Swan Lake Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Swan Lake Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689Oct 1, 2025

  Based on observations, record review, and staff interviews during the Recertification survey initiated on 09/25/2025 and completed on 10/01/2025, the facility failed to ensure that the resident's environment remained free of accident hazards. This was identified for one (1) (Resident #39) of six (6) residents reviewed for Accidents. Specifically, Resident #39, who had a diagnosis of Schizophrenia and had moderately impaired cognition with behaviors including requesting excessively hot water to wash their clothing in their bathroom sink. On multiple observations on 09/29/2025, Resident #39's bathroom sink water temperature was found to be 136.2 degrees Fahrenheit, 123 degrees Fahrenheit, and 127 degrees Fahrenheit. […]

• No harm, potential for more than minimal, patternF584Oct 1, 2025

  Based on observations, record review, and interviews during the Recertification Survey initiated on 09/25/2025 and completed on 10/01/2025, the facility did not ensure that each resident had a right to a clean, comfortable, and homelike environment. This was identified for one (1) (Second floor) of two nursing floors; and for three (Resident#88, Resident#101, Resident#35) of five residents reviewed during the environmental facility task. Specifically, during the Resident Council meeting on 09/25/2025, two (2) (Resident#88, Resident#101) of the eight (8) residents in attendance complained about dirty shower rooms on the second floor. During observation, the second-floor shower room was found to be unsanitary, and the privacy curtains were in disrepair. […]

• No harm, potential for more than minimal, patternF725Sep 23, 2022

  Based on observations, record review, and interviews during the Recertification Survey initiated on 9/18/2022 and completed on 9/23/2022, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This was identified for one of two nursing units. Specifically, 1) The facility nursing staffing assignments did not reflect the staffing needs as indicated in the facility assessment for the Certified Nursing Assistants (CNA), 2) during an initial tour of the 1st-floor nursing unit conducted on 9/18/2022 at 10:30 AM, Resident #266, who was cognitively intact, complained that they were sitting in a soiled diaper for a long time. […]

• No harm, potential for more than minimal, isolatedF550Oct 1, 2025

  Based on observations, record review, and interviews during the Recertification Survey initiated on 09/25/2025 and completed on 10/01/2025, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was identified for one (1) (Resident #39) of two (2) residents reviewed for Dignity. Specifically, Resident #39 had a diagnosis of Schizophrenia and moderately impaired cognition, with behaviors including flushing their clothing in the toilet bowl, resulting in flooding in the room. After the resident caused flooding in their room, the flush mechanism in the resident's bathroom toilet was disabled, and the resident was provided with a portable commode. […]

• No harm, potential for more than minimal, isolatedF657Oct 1, 2025

  Based on observation, record review, and interviews during the Recertification Survey initiated on 05/13/2025 and completed on 05/19/2025, the facility did not ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team to reflect each resident's preferences and status after each assessment. This was identified for one (Resident #24) of six residents reviewed for Accidents. Specifically, Resident #24 was identified as having a behavior of rolling out of bed onto the floor mat. […]