Swiss Villa Nursing and Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF761Aug 2, 2023

  Based on observation and interview, the facility failed to store medications appropriately related to having multiple unsecured loose tablets in the medication carts for 3 of 3 medication carts reviewed. (Medication Carts on the 200 Hall, 300 Hall, and 100 Hall) Findings include: 1. The 200 Hall Medication Cart was observed on 07/31/23 at 10:42 A.M., with LPN (Licensed Practical Nurse) 2 and contained the following loose pills laying in the bottom of the drawers: - two small white oval tablets, - one medium white oval tablet, - two small tan round tablets, - one small white round tablet, - two small pink round tablets, and - two clear round tablets. […]

• No harm, potential for more than minimal, isolatedF684Aug 26, 2025

  Based on record review and interview, the facility failed to follow physician's orders related to monitoring vital signs prior to medication administration for 1 of 13 residents reviewed for Quality of Care. (Resident 16)Findings include:The clinical record for Resident 16 was reviewed on 08/21/25 at 12:59 P.M. An admission Minimum Data Set (MDS) assessment, dated 03/06/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, end stage renal disease, hypertension, diabetes, Chronic Obstructive Pulmonary Disease, anxiety, and depression. The Electronic Medication Administration Record (EMAR) for March and April 2025, was provided by the Director of Nursing (DON) on 08/26/25 at 10:40 A.M. […]

• No harm, potential for more than minimal, isolatedF690Aug 26, 2025

  Based on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines during indwelling urinary catheter care for 1 of 2 residents reviewed for Catheters/Urinary Tract Infections (UTI). (Resident 6)Findings include:An observation, on 08/25/25 at 10:51 A.M., indwelling urinary catheter care for Resident 6 was observed. Certified Nurse Aide (CNA) 2 entered the resident's room, donned a gown and gloves, dropped the window blind by touching the cords, pulled a stained privacy curtain around the foot of the resident's bed, opened the drawer on the resident's night stand, and removed a package of cleansing wipes. The CNA proceeded to pull wipes out of the package and clean the resident's private area without changing her gloves. […]

• No harm, potential for more than minimal, isolatedF880Aug 26, 2025

  Based on observation, interview, and record review, the facility failed to follow infection control guidelines during medication administration for 1 of 11 medication administration observations.Findings include: During an observation, on 08/22/25 at 11:16 A.M., Licensed Practical Nurse (LPN) 5 prepared to administer Resident 30's insulin. LPN 5 checked the resident's blood sugar and indicated he would receive 13 units of Insulin lispro (short acting insulin) based on the physician's orders. LPN 5 went to the medication cart and started to prepare the insulin. She removed the insulin pen from the plastic bag, took off the lid and attached the needle. She did not cleanse the top of the insulin pen before attaching the needle. […]

• No harm, potential for more than minimal, isolatedF881Aug 26, 2025

  Based on record review and interview, the facility failed to ensure appropriate and accurate antibiotic stewardship was implemented related to tracking and trending of infections for 1 of 6 residents reviewed for antibiotic stewardship. (Resident 8)Findings include: The clinical record for Resident 8 was reviewed on 08/22/2025 at 11:07 AM. A Quarterly Minimum Data Set (MDS) assessment, dated 08/01/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, dementia, heart failure, hypertension, obstructive uropathy, diabetes, and anxiety. […]