**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to protect 1 (#106) of 2 sampled residents reviewed for abuse. Resident #106 was physically abused by Certified Nurse Aide # 8 causing two red marks on their right leg that was tender to touch. This caused Resident #106 to be afraid of the CNA. The administrator identified 95 residents resided in the facility Findings: On 09/28/25 at 5:15 p.m., Resident #106 was observed being propelled in a wheelchair to the dining room located on the memory care unit for the evening meal. An abuse policy, dated February 20, 2024, read in part, Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. An undated face sheet for Resident #106 showed they had diagnoses of chronic obstructive pulmonary disease, Alzheimer's, hypertension, and depression, A quarterly MDS, with an assessment reference date of 09/08/25 for Resident #106, showed they had a BIMS score of 05 which indicated severe cognitive impairment. The assessment showed Resident #106 required substantial assistance with chair to bed transfers and sit to stand. A behavior progress note, dated 09/20/25 at 8:35 p.m., read in part, Resident spitting, pinching, kicking, verbal abusive towards x3 CNAs refusing pericare and change Dristy [sic] clothing, unable to redirect, provided privacy. A nurse's progress note, dated 09/20/25 at 9:54 p.m., read in part, This nurse notified POA/SON [Name Deleted] of the allegations of the abuse and stated he would be by the community to see his [parent] on Sunday September 21, 2025. A nurse progress note, dated 09/20/25 at 10:17 p.m., read in part, Focus assessment rt allegation of assault. This Nurse observe x 2 red areas to the right leg , resident able to do Active ROM without pain denies pain, no s/s of distress noted call light in place. A signed statement from CNA #9, dated 09/20/25, read in part, I [CNA #9] was in the room with [CNA #8] and [Resident #106] and we were trying to change and [Resident #106] was getting aggressive and started hitting me and [CNA #8] and [CNA #8] grabbed [Resident #106's ] face and twisted [their] head side to side and was grabbing [their] hands and twisting [their] fingers. Then [CNA #8] pulled [their] hair as well. After we got [them] into the bed, [Resident #106] was kicking [CNA #8] and [CNA #8] proceeded to punch [Resident #106] in the leg twice.When [CNA #8] punched [Resident #106] you could hear the punch hitting [their] leg. [CNA #8] hit [Resident #106] on the top part of [their] right leg.A signed statement from the DON, dated 09/20/25, showed the DON assessed Resident #106 for injuries from the allegation of being hit in the right leg, having hair pulled, hands being grabbed, and face being turned towards CNA #8. The statement read in part, DOHS asked [CNA #8] what happed in room [ROOM NUMBER]A with [Resident #106] tonight. [They] stated, ‘[Resident #106] tried to spit in my face and in reaction to the resident trying to spit in [their] face [they] hit [Resident #106].This nurse told [CNA #8] that is abuse and we will be calling the police, turning [them] into the nurse aide registry, and completing all required reports per state and federal regulations, [CNA #8] became very upset and angry and said ‘you all are gonna have me arrested tonight and said [they] is leaving the community and walked toward the front doors to the receptionist desk and walked out the front door.A signed statement from LPN #5, dated 09/20/25, read in part, on 09/20/25 at aprox 2045 [8:45 p.m.] [CNA #9] reported to this nurse [CNA #8] hit resident on her leg twice, grab her hair and twisted. This nurse assess Resident observed X 2 red areas to right leg. This nurse keep eye on CNA #8 when became angry, upset left the unit. DON arrived at 2115 [9:15 p.m.] this nurse, DON and CNA #9 assess resident identify areas. A nurse's full skin assessment progress note, dated 09/21/25 at 9:15 p.m., read in part, At approximately this nurse completed a full head to toe skin assessment, [Resident #106] was noted to have two red areas on the right upper front part of [Resident #106] leg and one area [Resident #106] voiced was tender, no other skin abnormalities noted or voiced at this time. [Resident #106] was able to recall that [Resident #106] was hit and hair pulled at the time of the assessment, but was not able recall who did, but was able to state it was a guy. [Resident #106] was laughing and smiling during the entire assessment.A nurse's progress note, dated 09/23/25 at 5:34 a.m., read in part, Resident stayed up late in bed and finally fell asleep. Resident denied any pain or discomfort during the shift but only stated that areas on [their] R Tigh are tenders to touch.A nurse's progress note dated 09/23/25 at 10:15 a.m., showed the facility contacted a mental health provider to come out and evaluate Resident #106 for services after the physical abuse. The progress note also showed services were started within three for Resident #106 psychosocial well-being. A review of the memory care unit roster and skin sheets showed all residents that resided in the memory care unit received a skin assessment on 09/21/25. The skin assessments were used due to residents' cognition and not able to verbalize if abuse occurred. A facility in-service, dated 09/20/25, 09/21/25, and 09/23/25, showed the facility completed training to all staff on their policy regarding abuse, neglect, and mistreatment of resident property. All current employees were confirmed as having received the in-service through comparison of the current employee roster, sign-in sheets and post training signatures on the abuse policy. The facility QAPI minutes, dated 09/20/25, showed the facility initiated their quality assurance process and addressed the incident of staff to resident abuse from 09/20/25. The following interventions were put into place: immediate termination of the certified nurse aide, in-service with competency validations, increased supervisory rounds to monitor and track for signs of abuse. The documentation showed the QAPI was followed up on 09/23/25, to review the progress of the event and the corrective actions were being implemented. On 09/30/25 at 9:23 a.m., Resident #106 was asked about the incident that occurred on 09/20/25. Resident #106 did not remember the incident or any staff member mistreating them. On 09/30/25 at 11:45 a.m., LPN #5 stated they were working on 09/20/25 when CNA #9 came to the nurse's station and stated Resident #106 was not wanting care. LPN #5 stated they went into the room and Resident #106 was agitated and refused care, hitting, and kicking us. They stated CNA #8, CNA #9, and themselves were present in the room when they went in. LPN #5 stated this was not normal behavior for Resident #106. LPN #5 stated CNA #8 and CNA #9 and CNA #11, that was passing by stayed in the room to assist and provide care. LPN #5 stated CNA #9 came out crying and told them CNA #8 punched Resident #106 twice in the right leg, pulled their hair, and twisted their neck around. LPN #5 stated they completed a skin assessment and found two red marks on Resident #106 right leg that was tender to touch. LPN #5 stated Resident #106 stated the man was mean and ugly and they should be careful around them. LPN #5 stated they were afraid of CNA #8 because they hit an innocent resident, and if they did that, what would CNA #8 due to them. LPN #5 stated CNA #8 kept asking if they were in trouble and left when asked what happened to Resident #106. LPN #5 stated they had not had any previous complaints or allegations of abuse regarding CNA #8. LPN #5 stated Resident #106 was afraid of CNA #8 and displayed aggressive behaviors as a result. On 10/01/25 at 9:35 a.m., Resident #106 family stated the facility notified them of their loved one had been struck and hair pulled leaving marks on them. They stated Resident #106 told them the next day a big guy had struck them. The family stated Resident #106 had no complaints about anyone in the past and this was the only time and were alright with knowing the facility terminated the employee. The family stated the facility did everything they could to prevent this, but you cannot control a bad actor and they responded appropriately. On 10/01/25 at 10:19 a.m., the DON stated Resident #106 recalled something happened and it was a male. The DON stated CNA #8 came to their office and told them they had been spit on and as a reactionary response hit Resident #106. The DON stated there had been no other allegations of abuse against CNA #8. The DON stated they completed skin assessments on all the residents in the memory care unit, suspended CNA #9 for not intervening sooner and terminated and reported CNA #8. within two hours. The DON stated they had mental health services evaluate, and staff would monitor for any trauma caused by the event. The DON stated there were two red marks that were tender to touch, and it would be monitored for 15 days for any additional changes. The DON stated CNA #9 was terminated for not informing the nurse of the abuse until after they had come out of the room a second time. The DON stated it was determined the abuse occurred before the CNA #9 came and told the nurse about Resident #106 being aggressive during care. The DON stated CNA #9 was reported and terminated for not letting the nurse know about the abuse when they first went to the nurse about Resident #106 being resistant to care. On 10/01/25 at 10:57 a.m., the administrator stated the facility has followed their abuse policy, but Resident #106 was not free of abuse.Interviews were conducted with staff throughout the survey regarding their knowledge of the abuse policy and training. All staff were knowledgeable on the abuse policy and confirmed they had training between 09/20/25 and 09/23/25.

Based on observation, record review, and interview, the facility failed to prevent a decrease in range of motion for one (#40) of one sampled resident reviewed for limited range of motion. The DON identified 101 residents resided in the facility. Findings: Resident #40 had diagnoses which included parkinsonism and pain. A nursing note, dated 02/18/24, documented Resident #40 had a fall and complained of pain to their right hand. An x-ray report, dated 02/19/24, documented acute fracture in the right proximal phalanx of the fourth finger with mild soft tissue swelling. A physician's order, dated 03/17/24, documented buddy tape 3-4 fingers for three weeks. A Provider office visit note, dated 04/03/24, documented a boutonniere deformity of the right ring finger and difficulty with extension. It documented Resident #40 was placed in a finger splint and consult placed for surgical evaluation. On 07/15/24 at 9:19 a.m., Resident #40 stated they fell in 02/24 and broke their ring finger. They stated they did not get therapy for the finger and did not see an ortho surgeon for two months. On 07/17/24 at 9:34 a.m., observations were made of Resident #40's right ring finger. The Resident stated they were unable to straighten their ring finger. They stated the facility did not provide range of motion exercise to their finger. There was no documentation the buddy tape was applied as ordered. On 07/17/24 at 11:06 a.m., LPN #4 stated Resident #40 had a decline in hand functionality in the first six weeks of the fracture due to pain and swelling. They stated they do not know if the Resident could straighten their ring finger prior to the fracture. On 07/17/24 at 11:10 a.m., LPN #4 reviewed Resident #4's records. They could not locate documentation the buddy tape was applied as ordered. On 07/18/24 at 9:15 a.m., the DON stated the buddy tape order was not implemented. On 07/18/24 at 9:14 a.m., the DON stated no range of motion or physical therapy was provided to the resident to prevent a decrease in range of motion to Resident #40's fractured finger. They stated they should have provided the Resident with range of motion, physical therapy, and an order to monitor the fractured finger.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to review medications for a gradual dose reduction for four (#14, 33, 40, and #41) of five sampled residents reviewed for unnecessary medications. The DON identified 14 residents were on psychotropics medications in the facility. Findings: The Baptist Village Communities Psychotropic Medication Policy and Procedure, dated 02/20/24, read in part, Residents who receive psychotropic medications will receive gradual dose reductions and behavioral interventions unless clinically contraindicated with the intention to decrease or discontinue the use of the psychotropic medication whenever safe and possible. 1. Resident #40 had diagnoses which included dementia and depression. A physician's order, dated 03/09/22, documented escitalopram 10 mg, give one tablet by mouth daily for depression. A physician's order, dated 03/12/23, documented trazodone 50 mg tablet, may give two 25 mg to equal 50 mg one time daily for depression. A review from 07/23 of Resident #40's monthly medication regimen review did not document a recommendation for a gradual dose reduction. On 07/18/24 at 2:19 p.m., the Pharmacist stated they did not suggest a gradual dose reduction recommendation for Resident #40. They stated they were following the Resident's wishes. 2. Resident #14 had diagnoses which included emotional lability and anxiety. A physician's order, dated 05/30/23, documented effexor 75 mg extended release every one day, give with 150 mg to equal 225 mg daily with breakfast for emotional lability. A physician's order, dated 05/30/23, documented effexor 150 mg extended release every one day, give with 75 mg to equal 225 mg daily with breakfast for emotional lability. A physician's order, dated 05/30/23, documented Xanax 0.25 mg tablet at hour of sleep at 10:00 p.m. for anxiety. A physician's order, dated 06/27/22, documented Seroquel 50 mg tablet at hour of sleep for emotional lability. A physician's order, dated 06/27/22, lamotrigine 25 mg, give two tablets to equal 50 mg at bedtime for emotional lability. A review from 07/23 of Resident #14's monthly medication regimen review did not document a recommendation for a gradual dose reduction. On 07/19/24 at 10:35 a.m., the Pharmacist stated they suggested a gradual dose reduction on the above medications on 01/16/24. They stated the Resident did not want their medications changed. A Pharmacist Consult to Provider, dated 01/16/24, documented to continue the above medication regimen as is due to resident behaviors. On 07/19/24 at 10:53 a.m., the APRN, was asked if they considered the above Pharmacist Consult to Provider a gradual dose reduction recommendation for Resident #14's medications. They stated it was not a gradual dose reduction recommendation. 3. Resident #33 admitted on [DATE] with diagnoses which included Alzheimer's disease and dementia. A physician's order, dated 07/24/23, documented to administer 3 mg of melatonin at bedtime for insomnia. A physician's order, dated 07/24/23, documented to administer 75 mg of bupropion HCL (anti-depressant) twice daily for depression. A physician's order, dated 07/24/23, documented to administer 100 mg of Zoloft (anti-depressant) daily for depression. A physician's order, dated 09/05/23, documented to administer 0.5 mg of risperidone (anti-psychotic) at bedtime for dementia with psychotic disturbance. A review of the October 24 MAR, documented Resident #33 had received the above medications as scheduled from 10/01 through 10/15/23. A Resident Incident Reporting Form, dated 10/15/23, read in part, Resident states he fell when leaving the bathroom. This nurse noted him laying on his left side complaining of high stabbing pain on his right side hip area .Called provider on call who stated to send to hosp [sic]. There was no documentation of a review of residents medication. An X-ray was obtained on 10/15/23 at the hospital. The discharge summary documented a diagnosis of acute, moderately displaced interochanteric fracture of the proximal right femur. A monthly drug regimen review, dated 09/11/23, did not contain documentation to gradually reduce any of the above medications. A monthly drug regimen review, dated 10/20/23, documented the psychoactive agents would be addressed at the next onsite visit. Resident #33 returned to the facility on [DATE]. A physician's order, dated 10/20/23, documented to administer 75 mg of bupropion HCL (anti-depressant) twice daily for depression. A physician's order, dated 10/20/23, documented to administer 100 mg of Zoloft (anti-depressant) daily for depression. A physician's order, dated 10/20/23, documented to administer 0.25 mg of risperidone (anti-psychotic) at bedtime for dementia with psychotic disturbance. A physician's order, dated 10/20/23, documented to administer 25 mg of Seroquel (anti-psychotic) daily for dementia with psychotic disturbance. A monthly drug regimen review, dated 11/13/24, did not contain documentation to gradually reduce any of the medications ordered on 10/20/23. A monthly drug regimen review, dated 11/30/24, documented the psychoactive agents would be addressed on the next onsite visit. A monthly drug regimen review, dated 12/09/23, documented a request to discontinue arformoterol 15 mcg per 2 ml. A monthly medication review, dated 01/14/24, documented chart notes indicate continues to have inappropriate behaviors. Has had no recent falls. May we continue? A monthly medication review, dated 02/16/24, documented orders and chart notes reviewed. No recent changes in medication. No reported falls or significant problems of late. Recommend no changes for now. A monthly medication review, dated 04/15/24, documented orders and chart notes reviewed. Two noted falls earlier this month. Can be very aggressive with staff and others. Will not challenge his psychoactive regimen at this time. Suggest no changes for now. A monthly medication review, dated 06/24/24, documented stable currently. No reported falls or significant problems of late. Will wait full 6 months to challenge his psychoactive regimen again. 4. Resident #41 admitted on [DATE] dementia with other behavioral disturbances. A physician's order, dated 02/23/24, documented to administer 25 mg (2 tabs) of quetiapine twice daily for vascular dementia with other behavioral disturbance. A physician's order, dated 06/27/24, documented to administer 25 mg of quetiapine daily related to behaviors On 07/17/24 at 9:20 a.m., the pharmacist stated appropriate Seroquel (generic: quetiapine) was an appropriate medication for dementia with psychosis. The FDA warning, documented, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel is not approved for the treatment of patients with dementia-related psychosis.