Swan Lake Nursing and Rehabilitation

Inspectors wroteBased 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. This resulted in a likelihood for serious injury and harm to Resident #39, that is Immediate Jeopardy. The finding is: [...]

Inspectors wroteBased 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. The shower room also had a strong, foul odor. Additionally, Resident #39's bathroom was observed with a strong foul odor. [...]

Inspectors wroteBased 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. During observation, the resident's toilet and commode were found in an unsanitary condition, filled with fecal material. [...]

Inspectors wroteBased 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. The comprehensive care plan and the Certified Nursing Assistant Accountability Record were not updated to include the use of the floor mats as an intervention. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the Recertification Survey initiated on 09/25/2025 and completed on 10/01/2025, the facility did not ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice. This was identified for one (1) (Resident #10) of one (1) resident reviewed for Respiratory Care. Specifically, Resident #10 had a physician's order to receive two liters of supplemental oxygen continuously via a nasal cannula; however, during an observation, the resident was receiving supplemental oxygen at four liters per minute. The finding is:The undated facility policy titled Oxygen Policy documented that nursing staff are to initiate and monitor oxygen therapy, perform assessments, document, and escalate concerns as applicable. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey initiated on 7/24/2024 and completed on 7/31/2024, the facility did not exercise reasonable care for the protection of the resident's property from loss or theft. This was identified for one (Resident #52) of one resident reviewed for grievances. Specifically, Resident #52's clothes were lost after the clothes were sent to the laundry. The facility was unable to determine the lost items because an inventory list of the resident's belongings was not maintained. The finding is: The Policy and Procedure dated 6/1/2024 for Resident's Personal Belonging documented The facility staff will take all practicable steps to safeguard residents' belongings. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification Survey and Abbreviated Survey (NY 00348285) initiated on 7/24/2024 and completed on 7/31/2024 the facility did not ensure that each resident was free from abuse. This was identified for one (Resident #68) of three residents reviewed for abuse. Specifically, Certified Nurse Assistant #4 had verbal arguments and threatened Resident #68 with physical harm. Resident #68 verbalized being scared and upset after the interaction with Certified Nursing Assistant #4. The finding is: The Policy and Procedure titled, Abuse Prevention last reviewed in 3/2024 documented that the resident has the right to be free from abuse, neglect, and misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an ongoing activities program was provided based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This was identified for one (Resident #59) of one resident reviewed for activities. Specifically, Resident #59 was observed on multiple occasions in their room without meaningful activities (activities as per resident preferences, such as stimulation/conversation, crafts and or newspaper/ magazine, television/music). [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 8/05/2024 and completed on 8/09/2024, the facility did not ensure that each resident received adequate supervision to prevent accidents. This was identified for one (Resident #38) of three residents reviewed for abuse. Specifically, Resident #241, with known history of peer-to-peer physical altercations and behaviors that annoy others such as yelling, crying, and wandering into other residents' rooms. Resident #241 was to be kept in the line of sight in a supervised area when out of bed as per their Comprehensive Care Plan (CCP). On 4/7/2024, the staff did not supervise Resident#241 as directed. Resident #241 wandered into Resident#38's room and threw the opened water bottle at Resident #38's face when Resident #38 asked Resident #241 to leave their room. [...]

Inspectors wroteBased on observations, interviews, and record review during the recertification survey initiated on 7/24/2024 and completed on 7/31/2024, the facility did not ensure that each resident's medical record was maintained in accordance with accepted professional standards and practices. The facility did not maintain medical records for each resident that were complete and accurately documented. This was identified for one (Resident #74) of one resident reviewed for Respiratory Care. Specifically, Resident #74 was observed receiving oxygen therapy without a physician's order on multiple occasions (7/24/2024, 7/25/2024, 7/26/24 and 7/29/2024). The finding is: The facility's policy and procedure titled Respiratory Care, undated, documented to verify that there is a physician's order in place and review the physician's orders or facility protocol for oxygen administration. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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 that a clean, comfortable, and homelike environment was maintained on one of two nursing units. Specifically, a vacant resident room was observed on 9/18/2022 and 9/19/2022 with a commode containing feces and urine with flies around the commode. The finding is: The Undated Facility's policy, titled Room Readiness, documented to provide a clean and safe environment for all residents. The Facility's policy dated 9/20/2022, titled Terminal Cleaning/Complete Room Cleaning, documented all resident rooms receive a terminal cleaning/completed room cleaning monthly, at the time of [resident] discharge, or as needed. [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 9/18/2022 and completed on 9/23/2022, the facility did not ensure that the resident environment remains as free of accident hazards as possible. This was identified for three (Resident #265, # 56, and #65) of six residents reviewed for Accidents. Specifically, 1) A Physician ordered Potassium Chloride tablet, that was dissolved in a half cup of water, was observed unattended on Resident #265's bedside table. Resident #265 was unaware of any medication in the observed cup of water; 2) Resident # 56, who needed assistance with personal hygiene and shaving, was observed with used razors at their bedside 3) Resident # 65, who was identified as at risk for falls, was observed on multiple occasions walking without appropriate footwear. The finding is: [...]

Inspectors wroteBased on observation, interviews, and record review during a Recertification Survey initiated on 9/18/2022 and completed on 9/23/2022, the facility did not ensure that medical care for each resident was effectively supervised by a Physician. This was identified for one (Resident #107) of five residents reviewed for unnecessary medications. Specifically, Resident #107's physician abruptly discontinued an antipsychotic medication (Seroquel) without tapering the dosage and did not provide instructions for staff to monitor for withdrawal symptoms. Furthermore, the Physician's assessment included a new diagnosis of Schizophrenia after the resident was admitted to the facility from the hospital. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 9/18/2022 and completed on 9/23/2022, the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs. This was identified for one (Resident #107) of five residents reviewed for unnecessary medications. Specifically, Resident #107 with a diagnosis of Dementia was admitted to the facility on [DATE] and was prescribed Seroquel (an antipsychotic medication) without an appropriate diagnosis for the antipsychotic medication use. Subsequently, the Physician discontinued Seroquel abruptly on 9/19/2022 without tapering the medication or providing instructions for staff to monitor the resident for withdrawal symptoms. [...]