Embassy of Swanton

In the surveyor’s words

From the most serious findings on record at Embassy of Swanton, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Jun 4, 2026

  Based on observation, medical record review, staff interview and policy review, the facility failed to ensure monitoring of Legionella control measures were in place. This had the potential to affect all residents. Additionally, the facility failed to wear proper personal protective equipment while caring for a resident in enhanced barrier precautions. This affected one (#67) of one resident reviewed for infection control measures. The facility census was 64. Findings include:1. Review of the facility Legionella Environmental Assessment Form, dated 02/11/26 revealed interventions to prevent Legionella were specific only to the flushing of the closed Assisted Living unit (ALU) showers and bathrooms. Interview on 06/03/26 at 4:00 P.M. […]

• No harm, potential for more than minimal, widespreadF880Jun 1, 2023

  Based on medical record review, observations, resident interview, staff interview, and review of the facility policy, the facility failed to ensure soiled linen for a resident on transmission-based precautions was handled per facility policy to potentially prevent the spread of a contagious infection. This had the potential to affect all residents, except Resident #21, who was identified by the facility as being on contact precautions. The facility census was 64. Findings include: Review of Resident #21's medical record revealed an admitted [DATE]. Diagnoses included Parkinson's disease, dementia, and fibromyalgia. Review of the annual Minimum Data Set Assessment (MDS) assessment, dated 04/02/23, revealed Resident #21 was cognitively intact. […]

• No harm, potential for more than minimal, widespreadF812Apr 30, 2021

  Based on observation, staff interviews, and review of facility policy, the facility failed to ensure hair restraints were worn in the kitchen, opened food was properly labeled and dated in the walk-in refrigerator, and proper kitchen sanitation was implemented during meal service. This had potential to affect 46 of 46 residents who receive food from the kitchen. The census was 46. Findings include: 1. Observation on 04/26/21 at 9:44 A.M., revealed Kitchen Staff #252 in the kitchen standing next to the steam table with no hairnet or hair restraint. Interview on 04/26/21 at 9:45 A.M., with Kitchen Staff #252 verified not wearing a hairnet in the kitchen. 2. […]

• No harm, potential for more than minimal, widespreadF880Apr 30, 2021

  Based on observation, resident and staff interview, medical record review, review of the Centers for Medicare and Medicaid (CMS) webpage, review of the Centers for Disease Control and Prevention (CDC) webpage, and review of the facility policy, the facility failed to implement a COVID-19 quarantine for a resident who was readmitted to the facility following a hospitalization greater than 24 hours and was not fully vaccinated or had a confirmed COVID-19 infection in the previous three months, and failed maintain infection control measures during medication administration. This affected one (#50) of two residents reviewed for transmission based precautions and one (#33) of five residents observed during medication administration. […]

• No harm, potential for more than minimal, patternF641Jun 4, 2026

  Based on observation, review of the medical record review, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately. This affected seven (#6, #7, #12, #44, #54, #22 and #46) of 22 records reviewed. The facility census was 64. Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 05/08/18 with diagnoses of parkinsonism, dementia, and multiple sclerosis. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment, dated 02/15/26, revealed the question Should Brief Interview for Mental Status (BIMS) be conducted? was answered yes. Further review revealed a dash (-) was entered by each question pertaining to the BIMS assessment indicating Resident #6's cognition was not assessed. 2. […]