Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Swaim Health Center during CMS and state inspections, most recent first.
The facility failed to implement effective supervision and safety measures for two residents identified as elopement risks, both with impaired safety awareness and one with Alzheimer’s disease and dementia. Despite care plan identification of wandering and prior documentation of exit-seeking behaviors, including attempts to open doors, checking windows, and searching for scissors to remove a wander guard, one resident was able to move through an unsecured internal door from an activity area into an administrative hallway, then into a front conference room and out a ground-level window without staff notice. The facility had not identified windows as potential exit points, and this failure to control internal access points and monitor a known wanderer resulted in an elopement and placed both at-risk, independently ambulatory residents in Immediate Jeopardy.
Three residents did not receive care and services as ordered, including missed wound care, foot cradle checks, provider notifications for weight changes, and incomplete documentation and administration of IV medications and PICC line care. The DON confirmed that required care and documentation were not completed as per physician orders and facility policy.
Surveyors identified that three residents' MDS assessments did not accurately reflect their clinical status, including incorrect documentation of medication administration and the origin of a pressure injury. These errors were found through review of clinical records and staff interviews.
Two residents with significant pressure injuries did not have their prescribed wound care treatments consistently documented as completed, including applications of Betadine, medical grade honey, and dressing changes. The facility's records and staff interviews confirmed these lapses in care and documentation for residents with chronic conditions such as diabetes, edema, and muscle weakness.
A resident with chronic pain and muscle weakness experienced significant weight loss, and the facility failed to consistently document required weekly weights and administration of prescribed enhanced shakes. The NHA was unable to provide explanations for the missing documentation, despite expectations that these actions should have been completed.
A resident with dementia and mobility issues sustained a skin tear during a transfer when two nurse aides failed to follow the care plan requiring a mechanical lift. Instead, they attempted a manual stand/pivot transfer, resulting in injury. The aides were aware of the care plan but did not seek assistance to reposition the lift pad, leading to the resident's harm.
The facility failed to monitor and maintain kitchen equipment temperatures according to professional standards. Observations revealed that the dish machine's wash and rinse cycle temperatures were consistently below safe levels, with no corrective actions recorded. Additionally, there were multiple instances of unrecorded temperatures for kitchen and cafe refrigerators and freezers, indicating a lack of consistent monitoring.
A facility failed to document the implementation of restorative care programs for a resident with limited mobility, chronic pain, anxiety, and a left above-the-knee amputation. The resident's care plan included scheduled sessions for active range of motion and grooming, but documentation was missing for several dates. The DON confirmed the absence of records indicating whether the programs were implemented or refused.
The facility failed to ensure timely review and action on medication irregularities for two residents. One resident's medication addition was delayed due to late receipt and return of the MRR, while another resident's lorazepam assessment was delayed due to late receipt of the MRR. These issues highlight a failure in timely communication and response to pharmacist recommendations.
Failure to Prevent Elopement of Identified Wander-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure an area was free from accident hazards and to provide adequate supervision and effective safety measures to prevent elopement of a resident identified as being at risk. One resident had diagnoses including Alzheimer’s disease and dementia, with an Elopement Evaluation indicating elopement risk and a care plan identifying the resident as an elopement risk and wanderer with impaired safety awareness. The care plan documented that the resident wandered into others’ rooms, had removed a wander guard in the past, and was independent with transfers and ambulation. Physician orders included behavior monitoring every shift for elopement-related behaviors and an order to check the wander guard site and placement every shift. Progress notes documented that this resident had been exit seeking and exhibiting behaviors consistent with elopement risk prior to the incident. On one date, notes indicated the resident was exit seeking most of the shift. On another date, the resident was observed searching the top of the medication cart for scissors to cut off the wander guard band. A subsequent note documented the resident entering other patient rooms and checking doors. Staff witness statements further reported that the resident had been exit seeking for several days, attempting to open doors, looking out windows, and searching the top of nursing carts for scissors to remove the alarm band. Despite these documented behaviors and known elopement risk, the resident was able to access unsecured internal areas and an unmitigated window exit. On the date of the elopement, the incident report indicated that the resident exited the facility without notice. The resident was last seen by staff ambulating in the hallway by the living room and was believed to have exited through an unlocked, unalarmed internal door at the rear of the activities room into an administration hallway, then moved to the front lobby and into a conference room. From there, the resident opened a ground-level window and exited into a front flower bed, where the Nursing Home Administrator later found the resident outside. The facility is located in a wooded area adjacent to a body of water, with a parking area and access road directly in front of the building. The facility’s failure to implement appropriate interventions, supervision, and effective safety measures, including failure to identify windows as a potential point of exit, allowed this elopement to occur and placed this resident and one additional ambulatory resident with elopement risk in an Immediate Jeopardy situation.
Failure to Provide and Document Care According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and physician orders for three residents. For one resident with diabetes and neuropathy, there were multiple instances where wound care and foot cradle checks were not documented as completed according to physician orders. The Treatment Administration Records showed several dates where required wound care and foot cradle checks were either not signed or not completed, and the Director of Nursing confirmed that this care and documentation should have occurred as ordered. Another resident with congestive heart failure and Parkinson's disease had physician orders for daily weights and required provider notification for specific weight gains. The clinical record revealed several occasions where the resident experienced weight gains that met the criteria for provider notification, but there was no evidence that the provider was notified as required by the orders. The Director of Nursing was unable to provide documentation or evidence that these notifications took place. A third resident, admitted with an infection related to a hip prosthesis and receiving IV antibiotics via a PICC line, had multiple missing entries in the Medication Administration Record and Treatment Administration Record for administration of antibiotics, saline flushes, and PICC line care. The records also showed incomplete documentation of PICC line dressing changes and measurements, with one instance of a measurement being recorded as zero, which was not accurate. The Director of Nursing confirmed the missing documentation and that staff should have completed and documented all required care and measurements as per policy and physician orders.
Inaccurate Resident Assessments Identified
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' clinical status for three of nineteen residents reviewed. For one resident with diabetes mellitus and neuropathy, the Minimum Data Set (MDS) assessment did not indicate that the resident received an anticonvulsant medication, despite the Medication Administration Record (MAR) showing administration of gabapentin during the assessment period. For another resident with dementia and anxiety disorder, the MDS was coded to show receipt of a hypnotic medication, but the MAR did not document administration of such medication during the same period. Additionally, a third resident with type 2 diabetes mellitus and edema was found to have an unstageable pressure injury to the right heel that originated after admission. However, two MDS assessments incorrectly indicated that the pressure injury was present upon admission. These discrepancies were identified through clinical record reviews and staff interviews, demonstrating a failure to ensure the accuracy of resident assessments as required.
Failure to Document and Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. For two residents with pressure injuries, there were multiple instances where prescribed wound care treatments were not documented as completed on the Treatment Administration Records (TARs). Specifically, one resident with stage 3 pressure injuries to both heels had missing documentation for Betadine swabstick applications and for a regimen involving cleansing, skin prep, medical grade honey, calcium alginate, and bordered gauze. Another resident with an unstageable pressure injury to the right heel had missing documentation for wound care treatments involving cleansing, Betadine application, and dressing changes as ordered by the physician. The clinical records and wound care tracking confirmed the presence of significant pressure injuries in both residents, with relevant diagnoses including chronic pain, muscle weakness, type 2 diabetes mellitus, and edema. During an interview, the Nursing Home Administrator was unable to provide additional information regarding the missing wound care documentation and acknowledged that wound care should have been documented as completed. The findings were based on policy review, clinical record review, and staff interviews.
Failure to Monitor and Document Resident's Nutrition and Hydration Status
Penalty
Summary
A resident with diagnoses including chronic pain and muscle weakness experienced a significant weight loss of 9.52% over approximately one month. The dietician acknowledged this weight loss and implemented a plan to monitor the resident's weight weekly for one month, with corresponding physician orders to weigh the resident weekly on Tuesdays. However, there was no documentation of the resident's weight being recorded on one of the scheduled dates. Additionally, the resident had a physician's order for an enhanced shake to be provided three times daily to support nutritional intake. Review of the Treatment Administration Record (TAR) revealed that the enhanced shake was not documented as given at several scheduled times. During interviews, the Nursing Home Administrator was unable to provide explanations for the missing weight and shake documentation, though she confirmed that these actions were expected to have been completed and recorded.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility was found to be non-compliant with the requirement to ensure a resident environment free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents. This deficiency was identified following an incident involving a resident with dementia, gait abnormalities, and muscle weakness, who sustained a skin tear during a transfer. The resident's care plan required a two-person assist using a mechanical lift for transfers, but this protocol was not followed. On the day of the incident, two nurse aides were involved in transferring the resident. They discovered that the lift pad was not properly positioned under the resident, which led them to decide on a stand/pivot transfer instead of using the mechanical lift as per the care plan. One of the aides, acting alone, lifted the resident by himself, resulting in the resident sustaining a significant skin tear on the right forearm. The aides were aware of the care plan requirements but chose to proceed with the manual transfer, believing it to be safer under the circumstances. The incident was further complicated by the fact that one of the aides did not assist with the transfer and only observed the process. The aides later admitted to not following the care plan and failing to seek assistance from a nurse to reposition the lift pad. The skin tear required treatment, and the resident experienced pain as a result of the injury. The facility's management expected the staff to adhere to the care plan and seek help if needed, which was not done in this case.
Failure to Monitor and Maintain Kitchen Equipment Temperatures
Penalty
Summary
The facility failed to monitor and utilize kitchen equipment in accordance with professional standards, specifically regarding the dish machine in the main kitchen. Observations on August 12, 2024, revealed that the dish machine's wash cycle temperature was consistently below the minimum safe temperature of 160 degrees Fahrenheit, and the rinse cycle temperature was below the minimum safe temperature of 180 degrees Fahrenheit on several occasions. Despite these discrepancies, no corrective actions were recorded in the temperature logs for the dates when the temperatures were outside the acceptable range. Interviews with the Food Service Director and a Dietary Employee indicated that the dish machine might need more time to heat up to reach the required temperatures. However, the temperature logs from August 2024 and previous months, including May, June, and July 2024, showed repeated failures to meet the minimum temperature requirements during various meal shifts. Additionally, there were multiple instances where temperatures were not recorded at all for the kitchen and cafe refrigerators and freezers, indicating a lack of consistent monitoring. The facility's failure to maintain proper temperature logs and address the dish machine's temperature issues was further highlighted by the absence of any recorded corrective actions. This lack of adherence to professional standards for food service safety was acknowledged by the Nursing Home Administrator, who expressed an expectation for kitchen equipment to be properly utilized and monitored.
Failure to Document Restorative Care for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure that a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. The facility's policy, titled Restorative Care Program, mandates that restorative services should prevent or slow functional decline and maintain the resident's highest practicable level of functioning. However, the facility did not adhere to this policy for a resident with chronic pain, anxiety, and a left above-the-knee amputation. The resident's care plan included restorative nursing programs for active range of motion to upper and lower extremities and dressing and grooming scheduled twice daily. Upon review of the resident's point of care documentation, it was found that there were multiple instances where the minutes or tolerance for the restorative programs were not documented. Specifically, there was a lack of documentation for the 7:00 AM sessions on several dates in July 2024, and for the 3:00 PM sessions on other dates in July and August 2024. Additionally, there were days when documentation was missing for both scheduled times. An interview with the Director of Nursing confirmed the absence of documentation and no evidence was provided to indicate that the resident's restorative program was implemented or refused on those dates.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure timely review and action upon medication irregularities reported by the licensed pharmacist for two residents. For one resident with diagnoses including dementia, anxiety, and osteoarthritis, a Medication Regimen Review (MRR) recommended the addition of a calcium and vitamin D supplement. Although the physician agreed with the recommendation, the order was not signed until over a month later, and the medication was not ordered until even later. The delay was attributed to the facility not receiving the pharmacy recommendation until two weeks after the MRR date, and further delays occurred in the return of the MRR by the Medical Director. For another resident with chronic pain, anxiety, and depression, an MRR noted the need for an assessment of lorazepam dosage related to regulations for a gradual dose reduction. The physician provided the rationale for no dosage reduction over a month after the MRR date. The delay was due to the facility not receiving the MRR from the pharmacy until nearly three weeks after it was dated. These delays indicate a failure in the timely communication and response to pharmacist recommendations, as required by the facility's policies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Newville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shippensburg Rehabilitation And Health Care Center | 8.5 mi | — | 5 | 0 |
| Carlisle Skilled Nursing And Rehabilitation Center | 10.7 mi | — | 3 | 0 |
| Sarah A Todd Memorial Home | 10.8 mi | — | 2 | 0 |
| Forest Park Nursing And Rehabilitation | 10.9 mi | — | 7 | 0 |
| Thornwald Home | 10.9 mi | — | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.