Swaim Health Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Intravenous Care will be documented in the medical record, Electronic Medication Administration Record, and/or Electronic Treatment Administration Record. Section titled PICC Line Care, indicated Intermittent Infusion - Change tubing and needleless connection devices every 24 hours; Dressing Change - Change transparent dressing and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 19 residents reviewed (Residents 5, 23, and 47). Findings include: Review of Resident 5's clinical record revealed diagnoses that included diabetes mellitus (chronic condition that affects the way your body metabolizes sugar [glucose], leading to high blood sugar levels) and hereditary and idiopathic neuropathy (a group of inherited disorders that affect the peripheral nervous system and a type of nerve damage where the cause remains unknown despite thorough testing, leading to symptoms like numbness, pain, and balance issues). Review of Resident 5's Comprehensive MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental or psychosocial needs) with the assessment reference date (last day of the assessment period) of October 4, 2024, indicated in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection of a pressure ulcer for two of four residents reviewed for pressure ulcers (Residents 10 and 47). Findings Include: Review of policy, titled Wound Care, last approved December 24, 2024, revealed, Care of wounds is provided in accordance with current research and practice guidelines in order to facilitate healing and/or provide comfort and provide symptom control as appropriate .Treatments will be performed by personnel in accordance with licensure practice acts. Review of Resident 10's clinical record revealed diagnoses that included chronic pain and muscle weakness. Review of facility wound care tracking revealed that Resident 10 had stage 3 pressure injuries (full-thickness skin loss exposing underlying fat tissue) to both his left and right heels. Review of Resident 10's May 2025 TAR (Treatment Administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure proper monitoring for acceptable parameters of hydration and nutritional status for one of three residents reviewed for nutrition (Resident 10). Findings include: Review of Resident 10's clinical record revealed diagnoses that included chronic pain and muscle weakness. Review of Resident 10's weight documentation revealed that he experienced a significant weight loss of 9.52% between May 1, 2025, and June 2, 2025. Review of dietician progress notes dated June 3, 2025, revealed acknowledgement of the weight loss and a plan to monitor his weight weekly for one month, until July 3, 2025. Review of Resident 10's physician orders revealed an order to weigh weekly on Tuesdays through July 3, starting on June 10, 2025, and ending on July 3, 2025. Review of Resident 10's clinical record failed to reveal that a weight was recorded on June 24, 2025. Review of Resident 10's June 2025 TAR (Treatment Administration Record) revealed a physician's order for an enhanced shake (prepared to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, review of select facility documentation, and staff interviews, it was determined that the facility failed to monitor and utilize equipment in accordance with professional standards for food service safety in the main kitchen and café area. Findings include: Observation of the dish machine in the main kitchen on August 12, 2024, at 9:36 AM, revealed the wash cycle temperature was reading 150 degrees Fahrenheit (F- unit of measure) and the rinse cycle temperature was reading 172 degrees F. During an interview with Employee 1 (Food Service Director) on August 12, 2024, at 9:38 AM, he revealed it is possible the machine needs to heat up more for the day before it reaches the minimum acceptable temperatures. Observation of the August 2024 dish machine temperature log on August 12, 2024, at 9:40 AM, revealed the recorded wash cycle temperatures were below the minimum safe temperature of 160 degrees F on August 1-3, 2024, during breakfast; and August 2, 3, and 5, 2024, during lunch. Further…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, record review, and staff interview, it was determined that the facility failed to ensure residents with limited mobility received appropriate services and assistance to maintain or improve mobility for one of two residents reviewed for limited range of motion (Resident 42). Findings include: Review of facility policy, titled Restorative Care Program, last reviewed August 15, 2023, read, in part, Presbyterian Senior Living facilities will provide restorative services which prevent, slow functional decline and/or maintain the resident highest practicable level functioning in accordance with state and federal regulations. Matrix Care Point of Care will be assigned for Nurse Aid documentation to include the program and the minutes the program is performed. Review of Resident 42's clinical record revealed diagnoses that included chronic pain (pain that lasts more than three months or beyond normal healing time), anxiety (a feeling of worry, nervousness, or unease), and left above the knee amputation. Review of Resident 42's care plan revealed she has…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that the licensed pharmacist's report of a medication irregularity was reviewed and acted upon timely for two of five residents reviewed for unnecessary medications (Residents 5 and 42). Findings include: Review of facility policy, titled Medication Regimen Review, last reviewed August 15, 2023, read, in part, The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The findings are phoned, faxed, or e-mailed within 24 hours to the director of nursing or designee and are documented and stored with the other consultant pharmacist recommendations in the resident's active record. The prescriber is notified if needed. Review of facility policy, titled Documentation and Communicating of Consultant Pharmacists Recommendations, last reviewed August 15, 2023, read, in part, The consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, observations, facility policy review, and staff interview, it was determined that the facility failed to provide care and services consistent with professional standards to promote healing and prevent infection of pressure ulcers for one of two residents reviewed for pressure ulcers (Resident 103). Findings include: Review of Facility policy, titled Wound Care, last approved on May 31, 2023, revealed it stated the facility's policy was, Care of wounds is provided in accordance with current research and practice guidelines in order to facilitate healing and/or provide comfort and symptom control as appropriate. Review of Resident 103's clinical record on October 10, 2023, at approximately 1:30 PM, revealed diagnoses that included stage 4 pressure injury of the sacrum (wound of the skin caused by pressure over a bony prominence that extends to the through the skin to the bone and other connective tissue) and osteomyelitis (infection of the bone). During wound dressing change observations on October 12, 2023, at approximately 10:05 AM, Employee 1 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review, investigation document review, and staff interviews, it was determined that the facility failed to ensure that a resident was free from neglect by failing to provide a two-person transfer and use of a device as per care planned for one out of three sampled residents (Resident 1). Findings include: A review of the facility policy, titled Abuse Neglect or Exploitation last reviewed October 22, 2022, indicated that neglect is the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress to the resident despite knowledge that the care and services are required. A review of Resident 1's clinical record revealed diagnoses that included osteoporosis (decreased bone density and softening of the bone), dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of clinical records, review of facility investigation reports, and staff interviews, it was determined that the facility failed to provide an environment that was free of accident hazards for residents who were at risk for falls by failing to follow care-planned interventions for one of three residents reviewed (Resident 1). Findings include: A review of Resident 1's clinical record revealed diagnoses that included osteoporosis (decreased bone density and softening of the bone), dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and was hospice status (end of life). Further review of Resident 1's admission record indicated she was admitted on [DATE]. Review of Resident 1's Quarterly MDS assessment (Minimum Data Set assessment: MDS - a periodic assessment of resident care needs) dated May 17, 2023, indicated a BIMS (brief interview of mental status) scored a 3, indicating severely impaired cognitive status. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.