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 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 2/9/23 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)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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)