Every finding on record at Swiss Village

Based on interview and record review the facility failed to follow physician orders for 1 of 3 residents reviewed (Resident B).Findings include:Resident B's record was reviewed on 6/22/26 at 10:36 AM. Diagnoses included hypertension, congestive heart failure and atrial fibrillation.A nurse practitioner (NP) note, dated 2/6/26, indicated Resident B was seen for low blood pressure and new orders were written. The note indicated new orders included to monitor Resident B's blood pressure and heart rate daily.Nursing notes were reviewed from 2/6/26 to 2/9/26. There was no blood pressure or heart rate monitoring documentation on 2/7/26 or 2/8/26.Vitals were reviewed from 2/6/26 to 2/9/26. There was no blood pressure or heart rate monitoring documentation on 2/7/26 or 2/8/26.Orders were reviewed from 2/6/26 to 2/9/26. There was no order for daily blood pressure or heart rate monitoring on 2/7/26 or 2/8/26.During an interview, on 6/22/26 at 11:12 AM, the Director of Nursing (DON) indicated when an order was received, the nurse entered the order into the resident's health record. The DON indicated an order should have been entered on 2/6/26 for Resident B's daily monitoring of blood pressure and heart rate. The DON indicated the staff did not monitor Resident B's blood pressure or heart rate daily as ordered by the NP on 2/7/26 and 2/8/26.A current undated policy, titled Implementation and Management of Physician Orders, was provided by the DON on 6/22/26 at 11:28 AM. The policy indicated the receiving nurse should enter the order into the resident's health record immediately and orders should be implemented as soon as possible after receipt.This citation relates to Intake 3025641. 410 IAC (Indiana Administrative Code) 16.2-3.1-19

Based on observation, interview, and record review, the facility failed to ensure fall interventions were followed for 1 of 5 residents reviewed (Resident 9).Findings include:A review of Resident 9's current care plan indicated the resident was to not sustain another serious injury from a fall through next review, with a goal date of 2/10/2026. Interventions included, lock walker in front of resident when sitting in recliner.A review of physician orders, dated 11/30/2025 at 6:00 PM, indicated a fall intervention was to lock the walker in front of the resident when sitting in a recliner.Resident 9's record was reviewed on 11/17/2025 at 10:48 AM. Diagnoses included a history of falling and a personal history of a healed traumatic fracture (fell on 7/24/2025 causing an upper right humerus fracture).During an observation, on 12/15/2025 at 9:55 AM, the following was observed: Resident 9 was sitting in her recliner. The resident's walker was located approximately four feet from the resident, in front of the bed.During an observation, on 12/17/2025 at 11:01 AM, the following was observed: Resident 9 was sitting in her recliner. The resident's walker was located approximately three feet from the resident, in front of the closet.During an interview, on 12/17/2025 at 11:04 AM, Licensed Practical Nurse (LPN) 2 observed Resident 9's walker. LPN 2 removed the walker from in front of the closet and demonstrated it should have been positioned in front of her recliner. LPN 2 indicated Resident 9's walker should be locked in front of her with the seat facing towards her. LPN 2 indicated when Resident 9 attempted to get up, the walker should be there so that she did not fall.A current policy, dated November 2025, provided by the Assistance Director of Nursing (ADON), indicated, .implement appropriate interventions to prevent future falls . In conjunction with the physician, staff will identify and implement appropriate interventions to try to minimize the serious consequences of falling.Appropriate interventions will be implemented, including adequate supervision, monitoring and assistive devices (when necessary), consistent with the resident's needs.3.1-45(a)

Based on interview and record review the facility failed to use non medication interventions related to pain for 1 of 1 resident reviewed. (Resident 5).Findings include: In an interview on, 12/16/2025 at 9:27 AM, Resident 5 indicated her pain was not controlled. Resident 5 indicated the only intervention used for pain control was medication. On 12/16/25 at 10:07AM, a review of Resident 5's record indicated there were physician orders for pain medications as follows:Dated 11/10/25, give oxycodone 5 mg 1 tablet by mouth every 8 hours as needed for pain rated 6-10 Dated 12/4/25, give gabapentin 100mg (2) tablets three times a day Dated 11/10/25, give Tylenol arthritis pain 650mg one tablet every 24 hours for pain rated 1-5 Resident 5's diagnosis included stable fracture of T11-T12 vertebra, low back pain, and pinched nerve. A review of Resident 5's Medication Administration Record (MAR) December dated, 12/1/25 to 12/16/25, indicated Resident 5 received Oxycodone 5mg on the following dates and times:12/2 at 10:32am 12/3 at 11:58am and at 8:50pm12/5 at 1345 and 10:25pm12/6 at 830am12/9 at 1:44pm12/16/2025 12:50pmA review of Resident 5's progress notes for the above dates did not indicate any non-pharmacological interventions during the times the medication was given. A review of Resident 5's November 2025 MAR and progress notes indicated the oxycodone was given as needed for pain without any documented non medication interventions on the following dates and times:November 7th 8:20pmNovember 8:10amNovember 10th at 11:34am and at 3:26pmNovember 11th at 12:43pmNovember 13 at 4:54pmNovember 15th 4:44pmNovember 16th 6:43pmA review of Resident 5's current care plan did not include non-medication pain interventions. A review of Resident 5's Minimum Data Set assessment dated [DATE], Section J, indicated as needed pain medication was given, pain frequency was constant, and resident did not receive non-medication interventions for pain. A policy and procedure titled Pain Assessment Policy and Procedure was provided, on 12/16/25 at 1:01PM, by the Director of Nursing. The policy indicated.5. All members of the interdisciplinary team will work together to establish optimal pain control for the resident. 3.1-37(a)

Based on record review and interview, the facility failed to provide education regarding influenza vaccine refusal for 1 of 5 residents reviewed, (Resident 13). Findings include:A record review began on 12/16/25 at 10:00 AM for Resident 13. Medical diagnoses included dementia, psychotic disturbance, mood disturbance and anxiety.A record review of the Influenza immunization consent included education and information on potential adverse reactions. The form noted a refusal, dated 5/21/24, was signed by the resident's representative.A review of progress notes indicated there was nothing in the progress notes to indicate the resident representative was educated regarding the refusal. In an interview, on 12/16/25 12:05 PM, the Director of Nursing indicated she spoke with the resident's representative, who declined the influenza vaccine.There was no progress note documentation to indicate the representative was educated regarding the risks and benefits associated with this refusal.A current facility policy, titled, Immunization Program for Residents, dated 12/25, was provided by the DON. The policy indicated. the resident or the resident's legal representative any refuse vaccines for any reasons. If vaccines are refused, the refusal shall be documented in the resident's medical record.

Based on record review and interview, the facility failed to provide education regarding COVID-19 vaccine refusal for 1 of 5 residents reviewed, (Resident 13). Findings include:A record review began on 12/16/25 at 10:00 AM for Resident 13. Medical diagnoses includes dementia, psychotic disturbance, mood disturbance and anxiety.A record review of the COVID-19 immunization consent included education and information on potential adverse reactions and noted a refusal, dated 5/21/24, was signed by the resident's representative.A review of progress notes: there was nothing in the progress notes to indicate the resident representative was educated regarding the refusal. In an interview, on 12/16/25 12:05 PM, the Director of Nursing indicated she spoke with the resident's representative, who declined the COVID-19 vaccine. There was no progress note documentation to indicate the representative was educated regarding the risks and benefits associated with this refusal.A current facility policy, titled, Immunization Program for Residents, dated 12/25, was provided by the DON. The policy indicated. the resident or the resident's legal representative any refuse vaccines for any reasons. If vaccines are refused, the refusal shall be documented in the resident's medical record.

Based on interview and record review the facility failed to ensure abuse allegations were reported in a timely manner for 3 of 5 residents reviewed (Resident B, Resident C and Resident D).Findings include: A report, dated 8/1/25, indicated Student Certified Nurse Aide (CNA) 7 indicated CNA 2 made inappropriate comments about Resident B while providing care to Resident B's genital area on 6/21/25 during 2nd shift. CNA 7 indicated she did not report the allegation to anyone until 8/1/25.An investigation file was provided by the Director of Nursing on 8/18/25 at 11:29 AM. The file included the following statements:CNA 3's statement, dated 8/1/25 at 2:16 PM, indicated he observed CNA 2 make inappropriate comments in front of Resident B, Resident C and Resident D. CNA 3 indicated he observed CNA 2 compare Resident B's genital sizes to Resident D's during pericare with Resident B. CNA 3 indicated he observed CNA 2 tell Resident C after getting him laid down she would come back and lay in bed with him and she could be the big spoon. The statement indicated he reported the incident to the nurse. CNA 9's statement, dated 8/1/25, at 2:25 PM, indicated she observed CNA 2 call Resident D sexy when she performed pericare. CNA 9 indicated she had also observed CNA 2 make statements about Resident B's genitals and size. CNA 9 indicated CNA 2 had made the comments in front of the nurse and the nurse was aware of the comments.Student CNA 7's statement, dated 8/1/25, untimed, indicated she heard CNA 2 make inappropriate comments during care with Resident B. Student CNA 7 indicated she overheard CNA 2 state after care was completed with Resident B she would return and lay with Resident B in his bed. Student CNA 7 indicated the statement occurred on 7/21/25 during second shift and CNA 7 reported the incident on 8/1/25 to the Assistant Director of Nursing (ADON). Student CNA 8's statement, dated 8/1/25, at 2:11 PM, indicated she overheard CNA 2 tell Resident B after Student CNA 7 and Student CNA 8 leave, CNA 2 would come back and lay with him in his bed. Student CNA 8 indicated she did not report the incident as CNA 2 made inappropriate comments all the time. Student CNA 8 also indicated CNA 2 made fun of other residents and comments had been reported the nurse. Student CNA 8 indicated the response from other staff indicated CNA 2 was just like that and then nothing was done about it.During an interview, on 8/18/25 at 1:06 PM, CNA 6 indicated she had never observed any inappropriate touching or comments towards residents by CNA 2 or any other staff but had overheard CNA 2 make comments about Resident B's genitals to other staff members. CNA 6 indicated abuse included physical harm, inappropriate comments/touching and verbal yelling. CNA 6 indicated when she observed abuse, she reported to the nurse. CNA 6 indicated when the nurse did not act immediately, she alerted the Director of Nursing (DON).During an interview, on 8/18/25 at 1:38 PM, CNA 3 indicated he had observed CNA 2 make inappropriate comments towards Resident B and Resident C. CNA 2 indicated he observed CNA 2 make comments about the male residents' genitals and size comparison. CNA 3 also indicated he overheard CNA 2 ask if she could come back later and lay with Resident C and she wanted to be the big spoon. CNA 3 indicated he reported this to the Qualified Medication Aide (QMA) on duty, but was unsure what her name was or if any follow up action was made.During an interview with QMA 5, on 8/18/21 at 1:26 PM, she indicated abuse included name calling and directly/indirectly talking inappropriately about residents. QMA 5 indicated she overheard CNA 2 make inappropriate comments about residents, but nothing was reported to QMA 5. QMA 5 indicated when abuse allegations were observed or reported, she reported the allegations to the DON immediately.During an interview, on 8/18/25 at 11:58 AM, the ADON indicated she had received no reports CNA 2 until Student CNA 7 indicated CNA 2 had made inappropriate comments about residents. Student CNA 7 indicated she overheard CNA 2 tell Resident B she would come back to lay with him when Student CNA 7 and Student CNA 8 left during 2nd shift on 7/21/25. The ADON indicated the allegation was not brought to the attention of the ADON until 8/1/25. The ADON indicated the DON and ADON started an investigation. Staff interviews with nurses and CNAs were included. Based on the investigation, many CNAs reported CNA 2 made inappropriate comments about Resident B, Resident C and Resident D as well as other residents. The investigation indicated the CNAs told the nursing staff at times but were told CNA 2 was just like that. When the nurses were questioned, many of the nurses did not receive any reports of abuse allegations, inappropriate touching or comments. The ADON indicated when any allegation of abuse occurred the staff were to report to the nurse, ADON, DON and Administrator immediately. A policy, undated, titled abuse prevention, was provided by the Administrator on 8/18/25 at 2:39 PM. The policy indicated abuse included any oral, written and/or gestured language that willfully includes derogatory terms to the residents, family, or anyone within hearing distance; regardless of age, ability to comprehend or disability. The policy indicated charge nurses and nursing staff are responsible for monitoring any employee or resident at risk for abuse, including derogatory language, rough handling and communication disorders. The policy indicated any potential abuse allegation was reported to the Administrator immediately for investigation.This finding relates to Intake 2579139. 3.1-28(c)

Based on interview and record review the facility failed to ensure side effect monitoring was completed for 4 of 6 residents reviewed. (Resident 31, Resident 52, Resident 72, and Resident 73) Findings include: In an interview with QMA 2 (Qualified Medication Assistant), on 02/07/23 at 01:56 PM, she indicated each medication class a resident received had side effects monitoring, including anticoagulants, insulin, and psych medications. 1) Resident 31's record review, began on 02/08/23 at 10:34 AM. The records indicated her diagnosis included; unspecified dementia, major depressive disorder, generalized anxiety disorder, and pain. Resident 31's medication orders included; Buspar 5mg three times a day for anxiety (an anti-anxiety medication), hydrocodone-acetaminophen 5-325mg three times a day as needed for pain (an opioid medication), Remeron 7.5 mg daily (an antidepressant medication), and Trintellix 10mg daily for depression (an antidepressant). These medications were documented as given as ordered. No documentation of side effect monitoring was provided other then involuntary movement assessments. No daily documentation of side effect monitoring for each drug class was available. Resident 31's current care plan indicated the interventions were to observe for side effects of the medications. 2) Resident 52's record review, began on 02/07/23 at 03:10 PM. The review indicated her diagnosis included: unspecified dementia, anxiety disorder, and mood disorder with depressive features. Resident 52's medication orders were: Klonopin 1mg twice a day (benzodiazepine medication), Ativan 0.5mg tablet twice a day as needed for anxiety (benzodiazepine), Remeron 30 mg tablet at bedtime related to major depressive disorder (antidepressant), and Zyprexa 2.5mg daily with Zyprexa 5mg given once a day (antipsychotic). Resident 52 had a physician order to monitor for side effects of antipsychotic medication every shift. No documented for monitoring the side effects of her antidepressant or benzodiazepines were available for review. Documentation indicated Resident 52 was administered medication daily as ordered for the month of January 2023. No daily documentation of side effect monitoring for each drug class was available. 3) Resident 72's record review, began on 02/08/2023 at 9:31 AM. The record indicated her diagnosis included; unspecified dementia, bipolar disorder, generalized anxiety disorder, and pain. Resident 72's medication orders included Abilify 2mg daily (antipsychotic) and Buspar 30mg daily (antianxiety). No documentation was available related to monitoring of side effects for Buspar or Abilify. Documentation provided indicated Resident 72 was administered medication as ordered daily during the month of January2023. 4) Resident 73's record review, began on 02/07/2023 at 1:42 PM. The review indicated her diagnosis included; neurocognitive disorder with [NAME] bodies, dementia with anxiety, dementia with psychotic disturbances, major depressive disorder, anxiety disorder unspecified, and insomnia. Resident 73's medication orders included: fluoxetine 40mg at bedtime (antidepressant), lorazepam intensol 2mg/ml give 0.25ml by mouth daily related to anxiety (antianxiety), melatonin 3mg at bedtime (hypnotic), Morphine Sulfate 20mg/ml give 0.25ml every 2 hours as needed for pain (opiate), and Zypexa 2.5mg at bedtime (antipsychotic). No documentation was available related to monitoring of side effects for the antipsychotic, opiate, antianxiety, and antidepressant medications. Documentation provided indicated Resident 73 was administered medication as ordered daily during the month of January 2023. Resident 73 received Morphine in January 2023 and February 2023. A policy was provided by the DON on 2/13/22 at 8:46AM, titled Psychotropic Medication Policy and Procedure, dated 9/20/2013, most recent update 12/2/22, and indicated .psychopharmacological medications in the long term care facility include regular review for continued need, appropriate dosage, side effects, risks and or benefits .psychotropic medications include antianxiety, hypnotic, antipsychotic, and antidepressant classes of drugs . evaluate the effects and side effects of psychoactive medications .monitor psychotropic drug use daily noting any adverse effects such as increased somnolence or functioning decline 3.1-48(a)(3)

Based on observation, interview, and record review the facility failed to ensure a pressure ulcer was accurately assessed and documented for 1 of 2 residents reviewed. (Resident 31) Findings include: During an observation and interview on 02/08/23 at 10:19 AM, LPN 6 (Licensed Practical Nurse), the wound nurse for the facility, observed LPN 6 complete a dressing change to the wound on Resident 31's coccyx. LPN 6 cleaned the area, stool was under the bandage, she applied sure prep to the outer edges, took a picture of the wound, then calculated the dimensions of the wound. LPN 6 compared the measurements to the prior week's measurement. LPN 6 then used a clean firm cotton tipped stick to measure depth. LPN 6 indicated the wound was acquired during a hospital stay in May of 2022. LPN 6 indicated the wound got worse before it got better. LPN 6 denied any other issues with the wound or care. Resident 31's record review began on 02/07/23 at 03:17 PM. The coccyx wound was identified as present on readmission after a 2 hospital stay. The coccyx wound was unstageable on 5/25/22, size was documented as 2.3cm x 2.7cmx 0.2cm. Wound notes from the physician indicated the foillowing: On 9/28/22 indicated to continue with wound care, On 10/26/22, labs were ordered. The physician noted poor nutritional intake, and scheduled an appointment with hospital wound care On 11/2/22, change the wound dressing daily and change treatment to Sorbact hydrogel gauze. On 11/23/22, hospital wound care refused to see Resident 31 due to being non ambulatory. The Physician documented he wanted Resident 31 to see general surgery. Thefamily declined. The Physician documented to offer hospice care and the family declined. On 11/3022, indicated to contiue the same treatment as prior. On 12/28/22, indicated to change the wound treatment, promote autolytic debridement: apply collagen to wound bed, apply Anasept hydrogel to gauze packing and apply to wound depth. Cover with a super absorbent dressing On 1/20/23, to continue wound care, although poor prognosis. The wound was slightly improved while Resident 31's overall condition declined. The coccyx wound measurements were documented as follows: On 11/23/22, the coccyx wound was unstageable and measured length 6.2 cm x width 3.5 cm x undermining 2.0 cm with no depth or tunneling documented. There were no characteristics of the wound documented. On11/30/22, the coccyx wound was unstageable and measured length 6.0 cm x width 4.6 cm x undermining 3.0 cm with no depth or tunneling documented. There were no characteristics of the wound documented. On 12/07/22, the coccyx wound wa unstageable and measured length 6.2 cm x width 2.7 cm x depth 5.0 cm x undermining 2.0 cm with no tunneling documented. There were no characteristics of the wound documented. On12/14/22, the coccyx wound was unstageable and measured length 6.0 cm x width 2.7 cm x depth 3.7 cm x undermining 3.0 cm with no tunneling documented. In the notes section it was documented the wound had changed to a stage 4 from unstageable. There were no characteristics of the wound documented. On 12/21/22, the coccyx wound was documented as a stage 4 pressure area. The wound measured 5.9 cm length x 3.6 cm width with depth, undermining, and tunneling not documented. There were no characteristics of the wound documented. On 12/29/22, the coccyx wound was documented as a Stage 4 pressure area. The wound measured 4.3 cm length x 3.1 cm width x 3.6cm depth x 2.0 undermining with tunneling not documented. There were no characteristics of the wound documented. On 1/4/22, the coccyx wound was documented as a stage 4 pressure area. The wound measured length 4.8cm x width 2.6 cm x depth 3.2 cm with undermining and tunneling not documented. There were no characteristics of the wound documented. On 1/11/22, the coccyx wound was documented as a stage 4 pressure area. The wound measured length 5.2cm x width 2.6 cm x depth 2.7cm x undermining 2.2cm with no tunneling documented. There were no characteristics of the wound documented. On 1/18/22, the coccyx wound was documented as a stage 4 pressure area. The wound measured length 4.7cm x width 2.4cm x depth 3.2cm x undermining 2.2 cm and no was tunneling documented. There were no characteristics of the wound documented. On 1/25/22, the coccyx wound was documented as a stage 4 pressure area. The wound measured length 4.2cm x width 2.1cm with no depth, undermining, or tunneling documented. The area was documented as improving no longer see bone or feel bone and the staging was changed to stage 3. There were no characteristics of the wound documented. On 2/1/22, the coccyx wound was documented as a stage 4 pressure area. The wound measured length 4.0cm x width 1.6cm x depth 2.5cm x undermining 2.0cm. No tunneling was documented. There were no characteristics of the wound documented. On 2/8/22, the coccyx wound was documented as a stage 3 pressure area. The wound measured length 4.1cm x width 2.5cm with no depth, undermining, or tunnelling documented. There were no characteristics of the wound documented. In an interview on 2/13/23 at 2;46PM, the ADON (Assistant Director of Nursing) indicated the program being used currently was not available until October 2022. The ADON indicated any discrepancies could be due to the difference in human measuring and the program measuring. A policy was provided by the DON on 2/13/22 at 9:00 AM, titled Skin Assessment Policy and Procedure, dated 8/1/15, most recent update 10/3/22, and indicated this was the policy currently used by the facility. The policy indicated the prevention, identification, treatment, and evaluation of skin breakdown are primary goals for the health and wellbeing of residents pressure injury definition usually over a bony prominence. The injury occurs as a result of intense and or prolonged pressure or pressure in combination with shear 3.1-40

Based on observation, interview, and record review the facility failed to provide fall prevention interventions for 1 of 3 residents reviewed. (Resident 52) Findings include: In an interview on 02/07/23 at 01:56 PM, QMA 2 indicated Resident 52 was a frequent faller. The QMA 2 indicated the 3 residents who were at highest fall risk were to be closely monitored. QMA 2 described closely monitored during her shift as a clinical staff within eyesight of the resident. QMA 2 indicated the high fall risk residents were frequently in the dayroom due to increased need of supervision. During a continuous observation from 02/07/23 01:40 PM to 02/07/23 02:17 PM, Observed 6 transfers completed without use of the gait belt secured around Resident 52's waist. The gait belt was positioned correctly yet was not used in transfers. During a continuous observation and interviews, on 02/09/23 at 10:53 AM to 11:50 AM, observed 6 residents in the dayroom with an agency CNA. In an interview with QMA 4, she indicated the CNA was minimally familiar with the residents. QMA 4 indicated she would call one of the neighboring units for any issues such as falls. QMA 4 indicated she had 3 CNAs and herself on the unit. During an observation on 2/9/23, at 10:48 AM, Resident 52 was observed in a broda chair with eyes closed and head to the right side. At 11:10 AM, Resident 52 woke up and was unable to push herself away from the table. Resident 31 began yelling. Resident 31 continued to become increasingly agitated and made derogatory remarks about staff and other residents. At 11:24 AM, Resident 52 was offered a diversional activity, going to sit by the window so she could look out. Resident 52 refused. Resident 52 was taken to the window area shortly afterwards. At 11:29 AM, Resident 52 was at a table near the window, pulled up all the way to the table with chair wheels locked. At 11:41 AM, Resident 52 began to yell out again, why do I have to sit here while everyone else gets to sit where they want?. She began heavily tapping the table. Resident 52 attempted to get up x3 from the table by moving the broda chair backwards with brakes locked. At 11:43 AM, 9 residents and 1 dietary aid were in large common area. There were no staff within visual range. 3 staff were observed in the hallway talking to each other. No residents were in the hallway. At 11:45 AM, Resident 52 attempted to stand by pushing the table forward. Resident 52 immediately complained loudly of knee pain. At 11:46 AM, Resident 52 was standing up out of the chair with both feet on the ground. 2 staff came around the corner and ran toward Resident 52. Resident 52's had 28 falls From February 7, 2022, to February 9, Of the 28 falls 24 of them were unwitnessed. Resident 52 fell on [DATE] about 3 PM. Only one dietary staff was in the common area with the residents. Resident 52's current care plan indicated a risk for falls related to an unsteady gait was initiated on 1/14/23. The interventions were documented as continue the risk plan. Interventions were as follows: 15min checks from 3a to 6am, have resident wear tennis shoes while propelling in broda chair, be sure gripper socks are on, if awake or restless get up and take to nurse's station for closer observation, bed in lowest position, frequent monitoring from 5am to 7:20 am, wide bed for safety, gripper socks on at bedtime, check every 30 min from 6pm to 8pm, and 30 min checks from 8pm to 3am. Post fall evaluations were documented. No fall risk assessments were provided by time of exit. A policy was provided by the DON on 2/13/22 at 8:46AM, titled Fall Prevention Policy and Procedure, dated 5/23/1997, most recent update 10/6/22, and indicated it is the policy of Swiss Village that each resident will be assessed for fall risk upon admission, quarterly, and with significant change.if falling reoccurs despite initial interventions, staff will implement additional interventions or different interventions or indicate why the current approach remains relevant . 3.1-45(a)

Based on observation and interview the facility failed to ensure sanitary practices were followed during dinning services for 14 of 17 residents observed. Findings included: A observation on 3-10-22 at 11:51 A.M. of the meal service for the hall Lavendel Place, 17 residents were seated in the dining room. There were 3 staff members assisting with tray pass in the dinning room. There was one antibiotic hand sanitizer (ABHS) dispenser inside the dinning room next to the door and another one at the opposite door on the outside. There was a small kitchenette with food in the steamers, one server was observed in the kitchenette. One staff member was going around and taking meal orders of the residents. The 2 other staff members were observed to be serving a small dish of fruit. One staff member was observed using ABHS in between serving residents. Certified Nurse Assistant 6 (CNA) was observed serving a resident, obtained another dish of fruit without using ABHS and served the resident. CNA 6 placed the small dish on the table, un-wrapped the utensils and placed one inside of the fruit for the resident. CNA 6 went back to the food line without using ABHS. While waiting, CNA 6 was observed to pull her hair back over her ear, then re-adjusted her face mask by pulling it down and back up again. CNA 6 did not use ABHS afterwards. CNA 6 was observed rubbing her stomach area, but did not use ABHS afterwards, then obtained 2 small dishes of fruit to serve 2 residents. CNA 6 did not use ABHS afterwards. At 11:58 A.M., the main entree was served. CNA 6 obtained a plate, served a resident, but did not use ABHS. CNA 6 went back to pour a cup of juice, placed the lid, and obtained a straw. She pulled the straw out of the paper and placed the straw into the cup for the resident. The resident was observed to be drinking out of the cup through the straw. CNA 6 did not use ABHS afterwards. As CNA 6 was waiting for the food to be plated, CNA 6 was observed pulling her hair back over her ear, but did not use ABHS. CNA 6 then obtained a plate and served another resident. While walking back towards the food line, CNA 6 was observed rubbing her stomach area and did not use ABHS afterwards. She then obtained another plate to serve another resident. CNA 6 was observed pulling out the utensils and assisted the resident by cutting up the food, then assisted the resident with one bite of food with fork. CNA 6 then went back to the food line to obtain another plate to serve another resident, CNA 6 did not use ABHS. CNA 6 served the resident then went back to the resident she was assisting earlier with food. CNA 6 assisted the resident with another bite of food, then went back to the food line. As CNA 6 was walking back to the food line she started to rub on her stomach area, CNA 6 did not use ABHS afterwards. CNA 6 obtained another plate to serve another resident. As CNA 6 was walking back to the food line she was observed to pull her hair back over her ear, but did not use ABHS afterwards. CNA 6 went to the food line and obtained another plate to serve another resident. CNA 6 was observed leaving the dinning room. A couple minutes later, she re-entered the dinning room and was not observed to use the ABHS. CNA 6 went to the food line to obtain another plate to serve another resident. CNA 6 was observed again to leave the dinning room. Moments later she re-entered the dinning room and did not use ABHS. During this time the dessert was being served. CNA 6 was observed to obtain a cup of fruit for a resident, CNA 6 assisted the resident to pull back the plastic cover. CNA 6 did not use ABHS afterwards. CNA 6 then went to assist a resident with eating. CNA 6 did not use ABHS before touching the resident or their utensils. CNA 6 then used the fork and assisted the resident with a bite of food. CNA 6 was observed to pull her hair back over ear, but did not use ABHS afterwards, then assisted the resident with another bite of food. On 3-15-22 at 11:57 A.M., in an observation of meal service, CNA 6 was delegating the meal service. CNA 6 was observed pulling her hair back over ear, but did not use ABS afterwards. On 3-15-22 at 1:59 P.M., in a interview, CNA 5 indicated then staff were use ABHS or wash hands in-between every resident during the meal service. On 3-15-22 at 2:01 P.M., in an interview, the Director of Nursing indicated the staff were to wash hands prior, and use ABHS in between resident or touching something un-clean in the middle of meal service. A current facility policy, Handwashing and Hand Hygiene, dated 3-24-20, was provided by the Director of Nursing on 3-15-22 at 2:16 P.M. The policy indicated . All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors .Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) water for the following situations .before and after assisting a resident with meals A current facility policy, Resident Centered Dinning Procedure, dated 11-19-21, was provided by the Director of Nursing on 3-15-22 at 2:16 P.M. The policy indicated .CNA responsibility: prior to serving all staff must wash hands with soap and water .CNAs are to sanitize their hands in between each serving and wash their hands if visibly soiled or if they touch any dirty surfaces-table, chairs, residents, clothing, etc .staff is to keep their hands off their face, hair, clothes, and counter top these are all considered contaminated surfaces .infection control practices will be followed during meal pass and between residents 3.1-21(i)(1) and (3)

Based on record review and interview the facility failed to have a baseline care plan for 2 out of 3 residents reviewed. (Resident 240 and Resident 32) 1} Resident 32's record was reviewed, on 3-15-2022 at 11:34AM, it indicated the resident had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted on [DATE]. His baseline care plan was completed on 1-8-22, 24 days after admission. The care plan summary did not indicate a copy had been given to the resident or thier representative. The initial care plan did not address the following needs: communication, walking, ADL (activities of daily living) needs, incontinence, falls, [CONDITION(S)] drug use, cognitive loss, and history of trauma. Resident 32's progress notes indicated they had 7 reported behaviors prior to the initial care plan being completed. The initial care plan did not include the need for psych services. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A baseline care plan was not established to address Resident 32's behavior and medication needs. 2) Resident 240's record was reviewed on 3-11-22 at 11:49 AM. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted on [DATE]. The initial care plan was completed on 3-8-22. Resident 240 was moved to the secured unit on 3-9-22. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan did not include any focus on elopement risk, falls, cognitive decline, behaviors, or sleep disturbance. Resident 240's prgress notes indicated she had 6 behaviors recorded prior to her move to the secured unit. Three of those behaviors were wandering into others rooms. One behavior included an attempt to shove a chairs under a door knob to block the doorway. A baseline care plan was not established to address Resident 240's behavior needs. In an interview on 3-15-22 at 2:08 P. M., the DON indicated the initial care plan should have all needs addressed to keep the resident safe, should be given to the family and recorded as such, be completed within 48 hours of admission, buthad not been completed for Resident 32 and Resident 240. She did not provide a policy and procedure regarding initial care plans.

Based on observation, interview and record review the facility failed to accurately document and monitor behaviors for patterns, effective interventions, and outcomes for 1 of 3 residents reviewed. (Resident 239) Findings include: In an observation beginning at 10:16 AM to 1:10 PM on 3-10-22, Resident 239 spent the time away from group activities in a recliner. When she was approached she was resistant to care. She refused to stand up, she complained loudly about the gait belt still fastened around her, she refused to go to lunch, refused to be checked for incontinence, and refused to talk with staff without yelling. A staff approached her calmly, requesting she allow help to stand then walk to her room with her. Resident 239 began yelling, let go of me and don't touch me. Three staff stood around Resident 239 in attempt to gain compliance, two on each side and one in front of the resident. One unidentified staff member began to touch Resident 239's gait belt. The resident began yelling and screaming. She was then allowed to sit in the reclining chair and lunch was brought to her in an alcove near the dining room. On 3-14-22, in a continuous observation from 9:30 AM to 11:15 AM, Resident 239 was in an activity with peers and smiling. Resident 239 was singing along with music and performing some of the exercises in the activity as well. In an interview on 3-14-22 at 11:21 A.M., CNA 2 indicated everyday was different with Resident 239. CNA 2 indicated some days she was bright and others she was not. She had worked as a CNA with Resident 239 for the last 2 years, but the team had found no rhythm or reason as to what upsets her or what makes her have a pleasant day. On 3-14-22 at 1:30 PM a record review was started. The record indicated Resident 239's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 239's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. on non shower days for anxiety, [MEDICATION(S)] 250 mg twice daily for mood disorder, the resident may reside on a secured unit, and to follow up with psych services as needed. A review of Resident 239's behavior monitoring sheets indicated they specifically requested the location, date and time of behavior. Check boxes for behaviors, precipitating factors, outcomes, interventions were to be listed in order of 1, 2, 3 etc, then if behavior was new or worsening signified by yes or no. The notes also indicated an explanation of the behavior cause and precipitation which was in a free text (paragraph) format. Review of behavior management notes, listed by dates and times notes were entered as follows: On 1-3-22 at 2:22 P.M. the time of behavior was listed as off and on all through the shift, but no behavior was described, no precipitating factors marked, outcome was not marked, a paragraph of behavior included the resident was weepy, refused to use the walker, refused a supplement, and behavior worsening was not answered. On 1-4-22 at 1:09 P.M. indicated a behavior was present on 1-3-22 shortly after lunch, but interventions were not indicated. On 1-16-22 at 6:13 A.M., the behavior was not marked, precipitating factors were not marked, the outcome was not marked, and behavior worsening not answered. On 1-21-22 at 1:39 P.M., no precipitating factors were marked, no outcome was marked, there was a paragraph of behavior details but no order of interventions were marked. On 1-22-22 at 9:23 A.M., precipitating factors were not marked, the outcome was not marked, a paragraph of behavior details was typed, but an order of interventions was not marked. On 1-24-22 at 5:47 P.M., precipitating factors were not marked, and behavior worsening not answered. On 1-25-22 at 9:41 A.M., no precipitating factors were marked, no outcome was marked, and behavior worsening was not answered. On 1-25-22 at 5:24 P.M., no behavior was marked, no precipitating factors were marked, no outcome was marked, there was an explanation of behavior in paragraph form. but behavior worsening was not answered. On 1-27-22 at 5:55 P.M., the behavior was not marked, precipitating factors were not marked, the outcome was not marked, and behavior worsening not answered. On 2-3-22 at 10:23 A.M. no precipitating factors were marked, no outcome was marked, there was no paragraph describing the behavior, and behavior worsening not answered. On 2-10-22 at 10:01 A.M., no behaviors were marked, no precipitating factors were marked, no outcome was marked, there was a paragraph describing behavior,but behavior worsening was not answered. No behavior sheets were provided for March. On 3-16-22 at 10:25 A.M., in an interview, Social Services Director (SSD), indicated they printed the daily behavior monitoring sheets for the day prior. They also had IDT (inter disciplinary team) meetings weekly to include monthly review of every resident. The SSD indicated the facility had behavior management meetings with the pharmacist, psych provider, and social services to go over any changes or gradual dose reductions needed. She indicated they rely on the behavior sheets to track and trend behavior. When they see a pattern they go directly to the Unit Manager for a better understanding. She indicated incomplete or inaccurate information on the behavior sheet would make the data unreliable. The IDT meetings were labeled as Behavior Summary and the findings were as follows: On 1-18-22 the report indicated the following behaviors and occurrences: delusions 7 on days and 2 on evenings refusing care 3 on days and 1 on evenings declining to use walker 2 on days and 1 on evenings striking out at staff one on days and one on evenings stated just let me die once on days loud or yelling twice on days weepy once on days and once on nights refusing meals once on days. A total of 24 incidents. The behavior monitoring sheets indicated a total of 13 behaviors between 12-14-21 and 1-18-22. The summary of causal factors was listed as the resident was living on a secured unit. The summary of effectiveness of staff interventions stated several interventions had been used, but there was no indication which interventions were more or less effective. Psychoactive medications were listed as [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. Psych The behavior committee recommendations for the plan was to discontinue [NAME] and [MEDICATION(S)]; medications Resident 239 was taking at the time. There were 6 initials and a date provided, but no titles or names were listed on the form. The report dated 2-15-22 indicated the following behaviors and occurrences: upset with staff 3 on days wander into others rooms once on days hallucinations once on days loud, yelling or nosiness 4 on days, 1 on evenings and 1 on nights. refusing meals 1 on days and 1 on evenings delusions 1 on days, 1 on evenings and 1 on nights refusing meds once on days up or down trying to walk on own 3 on days refusing care 1 on days, 1 on evenings and 1 on nights crying 1 on evenings striking out at staff two on nights A total of 26 incidents. The behavior monitoring sheets indicated a total of 12 behaviors. The summary of casual factors were the resident resided on the secured unit and wanted to go home. The summary effectiveness of staff interventions indicated several interventions were used, but the interventions were not listed and were not commented on regarding effectiveness. The psychoactive medications were listed as [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. The behavior committee recommendations were to discontinue [MEDICATION(S)] and [MEDICATION(S)]. [MEDICATION(S)] and [MEDICATION(S)] were not listed under Resident 236's active medication list. There were 5 initials and a date, but no titles or names were listed on the form. The behavior summary dated 3-8-22 indicated the following behavior and occurrences: attempt to get up and walk per self once on days resistive to care once on days delusions twice on days refusing meds once on days A total of 5 occurrences. There were no behavior monitoring sheets provided for March. The summary of causes was the resident resided on the secured unit. The summary of effectiveness of staff interventions listed the following interventions: reassurance, reapproach later, alternate caregiver, toilet, snack, walk, and encourage to sit or rest, but there was no indication of the effectiveness of the interventions listed. The psychoactive medications were listed as [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The behavior committee recommendations were to discontinue [MEDICATION(S)] and [MEDICATION(S)]. The same recommendation for three months regardless of the number of behaviors or medications Resident 239 was listed as taking. The psych provider documentation, indicated that resident was to be monitored for any changes in sleep, mood, and behaviors. The changes were to be documented and reported. In January, the provider note indicated her cognitive score changed from 7 to 5. It was determined that [MEDICATION(S)] and [MEDICATION(S)] were not beneficial. The two medications were discontinued. Resident 239's [MEDICATION(S)] was increased to 750 mg daily from 375 mg daily previously. Resident 239 had no changes in her prescribed [MEDICATION(S)] and [MEDICATION(S)]. In February, the provider note indicated Resident 239 was seen 2-1-22 and 2-10-22. The notes indicated Resident 239's [MEDICATION(S)] was changed from as needed on shower days to a routine daily dose. Resident 239's [MEDICATION(S)] was to remain the same and [MEDICATION(S)] was not mentioned in the treatment plan. On 3-2-22, the provider note indicated [MEDICATION(S)] was changed from 750 mg daily to 500 mg daily as an attempt to gradually reduce the dose. Resident 239's care plan indicated a focus on cognitive loss was initiated in November of 2019. The goal had not changed. Some interventions were added in July of 2020. The other additions to care plan simply indicate medication changes and that Resident 239 was seen by provider. The care plan indicated to follow the dementia protocol. the protocol included when a staff finds something that works they were to share the technique with everyone, consistency and redundancy were helpful with demented residents. The policy and procedure titled, behavioral management with a date of 2008 indicated .2. As part of a comprehensive assessment, staff will evaluate a The resident's usual pattern of cognition, mood and behavior. b) The resident's usual method of communicating things like pain, hunger, thirst, and other discomforts. c) The resident's typical or past responses to stress, fatigue, fear, anxiety, frustration or other triggers and d) The resident's previous pattern of coping skills . 3.1-37(a)

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical procedures were followed for medication storage, discarding and not administering medication when expired for 2 of 6 medication carts observed affecting 2 of 5 residents reviewed. (Resident 56, and Resident 10) Finding included: 1. A record review for Resident 56 began on [DATE] at 12:35 p.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 56's most recent Quarterly MDS (Minimum Data Set) Assessment, dated [DATE], indicated a BIMS (Brief Interview for Mental Status) score was 9 which indicated moderately impaired cognition. The MDS assessment also indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 56's orders for the [MEDICATION(S)] [MEDICATION(S)] indicated a start date of [DATE]. The [MEDICATION(S)] [MEDICATION(S)] was to be injected subcutaneously per the prescriber's instruction. The [MEDICATION(S)] sliding scale was as follows: a blood sugar or glucose (BS) reading of ,d+[DATE] = 3 Units (a measurement of insulin dose) was to be given. A BS of ,d+[DATE] = 6 Units was to be given. A BS of ,d+[DATE] = 9 Units was to be given. A BS of ,d+[DATE] = 12 Units was to be given. A BS of ,d+[DATE] = 15 Units was to be given. BS greater than 450 was to give 15 units and call physician. The [MEDICATION(S)] [MEDICATION(S)] Insulin was scheduled at 8:00 a.m., 12:00 p.m., and 5:00 p.m per Sliding Scale. An order, dated [DATE], indicated to check the resident's blood sugar 4 times daily was scheduled at 7:00 a.m., 11:00 a.m., 4:00 p.m., and at 9:00 p.m. An order, dated [DATE] indicated to check the date opened on the [MEDICATION(S)] insulin pen and enter it in comment section on the MAR (Medication Administration Record). The nurse was to obtain a new pen as needed and write the date when it was opened. During observation of insulin administration on [DATE] at 11:49 a.m., with LPN 2, Resident 56's [MEDICATION(S)] [MEDICATION(S)] (an injection device with a needle to administer insulin) was stored in a plastic bag with a handwritten date of [DATE] on the label. LPN 2 indicated the [MEDICATION(S)] [MEDICATION(S)] insulin was opened on [DATE] and would be expired. The LPN indicated she would need to get the Resident's [MEDICATION(S)] Insulin pen from the refrigerator in the medication room. Review of Resident 56's [DATE] MAR (Medication Administration Record), provided by the DON on [DATE] at 12:42 p.m., indicated the resident had received 4 doses of the expired [MEDICATION(S)] Flex Pen Insulin. The Resident received 3 Units for a BS of 244 on [DATE] for 12:00 p.m. dose, 3 Units for a BS of 207 on [DATE] for 5:00 p.m. dose. Resident 56 received 3 Units for BS of 204 on [DATE] for 12:00 p.m. dose, and 6 Units for BS of 253 on [DATE] dose. Additional documentation on the MAR indicated [MEDICATION(S)] [MEDICATION(S)] was not administered on [DATE] at 8:00 a.m., [DATE] at 8:00 a.m. and [DATE] at 8:00 a.m., because the BS with within normal range. Further review of the [DATE] MAR, indicated a nurse had initialed they checked the open date of the [MEDICATION(S)] [MEDICATION(S)] on [DATE] and [DATE] from 6:00 p.m. to 6:00 a.m., the open date was not documented on the MAR. An interview with LPN 2 on [DATE] at 11:50 a.m., indicated insulin expired in 28 days after opening. LPN 2 indicated Resident 56 had received the [MEDICATION(S)] Insulin since it had expired. LPN 2 indicated the only other insulin in the medication cart for Resident 56 was the [MEDICATION(S)] Insulin FlexTouch (Insulin Pen), which had an open dated of [DATE] and was not expired. An interview with the Director of Nursing (DON) on [DATE] at 12:30 p.m., indicated [MEDICATION(S)] Insulin expired 28 days after being opened. She indicated when counting 28 days, Day-1 was the date it is opened. She also indicated Resident 56's [MEDICATION(S)] [MEDICATION(S)] Insulin would have expired on [DATE] when opened on [DATE], the last date to use it was on [DATE], the insulin should have been discarded and not used on [DATE] or after. She indicated she could provide a facility policy for medication storage and expiration dates medications. 2) On [DATE] at 1:23 P.M. in an observation of the medication cart on the secured unit, the following was observed: An eye drop for Resident 10, Latanprost give 1 drop each eye daily at bedtime was observed on the box. The pharmacy recommendations indicated it was to be discarded 6 weeks from the open date. The open date on the bottle was [DATE] and indicated it should have been discarded on [DATE]. A review of Resident 10's MAR dated [DATE] indicated the medication was administered each day from [DATE] on [DATE] at bedtime. An interview with RN 1 indicated that the eye drop was only good for 28 days after opening and should have been discarded. RN 1 did replace the eye medication. A policy titled, eye drops and eye ointment administration policy and procedure last revised [DATE], did not include when the eye drops are to be discarded. Review of the facility's current pharmacy policy, titled, Medication Storage Guidance, dated 2021, was provided by the DON on [DATE] at 12:43 p.m., indicated, .Ophthalmic Products .[MEDICATION(S)] Ophthalmic Solution ([MEDICATION(S)] [a [CONDITION(S)] eye medication]) .Date when opened and discard after 6 weeks Insulin Storage Recommendations .[MEDICATION(S)] cartridge or pen .opened at room temperature - 28 days Review of the facility's current policy, titled, Storage of Medications, revision date of [DATE], was provided by the DON on [DATE] at 11:53 a.m., indicated, .The facility stores all medications and biologicals in a safe, secure, and orderly manner .3. The nursing staff is responsible for maintaining medication storage and preparation areas in clean, safe and sanitary manner .5. Discontinued, outdated, or deteriorated medications or biologicals are returned to the dispensing pharmacy or destroyed 3.,d+[DATE](j)(o)

Based on interview and record review, the facility failed to outline specific additional precautions in the staffing vaccination policy. Findings include: On [DATE] at 11:05 A.M., record review of COVID-19 staff vaccination status for Providers was provided by the Administrator. Total number of staff were 346. Total of partially vaccinated staff was 8. Total number of completely vaccinated staff was 191. Total number of pending exemption was 30. Total number of granted exemption was 117. Total number of temporary delay/new hire was 0. Total number of not vaccinated without exemption/delay was 0. On [DATE] at 11:10 A.M., a record review of facility mandatory vaccination policy was provided by the Administrator. The policy indicated . This policy is intended to comply in all respects with Swiss Village's legal obligations and is founded on the most current guidance available from applicable public health agencies such the Centers for Disease Control and Prevention, the Indiana Department of Health, and other federal, state, and local health agencies. This policy complies with the Center for Medicaid and Medicare (CMS) and OSHA vaccine mandates issued [DATE] .Except as otherwise provided, all employees, as a condition of their employment, shall be required to present proof that they have received all mandatory vaccinations as directed by Swiss Village, INC., which at this time includes the COVID-19 vaccination. Employees who fail to obtain a designated vaccine or submit a religious or medical exemption but the deadline designated by CMS may be placed on unpaid leave or otherwise laid off as determined by the Senior Leadership Team. All circumstances are addressed on a case by case basis, and Swiss Village, Inc., will reasonable accommodate employees with sincerely held religious beliefs or certain medical conditions in a manner consistent with this policy . to assist employees in receiving the vaccine, Swiss Village, Inc. maintains information related to locations where employees may receive the vaccine. Employees may contact the Human Resources (HR) department for vaccine location information. Employees should utilize their available health insurance benefits to cover the costs of any vaccines. All employees will be paid for time taken to receive vaccinations. For offsite vaccinations, employees are to work with their managers to schedule appropriate time to comply with this policy. Before the stated deadlines to be vaccinated have expired, employees will be required to provide either proof of vaccination or an approved reasonable accommodation to be exempted from the requirements. For applicants who have received conditional offers of employment, proof of vaccination or exemption must be submitted before work begins when do directed by Swiss Village, Inc . You should consult with your health care provider regarding any medical questions about the efficacy, side effects, and consequences of receiving any particular vaccine. Swiss Village, Inc. will not provide medical advice and Swiss Village, Inc. does not assume liability for any negative outcomes that may occur individually in the event an employee experiences an adverse reaction to a vaccine. Employees in need of exemption from the this policy due to a medical condition that is contraindication to the vaccination or because of a sincerely held religious belief must complete and submit a request for accommodation form to the Vice President of HR to being the interactive accommodation process as soon as possible after vaccination deadlines have been announced. As part of our commitment to equal employment opportunity, Swiss Village, Inc. provides reasonable accommodations to qualified individuals with disabilities unless the accommodations would impose an undue hardship or pose a direct threat to health and safety. Specifically. Swiss Village, Inc. provides reasonable accommodations to ensure equal opportunity in the application process, to enable a qualified individual with a disability to perform the essential functions of the job, and to enable an employee with a disability to enjoy equal benefits and privileges of employment. Swiss Village, Inc. cannot make an accommodation unless it is aware of the need. Employees must provide Swiss Village, Inc. with enough information to know of both the medical condition that is a contraindication to the vaccination and the desire for an accommodation that will enable the employee perform the essential functions of his/her job. Following receipt of the employee's Request for Exemption/Accommodation, the Vice President of HR and/or Vice President of Healthcare services will engage in an interactive process with the employee to identify a possible accommodation. The interactive process is intended to clarify the employee's request and identify the appropriate exemption/reasonable accommodation. Swiss Village, Inc. may ask the employee relevant questions that will enable Swiss Village, Inc. to make an informed decision about the request. The exact nature of the dialogue will vary. Swiss Village, Inc. makes these assessments on a case-by-case basis and in consultation worth available public health guidance. No employee will be retaliated against for making good-faith requests for reasonable accommodations. Employees, however, may be subject to discipline and termination for any bad-faith requests, which may be considered a form of dishonesty .All medical information received about an employee as a result of this policy will be treated as confidential and stored separately from the employee's personnel file. This includes an employee's statement that he/she has, or suspects he/she has, an infectious disease, such as COVID-19, as well as the employer's notes or other documentation from questioning an employee about symptoms. Medical information received about an employee as a result of this policy may be stored in the employee's medical file. Additionally, managers and supervisors will be not be disclose that an employee is receiving a reasonable accommodation . If you have questions regarding this policy, you should feel free to consult with the Vice President of HR or Vice President of Health Care services. Except with respect to those with approved accommodations, employees who fail to obtain any vaccinations that are mandatory under this policy maybe subject to disciplinary action, up to including termination In the facility vaccination policy there were not specific outlines for additional precautions for non-vaccinated employees to take when working directly with residents. On [DATE] at 11:05 A.M., a blank religious accommodation request form was provided by the Administrator, on page 2 of 3, question indicated, identify the accommodation provided. Administrator indicated this is where they will put the additional precautions. On [DATE] at 11:38 A.M., in an interview, the Vice President of HR indicated when they fill out the exemption form, once the exemtion was approved, they would fill out the portion to identify the accommodation provided, they would put in the accommodations- which is wearing a mask (surgical) and testing according to CMS guidelines. Currently, she indicated the facility was testing everyone 2 times a week becasue of the current county positivity rate. The facility did not want to discriminate those who are non-vaccinated, so the additional precautions were listed on the exempt form. On [DATE] at 2:15 P.M., in an interview, Certified Nursing Assistant 2, indicated they were to fill out the exempt paper and have it turned it in by [DATE]. HR would then review it for approval. They were told to wear a mask and get tested , that is was her understanding of additional precautions. 3.,d+[DATE](b)

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices for 1 of 3 residents observed. (Resident B) Findings include: The record review for Resident B began on 1-26-2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The last quarterly MDS (Minimum Data Set) assessment dated [DATE] indicated Resident B had a BIMS (Brief Interview of Mental Status) of 15/15, which indicated the resident was cognitively intact. The resident required supervision of 1 person for bed mobility and transfers, supervision with set up help for eating and an extensive assistance of 1 person for personal hygiene. The resident was marked for impairment on both sides of upper extremities. The resident was marked as having received an antidepressant, diuretic and opioid in the last 7 days prior to the assessment. A review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was renewed on 1-3-2022. There was not an order to indicate this medication could be left at the bedside for the resident to take on their own. A review of Resident B's MAR (Medication Administration Record) for the Tums for 1-26-2022 morning dose, indicated the medication was marked as administered at 6:44 a.m. The times on the MAR for administration of this medication were 8:00 a.m. and 5:00 p.m. A review of Resident B's assessments for the past 12 months indicated there was not a medication self administration assessment completed. During an observation on 1-26-2022 at 9:52 p.m., Resident B was observed in his room. The resident was in his wheelchair and the overbed table was observed next to him. A medication cup was observed with 2 round pills inside, one was a pink pill and the other was a yellow pill. The resident indicated the nurse left the pills there for him to take. He indicated it was Tums and he would take them later. He indicated the nurse also brought in other medications and he took those right away. An interview with RN 1 on 1-26-2022 at 9:44 a.m., indicated she was the nurse today on duty for the Lavendel unit and there were no residents with orders for medications to be left at bedside. RN 2, who was also the Unit Manager, was interviewed at this time. She indicated medications should not be left for residents to take on their own. An interview with QMA 3 (Qualified Medication Aide) on 1-26-2022 at 10:03 a.m., indicated she did not leave medications at the resident's bedside for the residents to take on their own. An interview with RN 1 on 1-26-2022 at 10:13 a.m., indicated Resident B would take Tums after breakfast and would not take Tums when his morning medications were administered. An interview with RN 2 at this time indicated the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with RN 4 on 1-26-2022 at 10:17 a.m., indicated when medications were passed on the Edelweiss unit, the medications were not to be left at the residents' bedside. The nurse indicated she was not aware of any resident on the Edelweiss unit with orders for medications to be left at the bedside. An interview with the DON (Director of Nursing) on 1-26-2022 at 10:40 a.m., indicated the nursing staff had been provided education on not leaving medications at the resident bedside. A current policy, Policy and Procedure for the Administration of Medications last revised on 9- 24-2018, was provided by the Administrator on 1-26-2022 at 10:56 a.m. The policy indicated, .Residents will have the right to self-administer medications unless the practice of doing so is determined clinically inappropriate and unsafe for that resident. The resident must be assessed by the unit manager and the resident's physician for cognitive, physical, functional, and visual ability to administer their own medications This Federal tag relates to Complaint IN 021. 3.1-37

Based on observation, interview and record review, the facility failed to properly ensure infection control procedures were followed in a yellow zone unit related to COVID-19 for 3 of 3 staff observed for infection control practices.(Environmental Staff, CNA 1, RN 2) Findings include: During an observation on 8-16-21 at 9:22 a.m., an environmental staff member was observed wearing a PPE (personal protective equipment) gown outside of a residents room. They were then observed walking down the hallway and entered another resident's room wearing the same PPE gown. During an observation on 8-16-21 at 9:25 a.m., CNA 1 (Certified Nursing Assistant) exited a resident's room, then went down the hallway and entered another resident's room while wearing the same PPE gown. During an observation on 8-16-21 at 9:33 a.m., CNA 1 was walking through out the hallway while wearing a PPE gown. During an observation on 8-16-21 at 10:47 a.m., RN 2 (registered nurse) was at a medication cart in the middle of hallway, while wearing a PPE gown. During an observation on 8-16-21 at 10:52 a.m., RN 2 was at the nurse's station sitting at computer on the phone, while wearing a PPE gown. During an interview on 8-16-21 at 11:28 a.m., the DON (director of nursing) indicated, from 375-399 (Lavendel Place) is consider a yellow zone. They made it a yellow zone on 8-12-21 because the first resident that tested positive lived on that unit, so they wanted to take precautions and put everyone in TBP (Transmission Based Precautions). During an interview on 8-16-21 at 12:12 p.m., RN 2 indicated for all residents on the unit they are to wear a gown. If they are just popping in and out for like medication, then they can wear the same gown, but if they are doing personal care, then they are to change gowns. During an interview on 8-16-21 at 12:50 p.m., CNA 1 indicated if it a quick in and out of the room they can wear the same gown. They also have gowns hanging inside of the resident's room. But if they are to do patient care then they will change their gowns. During an interview on 8-16-21 at 3:15 p.m., the DON indicated the facility is using reusable PPE gowns, after every shift they will send them out. They are to keep the PPE gowns in the resident's room. They are not suppose to wear them in the hallways. A current facility policy, Personal Protective Equipment-Gowns reviewed dated 7-28-20, was provided by the Vice President of Operations on 8-16-21 at 11:17 a.m. The policy indicated .1. Use gowns only once and then discard into an appropriate receptacle inside the room 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure sufficient staffing was present to meet the needs of the residents, which had the potential to affect 114 of the 114 residents who resided in the facility. Findings include: 1. Observation of lunch dining services in Alpenrose Place (the facility's secured memory unit) began on Sunday, 10/20/19 at 11:50 a.m. and indicated the following. The nursing staff was observed to be assisting residents into the dining room for the lunch meal. At 11:58 a.m., one female resident, who ambulated independently with her walker towards the dining room, stopped and told RN 2, she was not feeling good and did not want to eat lunch. RN 2 had the resident sit down in a recliner chair which was near the medication cart. At 12:00 p.m., The facility's Charge Nurse 3 arrived in Alpenrose Place. The Charge Nurse was observed to assess the resident who was not feeling well, while RN 2 completed the medication pass. At 12:09 p.m., meal service began, 11 residents were in the dining room for lunch service. Two CNAs (Certified Nursing Assistants), CNA 4 and CNA 5 were available to serve and assist the residents. The CNAs were observed to serve small bowls of cherries or applesauce to the residents. At 12:10 p.m., Charge Nurse 3 was observed to wash her hands and joined the CNA 4 and CNA 5 to serve residents their lunch meal. At 12:11 p.m., the first meal plates were served to the residents by the CNA 4, CNA 5, and Charge Nurse 3. They assisted the residents with their meal set up, such as cutting the food and providing them with their silverware. Five residents and 1 family member were served their lunch meals. At 12:20 p.m., Charge Nurse 3 was observed to retrieve a meal plate and put the plate on the table in front of a resident. She was then observed to move a chair next to the resident and began to feed the resident their meal. Then CNA 4 and CNA 5 were observed to to retrieve meal plates and serve their residents. The CNAs were seated next to a resident and they each assisted a resident to eat their meal. While the Charge Nurse and the 2 CNAs were feeding the residents, there were 5 residents observed to be seated at the tables who were not served their meals. At 12:23 p.m., RN 2 was observed to provide meal supplements to some residents during their meal. At 12:24 p.m., observed a resident, who was being assisted by CNA 4, refuse to eat their meal, although CNA 4 had offered several times. CNA 4 then requested a meal plate for another resident, she performed handwashing and retrieved the plate from the dietary staff, placed the plate on the table in front of a resident, and then sat down next to a resident and assisted the resident to eat their meal. Four Residents were observed not to be served their lunch meal at this time. At 12:27 p.m., observed RN 2 wash her hands and move a chair next to a resident to assist them with their meal. Four staff were feeding residents and three residents were not yet served their lunch meal. At 12:28 p.m., observed Charge Nurse 3 perform handwashing and retrieved 2 small bowls of gravy from the Dietary Staff for a resident and their family member. She was then observed to wash her hands and returned to assist the same resident she had been feeding their meal. At 12:35 p.m., observed Charge Nurse 3 perform handwashing and she retrieved a meal plate and placed it on the table in front of a resident. She provided silverware to the resident and the resident began to eat their meal. Charge Nurse 3 told RN 2 the resident was feeding herself for now and would assist another resident. The Charge Nurse performed hand hygiene and used her foot to move a bench near a resident who was sleeping and not eating. The Charge Nurse sat down and assisted a resident to eat their lunch meal. At 12:36 p.m., Charge Nurse 3 received a phone call and was observed to leave the dining room. At 12:37 p.m., the last resident was served their lunch meal. The resident was observed to feed themselves a pureed meal with a small spoon. RN 2 queued and assisted the resident to reach their beverages and supplement which were in lidded sippy cups. At 12:47 p.m., CNA 5 was observed to perform handwashing and then served apple pie to the residents. At 12:50 p.m., a resident was observed to stand up, holding onto the edge of the table and repetitively yelled out, What should I do .What should I do Observed CNA 4, while assisting a resident to eat their apple pie, ask the resident to sit down. The resident responded, Why? and continued calling out. The resident remained standing and holding onto the table. CNA 4 stopped feeding the resident. CNA 4 performed hand hygiene, put a gait belt on the resident, who was calling out, and assisted her to walk with a walker to the lounge, where she was seated in a recliner chair and covered with a knitted blanket. The resident quieted down. CNA 4 was observed to perform handwashing. CNA 4 entered the dining area and another resident stood up at the table and asked CNA 4 to take them to their home. Observed CNA 4 hold the resident's hand and she walked him to his room. At 12:53 p.m., RN 2 was observed to perform hand hygiene, then delivered the first meal tray to a resident in their room. At 12:55 p.m., RN 2 walked to the end of the longer hall to let a visitor out of the secured door from Alpenrose Place. At 12:57 p.m., RN 2 was observed to return to the dining room, performed hand hygiene, then retrieved a meal tray and delivered the 2nd meal tray to a resident in their room. At 1:09 p.m., RN 2 was observed to return to the dining room, performed hand hygiene, then retrieved a meal tray and delivered the 3rd meal tray to a resident in their room. At 1:11 p.m., CNA 5 was observed to deliver the 4th meal tray to a resident in their room. At 1:15 p.m., the meal service was completed. The residents who received meal trays in their room were eating. An interview with RN 2 on 10/20/19 at 1:40 p.m., indicated there were 18 residents residing on the unit that day and 8 residents who ate their meal in the dining room required assistance to eat their meals. She indicated, during the weekdays, there were more staff to assist with dining service and feeding the residents. She indicated the unit had a CNA-bath aide who worked on Mondays, Tuesdays, Thursdays and Fridays and helped assist residents with their meal. She indicated the restorative aide assisted a resident to eat during the weekday. She indicated the unit's Activity Staff was also CNA and assisted residents eat their meal. RN 2 also indicated the unit's Activity Staff was currently on vacation, but did not work every weekend. She indicated the unit's minimum staff was to be one nurse and two CNAs. She further indicated on some days a CNA from another unit would come and assist to feed the residents, but it depended if they were needed on their assigned unit. 2. During an observation of Alpenrose Place on 10/21/19 at 12:20 p.m., 15 residents were observed in the dining room. Six staff were observed to be assisting or feeding residents their meals. One resident was observed with a plate of food in front of her and was asleep in her wheelchair. 3. An observation of Alpenrose Place on 10/25/19 at 12:20 p.m., indicated the following: Observed 11 residents in the dining room and 3 staff, the restorative aide and 2 Unit CNAs were feeding 3 residents. There were 2 residents with meal plates in front of them, their eyes were closed. All residents in the dining room were served their food. At 12:22 p.m., observed RN 2 deliver a meal tray to a resident's room. At 12:25 p.m., observed the ADON (Assistant Director of Nursing) arrive in the dining room. She was observed to perform handwashing and then was seated by a resident who appeared to be asleep. The ADON woke the resident and assisted the resident to eat their meal. At 12:30 p.m., observed CNA 4 and CNA 6 perform hand hygiene and then each assisted a resident to eat their lunch meal. Another resident, who was finished eating, stood up, holding onto the table, was repetitively calling out, asking to see her parents. An unidentified staff was observed to enter the dining room, she asked the resident if they wanted to go back to their room. The staff put a gait belt on the resident and assisted the resident ambulate with their walker to the Activity room. The staff returned to the dining room and assisted another resident ambulate to the recliner chairs. At 12:32 p.m., CNA 4 was observed sitting by a resident and cued them to eat their meal. CNA 4 was then observed to perform hand hygiene, then sat down beside another resident at the table who was not eating their meal. The resident who was being cued, became repetitive, saying, I want breakfast! as she was eating her pureed meal with a spoon. CNA 4 encouraged the resident to eat their meal and told her she was eating lunch while she was assisting a tablemate to eat their meal. At 12:35 p.m., RN 4 was observed to perform hand hygiene and then sat by a resident who was not eating and assist the resident to eat. At 12:36 p.m., observed the Restorative Aide leave the dining room, CNA 4, CNA 6, RN 2, and the ADON were assisting resident with the meals while another CNA was observed to take resident to their rooms when they were finished eating their meal. Observed the Alpenrose Place Charge Nurse in the activity room with a resident. 4. During an observation on Sunday, 10-20-2019 at 11:15 a.m., the Nurse Staff Directly Responsible for Resident Care lists were observed to be posted on the window of the Administrator and DON (Director of Nursing) main office between Edelweiss and Lavendel Place for 10-18-2019, 10-19-2019 and 10-20-2019. The Nurse Staff Directly Responsible for Resident Care for Friday, 10-18-2019, had the following staff in place for 116 residents: First Shift Actual Shifts Worked (provided by DON 10-24-2019 at 12:30 p.m.) Charge Nurses 7:00 a.m. - 3:00 p.m. - 2 2 Registered Nurses 6:00 a.m. - 6:00 p.m. - 0 0 Licensed Practical Nurses 6:00 a.m. - 6:00 p.m. - 4 4 QMA (Qualified Medication Aides) 6:00 a.m. - 6:00 p.m. - 2 2 Certified Nursing Assistants 6:00 a.m. - 2:00 p.m. - 18 18 Second Shift Charge Nurses 3:00 p.m. - 11:00 p.m. - 0 0 Certified Nursing Assistants 2:00 p.m. - 10:00 p.m. - 7 10.5 Certified Nursing Assistants 3:00 p.m. - 9:00 p.m. - 0 2 Certified Nursing Assistants 4:30 p.m. - 8:00 p.m. - 1 0 Third Shift Registered Nurses 6:00 p.m. - 6:00 a.m. - 1 1 Licensed Practical Nurses 6:00 p.m. - 6:00 a.m. - 2 2 QMA (Qualified Medication Aides) 6:00 p.m. - 6:00 a.m. - 2 2 Certified Nursing Assistants 10:00 p.m. - 6:00 a.m. - 7 7 The Nurse Staff Directly Responsible for Resident Care for Saturday, 10-19-2019, had the following staff in place for 118 residents: First Shift Actual Shifts Worked (provided by DON 10-24-2019 at 12:30 p.m.) Charge Nurses 7:00 a.m. - 3:00 p.m. - 1 0 Registered Nurses 6:00 a.m. - 6:00 p.m. - 3 3 Licensed Practical Nurses 6:00 a.m. - 6:00 p.m. - 2 3 QMA (Qualified Medication Aides) 6:00 a.m. - 6:00 p.m. - 1 0 Certified Nursing Assistants 6:00 a.m. - 2:00 p.m. - 15.5 15.5 Second Shift Charge Nurses 3:00 p.m. - 11:00 p.m. - 0 0 Certified Nursing Assistants 2:00 p.m. - 10:00 p.m. - 12 12 Certified Nursing Assistants 3:00 p.m. - 9:00 p.m. - 1 1 Certified Nursing Assistants 4:30 p.m. - 8:00 p.m. - 1 1 Third Shift Registered Nurses 6:00 p.m. - 6:00 a.m. - .4 .4 Licensed Practical Nurses 6:00 p.m. - 6:00 a.m. - 2.6 2.6 QMA (Qualified Medication Aides) 6:00 p.m. - 6:00 a.m. - 2 2 Certified Nursing Assistants 10:00 p.m. - 6:00 a.m. - 7 7 The Nurse Staff Directly Responsible for Resident Care for Sunday, 10-20-2019, had the following staff in place for 114 residents: First Shift Actual Shifts Worked (provided by DON 10-24-2019 at 12:30 p.m. Charge Nurses 7:00 a.m. - 3:00 p.m. - 1 1 Registered Nurses 6:00 a.m. - 6:00 p.m. - 2 2 Licensed Practical Nurses 6:00 a.m. - 6:00 p.m. - 4 4 QMA (Qualified Medication Aides) 6:00 a.m. - 6:00 p.m. - 0 0 Certified Nursing Assistants 6:00 a.m. - 2:00 p.m. - 11.4 12 Second Shift Charge Nurses 3:00 p.m. - 11:00 p.m. - .3 .3 Certified Nursing Assistants 2:00 p.m. - 10:00 p.m. - 11.8 12 Certified Nursing Assistants 3:00 p.m. - 9:00 p.m. - 1 1 Certified Nursing Assistants 4:30 p.m. - 8:00 p.m. - 0 0 Third Shift Registered Nurses 6:00 p.m. - 6:00 a.m. - 0 0 Licensed Practical Nurses 6:00 p.m. - 6:00 a.m. - 2 2 QMA (Qualified Medication Aides) 6:00 p.m. - 6:00 a.m. - 3 3 Certified Nursing Assistants 10:00 p.m. - 6:00 a.m. - 6.9 7 During an observation in Sonnenblum Place on 10-22-2019 at 12:04 p.m., the following rooms were observed with a resident in them, room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. There were 4 CNAs observed to be in the main dining room obtaining orders and passing out clothing protectors. There were 2 staff members in the assist dining room passing out drinks to residents and the ADON and the unit manager were passing trays. During an observation in Sonnenblum Place on 10-23-2019 at 12:34 p.m., a call light was on for a resident room. There were no other residents in the hall where this resident's room was at that time. At 12:36 p.m., there were not any CNAs observed in the Sonnenblum halls. At 12:37 p.m., there were no CNAs observed in the halls and the call light was still on. At 12:38 p.m., the call light was now off. During an observation of resident care on Sonnenblum Place on 10-25-2019 at 10:18 a.m., Resident 84 was observed to be assisted with a lift transfer and showering by CNA 7 and CNA 8. At 10:20 a.m., the head of the bed was lowered and the resident had her brief removed. At 10:22 a.m., the resident was rolled side to side in order to place the sling beneath her. CNA 8 was observed to wash her hands and then left the room at 10:23 a.m. to get the lift and the bath chair. At 10:25 a.m., CNA 8 was back in the room but was observed to only have the bath chair. CNA 8 was observed to ask CNA 7 if she had gotten the lift and CNA 7 indicated No. CNA 8 was observed to leave the room at 10:26 a.m. to get the lift and returned to the room at 10:26 a.m. with the lift. At 10:27 a.m., the head of the bed was observed to be down and the 2 CNAs connected the sling to lift. At 10:28 a.m., Resident 84 was up in the sling. At 10:29 a.m., the resident was in the bath chair in her room. The CNAs disconnected the sling at 10:30 a.m. and placed the belt on around the resident in the shower chair. They left the room with the resident at 10:31 a.m. The time to clean the resident and place her in the shower chair to go to the shower was from 10:18 a.m. - 10:31 a.m., which was 13 minutes. Resident 84 was observed to be in the shower room at 10:32 a.m. CNA 7 was observed to leave the shower room at that time and returned to the resident's room at 10:34 a.m. to change the sheets. CNA 8 remained with the resident in the shower room. At 10:40 a.m., CNA 7 was observed to leave the resident's room with the bag of linens. The time observed for the CNA to make the resident's unoccupied bed was 8 minutes. At 10:44 a.m., Resident 84 was observed to come out of the shower room in the shower chair with CNA 7 and CNA 9. At 10:45 a.m., the resident was observed in her room in the lift chair. At 10:51 a.m., the door to resident's room was opened and Resident 84 was observed lying in bed and dressed in street clothes. At 10:52 a.m. the CNA took the lift back into the room with 2 CNAs. The resident was observed out of her bed in her wheelchair at 10:55 a.m. The time to get the resident out of the shower chair, dressed and into her wheelchair was from 10:44 a.m. to 10:55 a.m., 10 minutes. The entire process from, cleaning up the resident, transferring the resident from her bed to the shower chair in her room, showering, dressing, and transferring the resident to her wheelchair took 31 minutes with 2 CNAs and a shower aide. There were 9 residents identified in Sonnenblum Place who required a lift for transfers. Confidential interviews were conducted with the following residents: During an interview on 10-21-2019 at 9:57 a.m., a resident with a BIMS (Brief Interview for Mental Status) of 15/15, which indicated the resident was cognitively intact, indicated there was not enough staff. The resident indicated they were dependent on staff for transfers and staffing depended on who showed up to work. The resident indicated short staffing affected second shift, during mealtime and at times in the morning as they were not getting to breakfast until 8:40 a.m. and breakfast started at 8:00 a.m. The resident indicated the facility needed another lift as the battery runs out and staff had to look for another lift or battery. During an interview on 10-21-2019 at 11:50 a.m., a resident with a BIMS of 15/15, indicated staff sometimes will answer the call light, turn it off, and leave and say they will be right back and not return. During an interview on 10-21-2019 at 2:19 p.m., a resident with a BIMS of 9/15, which indicated the resident's cognition was moderately impaired, indicated there was not enough staff. The resident indicated he could not put weight on his leg and required staff assistance. The resident indicated there were only 4 staff for around 30 residents and had to wait too long for the call light to be answered. The resident's spouse was sitting with the resident and indicated the staff do not answer the call light as for long periods of time. During an interview on 10-22-2019 at 11:19 a.m., a resident with a BIMS of 15/15, indicated a lift was required for their transfers. The resident indicated there were more residents admitted in the unit who required a lift, but no more staff were added to accommodate the added residents with lifts. During an interview on 10-25-2019 at 10:55 a.m., an anonymous family member indicated the facility needed more staff. The resident's spouse had been a resident here and they felt they needed more caring staff and not the agency staff. The family member indicated the agency did not do a good job when caring for the resident. During an interview on 10-22-2019 at 11:28 a.m., a resident with a BIMS of 15/15, which indicated the resident was cognitively intact, indicated they were dependent on 1 staff for transfers. The resident indicated it usually took 10 minutes to answer the call light, but during meal times the resident wished they had someone to answer the call light as they had to wait longer than 30 minutes. The resident indicated they were in their room during mealtime and had to use the bathroom. The resident indicated they had to wait while the staff were serving the meal before help arrived. The resident indicated they had soiled themselves while waiting for someone to come take them to the bathroom. During meal times, the resident indicated they had to wait up to 1/2 hour to get taken to toilet and/or to get taken off the toilet. The resident indicated it had been this way and the last time was this past Saturday (10-19-2019). The resident indicated the facility had 2 staff that did the lifts and then 1 staff that did the 1 person assist. The resident indicated their roommate was a 2 person assist and if they asked one of the 2 person team to help them, the staff would not split up to provide a 1 person assist on Sarah lift. The resident indicated they had to wait for the one person to come help them. The resident indicated it took awhile for the 1 person assist to come help them and this situation usually happened most during the evening meal. The resident indicated this concern had been discussed in the Resident Council Meetings and the facility was aware of the concern. During interviews with residents in the Resident Council Meeting with the survey team on 10-210-2019 at 3:00 p.m., 3 residents with BIMS of 15/15 on their last MDS assessments indicated the following: The facility did not have enough staff and call lights took too long to get answered. The residents indicated they sometimes took 10 minutes for their call light to be answered and sometimes up to 30 minutes. This was a long time if you have to go the bathroom. The residents also indicated on some days they were short of help but sometimes, it depended on who was working. The residents indicated the facility needed more help around meal time to answer lights in the hall when staff were passing trays in the dining room. Two of 9 residents indicated they had soiled themselves while waiting for their call light to be answered. One resident indicated they had to wait 40 minutes one time to get help. They indicated it depended on the time of day and who was working. The resident indicated some staff were quick to answer lights and some really took their time. One of 9 residents had to wait for help a long time to get them off the toilet. A review of the Resident Council Minutes for the last 4 months was completed on 10-21-2019 at 12:46 p.m. A concern in the (MONTH) 10, 2019 Old Business indicated residents wanted a staff member available to answer call lights during mealtimes. A note by the Administrator indicated she was sending notes to staff regarding this concern to staff members. A review of the New Business in the (MONTH) 14, 2019 Resident Council Minutes indicated residents in Lavendel Place and Sonnenblum Place often ask staff for items and staff will leave their room and not return. Also, residents in the main dining room at Sonnenblum Place noted that they wait long period of time to be served due to serving and assisting those in the assisted dining room first. A review of the (MONTH) 11, 2019 Resident Council Minutes indicated in the Old Business, the ADON responded to the concerns about staff not returning to residents' rooms after asking for items. The ADON indicated they would like more details about specific incidences and a message was sent reminding staff to follow up on all requests in a timely manner. In regard to the dining concerns in Sonnenblum Place, the facility responded with an adjustment in the serving process. In the New Business, residents in all areas indicated the staff were turning off call lights and not returning. This was happening on all three shifts becasue there was no enough staff. A review of the (MONTH) 9, 2019 Resident Council Minutes indicated in the Old Business, the DON responded to the concerns of staff turning off call lights and not returning as stated. The DON indicated a message was sent out to all staff on 9-17-2019 reminding them that call lights were to remain on until they were able to assist the resident and meet their needs. If the staff was turning out the light and not assisting the resident and instead stating they will be right back, the DON indicated for the resident to turn the call light back on and ask to speak to the nurse. In the New Business of this meeting, resident in Lavendel Place and Sonnenblum Place noted that staff was still turning off call lights and stating they will return later and do not return. The Resident Census and Conditions of Residents form was provided by the DON on 10-21-2019 at 11:00 a.m. The following assistance was required from staff for the 114 residents in the facility: Ninety-nine residents needed the assist one or two staff for bathing, 109 residents for dressing, 79 residents for transferring, 102 residents for toilet use, and 94 residents for eating. Fifteen residents were dependent on staff for bathing, 2 residents for dressing, 16 residents for transferring, 1 resident for toilet use, and 1 resident for eating. The CNA and Nursing work schedules were provided by the DON on 10-24-2019 at 12:30 p.m. for the week of 10-20-2019 through 10-26-2019: For Sunday, 10-20-2019, for 114 residents - 144 nursing hours and 266.9 CNA hours For Monday, 10-21-2019, for 115 residents - 152 nursing hours and 278.3 CNA hours For Tuesday, 10-22-2019, for 114 residents - 172 nursing hours and 281 CNA hours For Wednesday, 10-23-2019, 114 residents - 160 nursing hours and 312.3 CNA hours For Thursday, 10-24-2019, 115 residents - 144.6 nursing hours and 321.7 CNA hours For Friday, 10-25-2019, 116 residents - 132 nursing hours and 269.9 CNA hours For Sat 10-26-2019, number of residents not indicated and the schedule had 144 nursing hours and 201.7 CNA hours. The weekend nursing hours were 8 - 16 hours less than during the week and the CNA weekend hours ranged from 3 to 120 hours less than during the week. An additional 2 weeks of the nursing/CNA schedules were provided by the DON on 10-25-2019 at 10:34 a.m.: For Sunday, 10-13-2019, for 115 residents - 145.8 nursing hours and 268.6 CNA hours For Monday, 10-14-2019, for 115 residents - 170.1 nursing hours and 320.7 CNA hours For Tuesday, 10-15-19, for 115 residents - 169.5 nursing hours and 302.3 CNA hours For Wednesday, 10-16-2019 for 116 residents - 180 nursing hours and 286 CNA hours For Thursday, 10-17-19, for 116 residents - 157.2 nursing hours and 331.7 CNA hours For Friday, 10-18-2019, for 116 residents - 146.9 nursing hours and 290.9 CNA hours For Saturday, 10-19-2019, for 118 residents - 132.2 nursing hours and 289.4 CNA hours The weekend nursing hours were 1 - 37 hours less than during the week and the CNA weekend hours ranged from 17 to 61 hours less than during the week. For Sunday, 10-6-2019 for 117 residents - 144.6 nursing hours and 268 CNA hours For Monday, 10-7-2019 for 117 residents - 180.6 nursing hours and 304.8 CNA hours For Tuesday, 10-8-2019 for 117 residents - 184.5 nursing hours and 310.9 CNA hours For Wednesday, 10-9-2019 for 117 residents - 186.3 nursing hours and 302.7 CNA hours For Thursday, 10-10-2019 for 117 residents - 164 nursing hours and 325.9 CNA hours For Friday, 10-11-2019 for 115 residents - 169.3 nursing hours and 266 CNA hours For Saturday, 10-12-2019 for 115 residents - 144 nursing hours and 258.3 CNA hours The weekend nursing hours were 20 - 42 hours less than during the week and the CNA weekend hours ranged from 8 to 67 hours less than during the week. On 10-25-2019 at 10:34 a.m., the DON provided a list of 24 residents who required lifts (Maxi lift and Sara Lift) and 2 staff members to assist for these lift transfers in the following units: Alpenrose Place - 2 residents Edelweiss Place - 4 residents Lavendale Place - 9 residents Sonnenblum Place - 9 residents Westenfeld Place - none An interview with the Administrator, DON and ADON on 10-25-2019 at 2:45 p.m., indicated for the Maxi and Sara lift, each required 2 CNA staff for the transfers. The Administrator indicated there was 1 Maxi lift and on 3 units (Alpenrose Place, Edelweiss Place and Westenfeld Place) and 2 Maxi lifts on Lavendale Place and Sonnenblum Place. There was 1 Sara lift on Edelweiss Place, Lavendale Place, and Sonnenblum Place. The Administrator indicated there were extra batteries on each unit in the clean utility rooms on each unit and maintenance kept extra batteries. The Administrator indicated every year they have budgeted for 2 new lifts and the older ones were kept for parts. During an interview with the Administrator, DON and ADON on 10-25-2019 at 2:47 p.m., the following concerns regarding staffing were discussed: The Administrator indicated, they (Administrator, DON and ADON) knew they had less staff on the weekends due to the reports they could see from CMS (Center for Medicare and Medicaid Services). The Administrator and DON indicated they utilized CNA bath aides during the week for resident showers as the residents prefer to have their baths and showers during the week. They indicated there are 4-5 CNA bath aides on the schedule Monday through Friday, that were not scheduled on the weekends. They indicated some of the CNA bath aides work their regular scheduled weekend day and there may be some residents who request a bath/shower on the weekend. They indicated they would ensure a CNA was trained for baths/showers if any resident wanted a bath on the weekend. They also indicated they have 1-3 CNA restorative aides scheduled during the week, but only 1 or 2 on Saturdays and none on Sundays. A concern regarding not enough staff on the past Sunday (10-20-2019) in the Alpenrose Place dining room with 8 residents needing assistance with feeding and only 3 staff available was discussed with the Administrator, DON and ADON. They were also notified the residents with room trays had to wait until all the residents who needed to be fed were finished prior to getting their lunch tray delivered to their room. It was 1:00 p.m. before hall trays delivered. The Administrator indicated they had a plan for the weekend assistance for Alpenrose Place during dining and the CNA mentor was to assist, along with the nurse on Short hall in Sonnenblum and the Unit Manager on duty. The Administrator was informed that the CNA mentor was observed in Lavendel Place dining room training a new CNA during lunch. Another surveyor observed the Unit Manager on duty did assist in Alpenrose Place with feeding a resident, but was called away and did not return. The nurse from Sonnenblum did not assist. The DON indicated there was a death during the noon hour this past Sunday and that was (TRUNCATED)

Based on interview and record review, the facility failed to ensure a Quality Assurance process was in place to identify and correct a quality deficiency which had the potential to affect 5 residents out of 114 residents who resided in the facility. Findings include: A review of the QA (Quality Assurance) Committee Members, provided by the DON (Director of Nursing) on 10/21/2019 at 11 a.m., included the following: Medical Director, CEO (Chief Executive Officer), DON (Director of Nursing), ADON (Assistant Director of Nursing), Administrator, Human Resource Coordinator, Unit Managers, Administrative Assistant, Director of Housekeeping, MDS (Minimum Data Set) Coordinator, Consultant Pharmacist, CNA (Certified Nurse Aide) Mentor, Vice President of Operations, Director of Residential Services, Director of Food Services, Director of Pastoral Services, Director of Healthcare Activities, Director of Social Services, and the Director of Facilities Management. During an interview on 10/25/2019 at 4:25 p.m., the Administrator indicated the QA committee meets quarterly. The QAPI (Quality Assurance Performance Improvement) Plan, 2019 Swiss Village QAPI Plan, dated (MONTH) 2019, indicated the following: .The QAPI plan will guide our facility's performance improvement efforts . and .Goal 1: Self-Administration of Medications - F554 SS=E Resident Self-Admin Meds-Clinically Approp CFR(s): 483.10(c)(7) Nurses/QMAs (Qualified Medication Aide) should not administer medication in the dining room and should not leave medication at bedside for residents to take own discretion unless these residents have orders and assessments in place to approve self-administration of medications. Only cognitively intact residents (BIMS Brief Interview of Mental Status scores 13-15, meaning cognitively intact) can self-administer medications. The goal of compliance is 90% for the first 3 months, 95% for the following 3 months, and 100% for the 6 months thereafter . The facility will be cited for Quality Assurance for not having two quarterly assessments documented for a resident who self administered their own medications. During an interview on 10/25/2019 at 4:25 p.m., the Administrator indicated after last years annual survey, the facility implemented not passing medications in the dining rooms, and completed assessments for 5 residents who self administered their own medications. She further indicated the facility only had 5 residents who self administered medications and the 1 resident who was missing two assessments was reviewed during this years annual survey.

Based on interview and record review, the facility failed to ensure self medication administrtion assessments were completed for 1 of 5 residents reviewed. (Resident 92) Findings include: A review of Resident 92's record on 10/23/2019 at 10:28 a.m., indicated she had a BIMS (Brief Interview of Mental Status) score of 13 out of 15, meaning cognitively intact. The score was obtained from the MDS (Minimum Data Set) Quarterly Assessment, dated 9/9/2019. [DIAGNOSES REDACTED]. During the initial interview on 10/22/2019 at 3:16 p.m., Resident 92 indicated she takes her own medications from a cup that the nurse has provided for her in the morning and the evening. A physician's orders [REDACTED]. There were two forms located in Resident 92's record, Evaluation to Self Administer Medications, dated 6/10/2019 and 9/9/2019. Both evaluations indicated the Interdisciplinary team found the resident to be safe and clinically appropriate to self-administer medications. The Care Plan review indicated an intervention that the resident may self-administer all oral medications after the medications were set up by the nurse or QMA (Qualified Medication Aide). The nurse and/or QMA were to follow up and ensure the medications were taken. During an interview on 10/23/2019 at 9:35 a.m., Resident 92 indicated that had taken her medications after the nurse left them for her this morning, but she did not know what she was taking or what the medications were for. During an interview on 10/24/2019 at 4:09 p.m., the Administrator indicated the facility had not completed two quarterly Evaluations to Self Administer Medications, she indicated the Unit Manager had missed them and could not confirm why they were missed. During an interview on 10/25/2019 at 4 p.m., LPN (Licensed Practical Nurse) 1 indicated Resident 92 did take her own medications after the nurse had set them up. LPN 1 indicated Resident 92 received medications twice on the day shift. LPN 1 indicated Resident 92 would not know what the medications were for, or be able to tell the staff the name of the pills and what they were for. LPN 1 was unsure if there was an assessment completed for the resident's who self administered their own medications. During an interview on 10/25/2019 at 4:05 p.m., Resident 92 indicated she had taken her medications that day, and then had asked the following: .Do you know what they are for ? I don't know . A current facility policy, Policy and Procedure for Self -Administration of Medications, dated 9/18/2018, provided by the Administrator on 10/24/2019 at 1:33 p.m., indicated the following: .the ability to recognize the medications, the purpose for the medications . and .The resident will be able to repeat to the nurse the above information regarding the medications . and .Unit Manager will complete self-administration of medications assessments quarterly to confirm that resident is capable of self-administering medications and that this practice is clinically appropriate and safe for this resident . 3.1-11

Based on observation, interview, and record review, the facility failed to ensure assessments were completed for 6 of 6 residents reviewed for safe administration of medications. (Resident 37, Resident 51, Resident 65, Resident 71, Resident 109, Resident 42) Findings include: On 9/06/18 at 11:56 a.m., LPN (Licensed Practical Nurse) 1 was observed, in Lavendel Dining Room, placing cups of medications on the dining tables of the following residents: Resident 37, Resident 51, Resident 65, Resident 71, and Resident 109. LPN 1 then walked out of the dining room. LPN 1 had not ensured that each resident consumed the medications that was put in front of them at their table. Other residents who did not receive medications at that time were also sitting at the same tables. At 12:14 p.m., LPN 1 was observed, in Lavendel Dining Room, placing a cup of medication on Resident 42's dining table. LPN 1 had not ensured that Resident 42 consumed the medication, and had walked out of the dining room. At 12:33 p.m., an empty medication cup was observed at the vacant place setting's of Resident 37, and Resident 65. 1. A review of Resident 37's medical record on 9/7/2018 at 1:35 p.m., indicated a BIMS (Brief Interview of Mental Status) score of 15 out of 15, which indicated cognition intact. [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. (MONTH) administer powders and supplements in DR (dining room) at meal times. The Care Plan indicated the following: (MONTH) leave medication for resident to take at own discretion- Nurse/QMA to follow up to make sure meds taken (in DR or room). Ok to administer powders and supplements in DR at meal times. Documentation was lacking of a written physician's orders [REDACTED]. 2. A review of Resident 65's medical record on 9/7/2018 at 1:30 p.m., indicated a BIMS score of 7 out of 15, which indicated severe cognitive impairment. [DIAGNOSES REDACTED]. Resident 65's medical record indicated the following: no written physician's orders [REDACTED]. 3. A review of Resident 51's medical record on 9/07/18 at 1:44 p.m., indicated a BIMS score of 15 out of 15, which indicated cognition intact. [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. (MONTH) administer powders and supplements in DR at meal times. The Care Plan indicated (MONTH) leave medication for resident to take at own discretion-Nurse QMA to follow up to make sure meds taken (in DR or room). There was no written physician's orders [REDACTED]. 4. A review of Resident 109's medical record on 9/07/18 at 1:52 p.m., indicated a BIMS score of 15 out of 15, which indicated cognition intact. [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. (MONTH) leave medication for resident to take at own discretion- Nurse/QMA to follow up to make sure meds taken (in DR or room). (MONTH) administer powders and supplements in DR at meal times. A review of the Care Plan indicated, the resident prefered that medication be given in DR and it may be left to take at own discretion. There was no written order for Resident 109 to self administer their own medications, except for the breathing treatment. An Assessment to Self Administer Medications was completed on 8/13/2018 for their breathing treatments. 5. A review of Resident 42's medical record on 9/07/18 at 2:09 p.m., indicated a BIMS score of 4 out of 15, which indicated cognitive impairment. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. (MONTH) administer powders and supplements in DR at meal times. Documentation was lacking of a written order for Resident 42 to self administer their own medications, no care plan for self administration of medications, and no self administration assessment was completed. 6. A review of Resident 71's medical record on 9/11/18 at 3:22 p.m., indicated a BIMS score of 6 out of 15, which indicated severe cognitive impairment. [DIAGNOSES REDACTED]. physician's orders [REDACTED]. A review of the care plan indicated: (MONTH) administer meds in DR during meals per residents preference. Documentation was lacking of a written order for Resident 71 to self administer their own medications, no care plan for self administration of medications, and no self administration assessment was completed. During an interview on 9/11/2018 at 9:45 a.m., the DON (Director of Nursing) indicated there were no self administration assessments completed because the meds aren't kept at the resident's bedside. The staff look up the medications and pull them from the cart. She indicated the nurse or QMA would go back to the resident and check the medication was gone. The DON indicated she could not ensure that the resident the medication was intended for was the resident that consumed the medication, since the resident had not been watched. During an interview on 9/11/18 at 11:10 a.m., LPN 1, indicated they are allowed to leave medications in the dining room or at the residents bedside for them to take at their own discretion. They have an order for [REDACTED]. During an interview on 9/11/18 at 11:18 a.m., RN (Registered Nurse) 2 indicated the residents with low BIMS scores like 4 or 7 would not be allowed to take the medication at their own discretion. She indicated if a resident declined the unit managers would assess them to make a determination if the resident would be allowed to take their meds at their own discretion. Furthermore, RN 2 indicated they do not have a self administration form that was used for this process. On 9/11/2018 at 5:30 p.m., during an interview with the ED (Executive Director), they indicated they had been doing the self 'discretion' process for a long time. Neither could ensure that a resident would receive their own medication when placed on the dining room table where other residents were seated, when they were not watched by the nurse. A Policy for Administration of Bedside Medications, dated 1/2018, provided by the DON on 9/7/2018 at 1:13 p.m., indicated the following: .For resident's who have expressed their preference to take their medications at their own discretion either in their room or in the dining room at meals and they have been deemed appropriate to do so, the following conditions will be met: a. An order will be obtained from the physician noting that nurses may leave medication ensure that meds are taken. b. This resident preference will be care planned. c. Unit Manager will periodically assess to confirm that resident is still appropriate to take medication at their own discretion. A Policy and Procedure for the Administration of Medications, dated 1/2018, provided by the DON on 9/7/2018 at 1:13 p.m., indicated the following: .Residents in Healthcare will have the right to self-administer medications unless the practice of doing so is determined clinically inappropriate and unsafe for that resident. The resident must be assessed by the unit manager and the resident's physician for cognitive, physical, functional, and visual ability to administer their own medications . 3.1-11

Based on record review and interview, the facility failed to ensure adequate supervision and assistive devices were maintained to prevent a fall during bathing for 1 of 3 residents reviewed for falls in a sample of 3. (Resident C). This resulted in a fall with severe bruising and a fracture for Resident C. Findings include: Review of the clinical record for Resident C on 12/12/11 at 10:15 A.M., indicated the resident had diagnoses, including but not limited to: Late effect [DIAGNOSES REDACTED] side NOS (not otherwise specified), and osteoporosis. A quarterly MDS (Minimum Data Set) assessment, dated 9/6/11, indicated Resident C was totally dependent for transfers and bathing requiring two or more persons for physical assist. The nursing care plan activity report for personal hygiene/bathing, dated 4/1/10, and reviewed by the facility staff on 9/20/11, for Resident C included: "needs extensive assist of two with personal hygiene and total staff performance in bathing. Interventions: provide two person extensive to total assist to transfer in/out tub and bathe upper/lower body..." (sic) The nursing progress notes for Resident C included: "10/21/11 at 8:32 A.M.: fell from shower chair. Hit head. Up per maxi lift and 4 assist into w/c (wheelchair) and transferred to bed. BP (blood pressure) 166/77, P (pulse) 80, R (respirations) 26. 7.8 cm (centimeter) x (by) 4.4 cm bump over right eye with 5.8 cm x 2.2 cm purple over eyelid. Resident c/o (complained of) left leg and will not straighten knee. Light purple bruising to left knee 9.3 cm x 4.2 cm and 1 cm x 1 cm. Also note 0.5 cm slit under right 4th toe, cleansed and Band-Aid applied. Ice applied to right eye." "10/21/11 at 8:36 A.M.: 7:45 A.M. dose of roxanol 0.125 ml (milliliters) given for left leg pain." "10/21/11 at 8:12 A.M.: New order received and implemented: send to (local hospital) emergency room for evaluation...8:20 A.M.: EMS here, resident transported to (emergency room at local hospital)." "10/24/11 at 4:58 A.M.: (local hospital) called at 4:15 A.M. and stated (Resident C) passed away at 4:05 A.M..." The radiology report from the local hospital for Resident C included: "Impression: Complex fracture of the left acetabulum (hip bone) with mild displacement as above. No actual left femoral fracture noted...large scalp contusion/hematoma is present in the right supraorbital region along with periorbital soft tissue swelling anteriorly." Review of the accident report form on 12/12/11 at 11:10 A.M., included the following: "Date/time: 10/21/11 at 7:30 AM. Description: Resident fell from shower chair onto right side. Hit head. Responsible party: Shower belt not being used. Outcome: Sent to (hospital) ER per EMS for eval: fracture. Contributing factors: Staff did not have safety belt in place." Review of the current undated facility policy and procedure for Gait Belt Usage provided by the Administrator on 12/12/11 at 11:10 A.M., included, but was not limited to the following: "Gait belts are to be utilized during episodes of transfers and ambulation with residents. Gait belts are to be used by those requiring weight bearing assistance as determined by the MDS, nursing assessment, or therapy recommendations for ambulation or transfers." The CNA who failed to apply a gait belt to transfer Resident C on 10/21/11 signed the gait belt policy on 5/4/08. An interview with the facility Administrator and the Director of Nursing (DoN) on 12/12/11 at 11:45 A.M., indicated the CNA with Resident C at the time of her fall did not have a gait belt on Resident C, did not have the seat belt attached to the bath chair around Resident C, had the call light on in the bathing room, and was waiting for assistance from another CNA to transfer Resident C when the resident fell out of the chair striking her head on the door to the tub when she fell . This federal tag relates to Complaint IN 415. 3.1-45(a)(2)