Swaim Health Center

In the surveyor’s words

From the most serious findings on record at Swaim Health Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 6, 2026

  Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failure to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). This failure placed one additional resident who was identified as at risk for elopement and independent with ambulation in an Immediate Jeopardy situation (Resident 4).Findings include: Review of the facility policy, titled Wandering Management Policy, created February 28, 2022, read, in part, Objective: To prevent wandering that could lead to resident elopement and to identify action steps to be… […]

• Actual harm, isolatedF689Jan 27, 2025

  Based on clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility displayed past non-compliance in its failure to ensure that interventions were put into place to prevent accident hazards during a transfer, resulting in actual harm as evidenced by a skin tear requiring treatment, for one of three residents reviewed (Resident 1). Findings include: Review of Resident 1's clinical record revealed diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), abnormalities of gait and mobility, and muscle weakness. […]

• No harm, potential for more than minimal, patternF658Aug 27, 2026

  Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for insulin administration for one of two residents reviewed (Resident 1).Findings include: Review of facility policy, titled IIB14: Injectable Medication Administration, with a last review date of March 31, 2026, revealed in part, Purpose: To administer medications via subcutaneous, intradermal and intramuscular routes in a safe, accurate, and effective manner. Sites for Administration: Subcutaneous: Abdomen (minimally 2 below and left or right of umbilicus for heparins) Upper arm - Fatty tissue over triceps Top of thigh - Fatty tissue over anterolateral thigh. […]

• No harm, potential for more than minimal, patternF812Aug 27, 2026

  Based on facility policy reviews, observations, and staff interviews, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in one of two nourishment refrigerators (Nursing Nourishment Center) and on the tray service line in the main dining room.Findings Include: Review of facility policy, titled Providing Outside Foods or Beverages to Residents, with a policy review date of March 31, 2026, revealed, in part, 5. All food must be labeled with a received date, residents name, room number when put in the refrigerator. Review of facility policy, titled Employee Sanitary Practices, with a policy review date of March 31, 2026, revealed, in part, 6. Use utensils to handle foods. […]

• No harm, potential for more than minimal, patternF684Jul 2, 2025

  Based on review of facility policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for three of 16 residents reviewed (Residents 5, 22, and 55). Findings include: Review of facility policy, titled Wound Care, with a last review date of August 14, 2024, revealed, in part, 15. Treatments will be performed by personnel in accordance with licensure practice acts. Review of facility policy, titled Intravenous Device Care, with a last review date of August 14, 2024, revealed, in part, 3. […]