Pennsylvania Department of Health
SWAIM HEALTH CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SWAIM HEALTH CENTER
Inspection Results For:

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SWAIM HEALTH CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Findings of an abbreviated complaint survey completed on April 6, 2026, at Swaim Health Center identified that the facility was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

This is the most serious deficiency although it is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one which places the resident in immediate jeopardy as it has caused (or is likely to cause) serious injury, harm, impairment, or death to a resident receiving care in the facility. Immediate corrective action is necessary when this deficiency is identified.

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

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 taken in the event of an unauthorized resident absence from the community."

Review of Resident 1's clinical record revealed diagnoses that included Alzheimer's disease (a brain condition that gradually affects memory, thinking, and behavior) and Dementia (cognitive and memory changes that disrupt everyday function).

Further review of Resident 1's clinical record revealed an assessment, titled "Elopement Evaluation," dated November 7, 2025. The assessment indicated that Resident 1 was a risk of elopement. Elopement Risk Note indicated Resident 1 had a wander guard in place.

Review of Resident 1's physician orders revealed an order dated September 26, 2025, for behavior monitoring every shift for the following: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care, and wandering. Further review of Resident 1's physician orders revealed an order dated September 30, 2026, for wander guard check site and placement left wrist every shift.

Review of Resident 1's plan of care revealed Resident 1 was an elopement risk and wandered related to impaired safety awareness; wandering in others' rooms; and has removed wander guard. Interventions included: if Resident 1 appears to be wandering aimlessly, offer to assist to the bathroom for toileting, offer to walk outside, offer to walk to a quieter area for less stimulation, redirect with snacks or cold soda, redirect with going to look out a window at the wildlife. Further review of Resident 1's plan of care revealed Resident 1 was independent with transfers and ambulation.

Review of Resident 1's progress notes revealed a note dated March 17, 2026 at 9:38 PM, that indicated Resident 1 was exit seeking most of the shift.

Further review of Resident 1's progress notes revealed a note dated March 27, 2026, at 4:18 PM, that indicated Resident 1 was searching the top of the medication cart for scissors to "cut this band off."

An additional progress note dated March 29, 2026, at 6:30 PM, indicated Resident 1 was entering other patient rooms and checking doors.

Review of the facility provided incident report for Resident 1 indicated under the section titled "Incident Description" that on March 29, 2026, at 7:19 PM, "Resident exited facility without notice. Resident is believed to have exited through admin hallway into small front conference room and proceeded to exit building through a window. Resident was observed by staff outside of building. Resident self-ambulates and has impaired cognition. Wander guard did work when tested by staff." Under the section titled "Immediate Action Taken" revealed: "Resident was taken back inside facility by staff. RN assessment for skin issues, none noted. Resident wander guard in place to left wrist and functioning properly."

Review of staff witness statements revealed that Resident 1 was last seen by staff at 7:00 PM ambulating in the hallway by the living room. The witness statements further reported that Resident 1 had been exit seeking for several days, attempting to open doors, looking out windows, and searching the top of nursing carts for scissors to cut off his alarm band.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on April 6, 2026 at approximately 10:30 AM, the NHA indicated that Resident 1 had exited the unit through an unlocked, unalarmed door at the rear of the activities room and into the administration hallway. From the administration hallway, Resident 1 was able to access the front lobby and front conference room. Resident 1 opened a ground level window and exited the building into the front flower bed. The NHA stated she found Resident 1 in the front flower bed at 7:15 PM and the conference room window was open.

Information provided by the facility indicated that there was one additional resident identified as an elopement risk and able to ambulate independently (Resident 4).

Review of Resident 4's plan of care revealed Resident 4 is an elopement risk/wanderer related to a history of attempts to leave the facility unattended and impaired safety awareness.

Review of the clinical record for Resident 4 revealed orders for a wander guard and to check placement every shift and to check function weekly.

The facility is located in a wooded area adjacent to a body of water, with a parking area and access road located directly in front of the facility.

The NHA was made aware of the immediate jeapardy and provided with the immediate jeopardy template on April 6, 2026, at 2:30 PM, and an immediate action plan was requested.

The facility initiated immediate interventions on March 29, 2026, after the incident. Documents and actions provided by the facility to address the Immediate Jeopardy included the following:

Resident 1 was immediately put onto a 1:1 that remained in effect until the provider determined Resident 1 was safe and the windows had been audited mitigated, completed March 31, 2026.

The NHA secured the front lobby conference room door on March 29, 2026, at approximately 8:15 PM.

Activity room's internal door had a staff member assigned to the door until an audible alarm was installed, completed March 29, 2026 at approximately 10:10 PM.

The DON and Registered Nurse (RN) Supervisor conducted an audit on current residents with wander guards to ensure function. No concerns were identified. Completed March 29, 2026, at approximately 8:45 PM.

The DON and RN supervisor conducted a healthcare facility audit of doors (internal and external) to verify doors were either secured and/or alarming as to prevent unknown exits by residents. Completed March 29, 2026, at approximately 9:30 PM.

The DON conducted an audit on current residents' elopement evaluations and ensured elopement evaluations were up to date with any identified care plan interventions implanted if indicated by the evaluation. Completed March 30, 2026, at approximately 6:00 AM.

Director of Environmental Services and the maintenance supervisor conducted an audit of windows in the facility that residents could access to ensure that no windows open greater than six inches and remediation was applied to all windows found to open more than six inches. Completed March 31, 2026 at 12:30 PM.

On March 29, 2026, at 9:17 PM, all staff were provided education via email on the conference room door remaining locked when not in use and a screamer alarm being placed on the activity's door.

Additional education was provided to facility staff on the requirement to keep the conference room door locked when not in use and an audible alarm installed on the activity room door leading to the administrative hallway with an expectation that staff need to respond immediately.

Audits were initiated on March 29, 2026 and will continue to be done three times per week for four weeks and then one time a week for two months to ensure the conference room door is locked when not in use and on the audible alarm to ensure functioning and staff response. Additionally, audit results will be reviewed by the Quality Assurance Performance Committee.

During an interview with the NHA on April 6, 2026 at 10:30 AM, the NHA stated that, upon returning to the unit, Resident 1 was immediately placed on 1:1 care and audits were conducted of all facility doors and windows. The NHA also stated that maintenance had installed chains on all the windows in the facility which prevent the windows from being opened more than six inches.

Date of compliance March 31, 2026

On April 6, 2026, at 3:46 PM, the facility's immediate action plan was accepted, which included:

The facility failed to provide adequate supervision and failed to identify windows in the facility as a potential point of exit. On March 29, 2026 at approximately 7:13 PM, the Resident was found outside by the NHA. The NHA returned Resident to the healthcare center at approximately 7:15 PM. RN assessment performed and revealed no injury. Investigation began immediately and revealed that Resident exited neighborhood through an internal door form the activity resident area and moved to the front lobby to a conference room and likely exited a window at ground level. The investigation determined that the Resident was out of the facility for a period of less than two minutes. Resident was immediately put onto a 1:1 that remained in effect until such time the provider determined the Resident was safe and windows had been audited and mitigated if determined necessary (March 31, 2026 at 6:00 PM). The DON and RN supervisor conducted a healthcare facility audit of doors (internal and external) of the health center to verify door are either secured and/or alarming as to prevent unknown exits by residents from the community on March 29, 2026 at approximately 9:30 PM.

The DON and RN supervisor conducted an audit on current residents with wander guards to ensure function on March 29, 2026 at approximately 6:00 AM. The NHA secured the front lobby conference room door on March 29, 2026 at approximately 8:15 PM and going forward it will remain locked when not in use. The maintenance supervisor installed an audible alarm on the activity room door leading to the administrative hallway on March 29, 2026 at approximately 10:10 PM to prevent unknown exits by residents. Director of Environmental Services and maintenance supervisor conducted an audit of windows in the healthcare center that residents have the ability to access to ensure that no windows open greater than six inches and if any windows are identified to open more than 6 inches remediation was applied by March 31, 2026 at 12:30 PM.

The NHA immediately sent an email to all staff on March 29, 2026 at 9:17 PM. The email included education on the conference door remaining locked when not in use and initial education on the screamer that was placed on the activities door. The NHA and DON provided further education to healthcare staff on: the requirement to keep the conference room door locked when not in use (sign also placed on conference door as staff reminder); that an audible alarm has been installed on the activity room door leading to the administrative hallway to prevent unknown exits by residents and staff are required to respond immediately if alarm sounds this education includes pictures and explanation of audible alarm use; and the elopement policy by March 31, 2026 at approximately 7:00 PM.

The NHA or designee will complete random audits on the conference room to ensure it is locked when not in use and on the audible alarm to ensure functioning and staff response to alarm three times a week for four weeks and then one time a week for two months. With audit results forwarded to the Quality Assurance Performance Committee for review and recommendations.

During an onsite survey on April 6, 2026, the immediate action plan documents were reviewed and no concerns were identified.

Observations made during a tour of the facility on April 6, 2026, revealed that the conference room in the front lobby was locked and had a sign on the door that read to keep the door locked when not in use, the internal activity room door had an alarm system in place with signage indicating not to use the door and that an alarm would sound if the door was opened, and that all windows throughout the facility had chains in place.

Facility staff were interviewed during the onsite survey regarding the facility's Immediate Action Plan and demonstrated knowledge of the education.

The Immediate Jeopardy was lifted on April 6, 2026, at 3:46 PM, after ensuring that the immediate action plan had been implemented.

The facility failed to implement interventions, supervision, and effective safety measures to prevent Resident 1 from elopement from the facility. This failure placed Resident 1 and one additional resident (Resident 4) in an Immediate Jeopardy situation.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management

Plan of Correction - To be completed: 04/10/2026

Past noncompliance: no plan of correction required.

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