewed for dining. Resident #40, who was severely cognitively impaired with a BIMS score of five, required supervision with eating and had a physician's order for a regular diet with mechanical soft texture and regular thin consistency, including the use of straws with liquids. During the lunch meal service, Resident #40 was observed sitting in the secured unit dining room with a regular cup instead of the required lidded cup with a straw. The Activity Aid (AA) #505, who was not familiar with the resident's needs, provided the regular cup, and it was only after prompting by Certified Nursing Assistant (CNA) #546 that the appropriate cup was provided. On a subsequent observation, Resident #40 was again provided a regular cup without a straw or Kennedy cup, leading to visible frustration as the resident struggled to drink independently due to hand tremors. Interviews with the resident and CNA #546 confirmed the necessity of the adaptive cup for the resident's independence and to prevent spills. The facility's policy on Assistance with Meals, which mandates the provision of adaptive devices for residents who need or request them, was not adhered to in this instance, resulting in the deficiency.
Failure to Notify Resident Representative of PRN Medication Administration
Penalty
Summary
The facility failed to notify the resident representative of changes in condition requiring as-needed intramuscular injections for behavior management. This deficiency affected one resident who was admitted with diagnoses including Alzheimer's, dementia with behavioral disturbance, delirium, restlessness, and agitation. The medical record review revealed that the resident was administered Zyprexa and Geodon intramuscularly on multiple occasions for agitation, but there was no documentation of notification to the resident's representative regarding the administration of these PRN antipsychotic medications. Interviews with the Director of Nursing, a Licensed Practical Nurse, and a Clinical Nurse Practitioner confirmed that it was the facility's expectation to notify family members or guardians of changes in behavior and the need for PRN medication. The facility's policy on changes in a resident's condition or status also required notification of the resident, their attending physician, and the resident representative. However, this policy was not followed, leading to the deficiency noted in the report.
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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) |
|---|---|---|---|---|
| Embassy Of Swanton | 0.2 mi | ★★★★★ | 4 | 0 |
| Whitehouse Country Manor | 6.3 mi | ★★★★★ | 0 | 0 |
| Elizabeth Scott Community | 8.4 mi | ★★★★★ | 0 | 0 |
| Addison Heights Health And Rehabilitation Center | 9.4 mi | ★★★★★ | 44 | 0 |
| Otterbein Monclova | 9.4 mi | ★★★★★ | 4 | 0 |
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