Every finding on record at Baptist Village of Oklahoma City

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 provide safe resident transfers for 1 (#65) of 3 sampled residents reviewed for accidents. The administrator identified 95 resided in the facility.Findings: On 09/30/25 at 9:02 a.m., Resident #65 was observed to be transferred from the bed to the wheelchair. CNA #4, CNA #5, and CNA #6 were in the resident's room for the transfer. The bed was elevated, resident the repositioned from side to side with two-person max assist for personal care, peri-care and brief change. The head of bed was elevated to assist with transfer and positioning of resident. A gait belt was applied around resident, under resident chest area and upper body, it was loose fitting. During the transfer, Resident #65 was lifted under their arms for most of weight by CNA #5 and CNA #6, and the gait belt was used for positioning by CNA #4 into wheelchair. The pressure under the resident arms could cause undue stress to resident arms, under arm area and shoulders and was unsafe, as the resident center of gravity was below the staff lifting point. Resident #65 was unable to bear weight on their lower extremities, and their lower extremities were flaccid. Resident #65's arms were crossed at the center of the chest during the transfer. The resident moaned and groaned during the transfer with significant facial grimacing.A care plan, dated 09/26/25, with a functional activities section, read in part, it takes two staff assist to transfer at all times.On 09/30/25 at 9:02 a.m., during the transfer, Resident #65 was asked if they were hurting. They were unable to communicate their pain level.On 09/30/25 at 9:22 a.m., CNA #5 was asked if they felt like the transfer of resident #65 was a safe transfer for resident. CNA #5 stated they did the best they could to make it safe for the resident while getting the job done. CNA #5 was asked about education and training they had for resident transfers. CNA #5 stated they had in-services and hands on training, when hired and throughout the year. CNA #5 was asked what they would do if they felt they needed additional equipment to transfer a resident safely. CNA #5 stated they went to the charge nurse and reported difficulties they may have had and if there were any changes in the resident that may have caused them to need more assistance.On 09/30/25 at 9:24 a.m., CNA #6 was asked if Resident #64 had any recent changes that affected the amount of assistance that was required for the resident to transfer. CNA #6 stated the resident had declined over the past couple months and they were a total lift now and not able to help them at all. CNA #6 stated the hospice provider had stopped providing showers and only provided bed baths since they were not able to transfer them without being a full body lift with at least two to three staff members, and for concern for resident comfort and safety without a lift. CNA #6 was asked if they had reported the need for additional assistance with transfers such as a mechanical lift. They stated they had reported to the charge nurse and hospice staff several times over the past couple of months, and they did not feel it was safe for the resident or staff to continue with total lifts since resident was not able to help at all, and it seemed to hurt them during transfers. On 09/30/25 at 9:30 a.m., LPN #3 was asked about the process for evaluating the need for assistance with resident transfers. LPN #3 stated that transfer assistance was documented on the care plan that aides could see on the pocket care plan. LPN #3 stated the assessment was performed by the nurse on admission, and the resident needs were addressed on the care plan. LPN #3 stated the aides came to the charge nurse if there were changes or additional needs that may need to be addressed, then the charge nurse took the information to the weekly interdisciplinary team meetings and care planning meetings. If the interdisciplinary team felt changes needed to be made, they would assess the situation and update care plan. LPN#3 was asked about the training aides get for transferring residents. LPN #3 stated each new aide gets trained and it was also in annual education. LPN #3 was asked about Resident #65 and if they were aware of the difficulty aides had with transfers. LPN #3 stated the aides had come to them and they had discussed the need of a possible mechanical lift with hospice provider, and it was also taken to team meetings and ADON, but at the time they did not feel there needed to be a change in the resident transfer process. On 10/01/25 at 2:11 p.m., the DON was asked how they determined what transfer method was used for a resident. The DON stated they assessed the resident and cognition ability and assessed for whether they required multiple persons assist, stand by or if they were independent. The DON stated they would get physical therapy to assess if needed. The DON was asked if the need for additional assistance for transfers was discussed for Resident #65 in the last interdisciplinary team meeting. The DON stated last interdisciplinary team meeting note for Resident #65 was dated 09/10/25, and transfers were not documented as discussed in the meeting. The DON was asked who evaluated the resident for transfer assistance. The DON stated the ADON participated in that decision and there had been a change in ADON staff in the last few months.

Based on observation and interview, the facility failed to ensure enhanced barrier precautions were utilized for two of two (#1 and #3) residents observed with indwelling devices. A Resident/Guest Suite List, dated 10/15/24, documented 96 residents were residing at the facility. Findings: 1. Resident #1 had diagnoses that included diabetes mellitus with peripheral angiopathy with gangrene. The initial MDS assessment, dated 09/17/24, documented Resident #1 was dependent upon staff for activities of daily living. They had a central line and were receiving antibiotics through it. 2. Resident #3 had diagnoses that included cystitis and bacteremia. The quarterly MDS assessment, dated 08/27/24, documented Resident #3 was dependent upon staff for activities of daily living. They had an indwelling catheter. On 10/15/24 at 1:51 p.m., these resident rooms were observed to not have signage indicating enhanced barrier protections were required and there were no PPE carts observed nearby. On 10/15/24 at 1:59 p.m., LPN #1 stated they did not know what enhanced barrier precautions were, but they use precautions when a resident has extended-spectrum beta-lactamase (ESBL) or Clostridium difficile (CDIFF). On 10/15/24 at 2:30 p.m., Resident #3 stated that staff did wash their hands and wear gloves when providing catheter care but did not wear a gown. On 10/15/24 at 2:27 p.m., the DON stated enhanced barrier precautions are put into place when there is a confirmed diagnosis of a communicable disease. On 10/15/24 at 2:48 p.m., LPN #2 stated they did not know what enhanced barrier precautions were, but they knew what standard precautions and isolation precautions were. On 10/16/24 at 8:05 a.m., both resident rooms were observed to have enhanced barrier signage on the doors and PPE outside of the doors. On 10/16/24 at 8:10 a.m., Resident #1 stated staff did wash their hands and wear gloves when providing care for the central line, but the staff did not wear gowns. Resident #1 stated they had received their last dose of intravenous antibiotics yesterday. On 10/16/24 at 10:17 a.m., the assistant administrator stated they had put the enhanced barrier precautions into place as soon as it was brought to their attention that their understanding was incomplete.

Based on record review and interview, the facility failed to prevent a CNA from physically restraining one resident (#4) of three sampled residents reviewed for abuse. A Resident/Guest Suite List, dated 10/15/24, documented 96 residents were residing at the facility and 30 of the residents were in memory care. Findings: An ABUSE, NEGLECT, MISTREATMENT AND MISAPPROPRIATION OF RESIDENT PROPERTY 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. Resident #4 had diagnoses which included Alzheimer's, anxiety, depression, and cognitive communication deficit. A quarterly assessment, dated 07/07/24, documented the resident was severely cognitively impaired, and had wandered throughout their environment 4-6 of the last 7 days. An Incident Report Form, dated 09/23/24, documented that after receiving an allegation of abuse, camera playback was viewed, and CNA #1 was seen grabbing Resident #4 several times by the right arm and shirt to pull them down into a seated position. The CNA was terminated. A head-to-toe assessment was completed with zero redness, new bruising, swelling, or pain noted. Relevant History: Resident #4 resided in memory care and was independent with ambulation without an assistive device and walked frequently in their environment. On 09/25/24, an in-service was conducted regarding abuse, neglect, mistreatment, and misappropriation of resident property. There were 36 signatures of staff in attendance. On 10/15/24 at 3:36 p.m., a Performance Improvement Plan was provided that documented an in-service on abuse had been provided, and abuse would be included in their annual skills fair on 10/30/24. On 10/16/24 at 10:12 a.m., the assistant administrator stated the way CNA #1 handled Resident #4 was inappropriate and CNA #1 was terminated as soon as the investigation substantiated the allegation. They stated an in-service was provided as soon as possible and a performance improvement plan was put into place.

On 07/15/24, an Immediate Jeopardy (IJ) situation was determined to exist related to the facilities failure to ensure the shower room door on the memory care unit closed and locked behind them to ensure residents were not able to enter the room. On 7/15/24, during initial tour, the shower room floor was wet and slippery, there was a hair dryer placed in the grab bar area and it was plugged it to the electrical outlet. There were greater than 10 bottles of shampoos, conditioners, alcohol based surface cleaner, and shaving cream covering over half of the shower bench. The cabinet in the shower room was unlocked, razors within reach. Staff stated the shower room door was supposed to close behind them automatically. On 07/15/24 at 4:47 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation related to the shower room door being unsecured on the memory care unit. On 07/15/24 at 4:55 p.m., the Administrator was notified of the IJ situation. On 07/16/24 at 7:19 a.m., an acceptable plan of removal was submitted to the Oklahoma State Department of Health. The plan of removal documented: 1. The shower room door was trimmed to ensure self-closure by 1800 on 07/15/24. 2. By 10:15 a.m. on 07.15.24, the hair dryer had been removed from the grab bar and locked in the shower room cabinet. At 1700, the hair dryers were removed from the locked cabinet and completely removed from the shower room. 3. The ten bottles of shampoos, conditioners, alcohol-based surface cleaner and shaving cream were removed from the shower room by 10:15 a.m. on 07/15/24. 4. The cabinet in the shower room was locked by 10:15 a.m. on 07/15/24. 5. All nursing team members in the building were educated by 10:15 a.m. on 07.15.24, and all remaining team members were educated by 2000 on 07.15.24. Proof of education is attached. The IJ was lifted, effective 07/17/24 at 8:55 a.m., when all components of the plan of removal had been completed. The deficiency remained at an isolated level with a potential for harm. Based on observation, record review, and interview, the facility failed to ensure the residents were free from accident hazards for 28 residents who resided on the memory care unit. The DON identified 28 residents resided on the memory care unit. Findings: A Know Your Rights policy, undated, read in part, You have the right to a safe, clean, comfortable, and homelike environment. On 7/15/24 at 9:39 a.m., during initial tour, the shower room floor was wet and slippery, there was a hair dryer placed in the grab bar area and it was plugged it to the electrical outlet. There were greater than 10 bottles of shampoos, conditioners, alcohol based surface cleaner, and shaving cream covering over half of the shower bench. On 07/15/24 at 9:41 a.m., the cabinet in the shower room was unlocked, razors within reach. Two emergency call lights were observed to be looped around grab bars in the shower room, they were unable to be pulled to alert staff for assistance. On 07/15/24 at 9:47 a.m., LPN #1 stated the shower room door was to be shut and locked. They stated the hair dry was not to be plugged in and the chemicals were not to be there. They stated the running water posed a hazard and the call lights should not be wrapped around the grab bar. LPN #1 stated residents were not to be in the shower room without staff.

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.

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. 48344

Based on observation, record review and interview the facility failed to ensure breakfast menu was posted. Findings: The DON reported 101 residents, resided in the facility. The facility's policy Menu Posting and Menu Substitution dated 1/24, read in part Menus are to be posted at least one week in advance or more if state regulation requires. Menus are to be posted at a height and in font (minimum 14 Font) that can be easily read by all residents. Menus should include all daily available for each meal. On 07/12/24 at 8:31 a.m., no breakfast menu was posted. On 07/16/24 at 2:08p.m. the Registered Dietician reported they were not sure if the menu was posted.

Based on record review and interview the facility failed to notify residents they were allowed to have resident council without staff present. The facility's deficient practice interfered with the resident's right to hold group meetings privately. The DON identified 101 residents resided in the facility. Findings: A Resident Rights: Resident and Family Groups policy, dated 02/20/24, stated team members, visitors and other guests may only attend the meeting upon invitation. On 07/17/24 at 10:55 a.m., the nine residents in attendance stated they were unaware they were allowed to have a resident council meeting without staff present. The social service staff member stated the were unaware but would review the policy.

Based on observation, record review and interview, the facility failed to ensure the ombudsman's contact information was posted in view of residents. The facility's deficient practice interfered with the resident's rights to communicate and access the state's ombudsman office. The DON identified 101 residents resided in the facility. Findings: Review of the facility's policy titled Resident Rights provided by the Administrator revealed .resident's right to . communication with and access to people and services, both inside and outside the facility .exercise his or her rights as a resident of the facility and as a resident or citizen of the United States .exercise his or her rights without interference, coercion .from the facility communicate with outside agencies .state long-term care ombudsman . On 07/17/24 at 11:36 a.m., an interview with the nine resident council members in attendance revealed they were unaware of who the ombudsman was, what their purpose was, or where to find that information. On 07/17/24 at 11:43 a.m., an eight by ten document with the Ombudsman name was located on the information board by the long-term care halls, but was written in small print, displayed out of view for resident's utilizing a wheelchair. There was no information board located on the skilled halls.

Based on interview, the facility failed to provide mail delivery to residents on Saturdays. The DON identified 101 residents resided in the facility. Findings: On 07/17/24 at 11:22 a.m., nine members of resident council stated the mail did not get distributed on the weekends. On 07/17/24 at 11:24 a.m., the social services staff stated mail gets delivered Saturdays but does not get passed out until Monday.

Based on observation and interview, the facility failed to ensure survey results were readily accessible/available to residents and visitors. The DON identified 101 residents resided in the facility. Findings: On 07/17/24 at 11:28 a.m., the nine resident council members stated they did not know where the state inspection book was. On 07/17/24 at 11:43 a.m., a sign was observed posted on the information board on the long-term care halls. The sign documented that survey results could be found at the front desk. There was no sign or mention of the survey results by the skilled halls.

Based on interview and record review, the facility failed to ensure residents and resident representatives were able to file a grievance form anonymously and post information regarding the name of the grievance official. The DON identified 101 residents resided in the facility. Findings: A Grievance Policy and Procedure, dated 02/2024, read in part the health center will provide a mechanism for filing a grievance/complaint without fear of retaliation .will provide residents, resident representatives and others information about the mechanisms and procedure to file a grievance; provide a designated individual to oversee the grievance process . On 07/17/24 at 11:10 a.m., the resident council members stated they did not know how to file a grievance, but that staff usually take care of their issues. On 07/17/24 at 11:22 a.m., the social services staff stated they were not positive who the grievance official was.

Based on observation, record review, and interview, the facility failed to provide care in a timely manner to a resident with a fractured finger for one (#40) of three sampled residents reviewed for falls. 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 02/19/24, documented ice pack, four times daily for 14 days. Apply ice pack to right hand for 20 minutes max. A physician's order, dated 02/20/24, documented appointment ortho hand specialty referral, send x-ray result. Resident #40 was not seen by any provider until 03/17/24. A physician's order, dated 03/17/24, documented buddy tape 3-4 fingers for three weeks. Resident #40 was first seen for the ortho consult on 04/03/24. 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 10:52 a.m., LPN #4 stated Resident #40 did not see the ortho hand specialist until 04/03/24. They stated the appointment was not set up and they should have followed up to prevent delay in care. On 07/17/24 at 11:03 a.m., LPN #4 stated Resident #40 had a delay in receiving care. On 07/18/24 at 8:48 a.m., the DON stated Resident #40 was first seen by a provider on 03/17/24. On 07/18/24 at 9:14 a.m., the DON stated the interventions implemented between 02/18/24 through 03/17/24 were ice pack and Tylenol as needed for pain.

Based on observation, record review, and interview, the facility failed to ensure a resident was assessed for the use of bed rails, an order and consent had been obtained prior to installation for two (#4 and #19) of two sampled residents reviewed for bed rails. The DON identified 13 residents who used bedrails in the facility. Findings: The BAPTIST VILLAGE COMMUNITIES BED RAIL POLICY AND PROCEDURE dated 02/20/24, read in part, completion of individual bed rail evaluation. The policy also read, .obtain informed consent from resident and/or resident representative .obtain physician order for medical symptoms evaluating the need for bed rail use. 1. Resident #4 had diagnoses which included fracture of right lower leg and need for assistance with personal care. Resident #4's quarterly resident assessment, dated 06/18/24, documented Resident #4 required extensive assistance with transfers. On 07/17/24 at 7:45 a.m., Resident #4 was observed in bed with two rails up on each side of the head of the bed. There was no documentation the facility assessed the Resident prior to the use of bed rails and no documented order for the bed rails. On 07/17/24 at 10:24 a.m., CNA #2 made observation of Resident #4's bed rails. They stated the resident used the rails to aide in positioning. On 07/17/24 at 11:14 a.m., LPN #4 stated the Resident had used the positioning rails since 01/24. On 07/17/24 at 11:17 a.m., LPN #4 stated there should be a form the facility and resident family filled out prior to the use of the positioning rails, an assessment completed, and should have a physician's order. They stated they could not locate any of the above documents for Resident #4. On 07/17/24 at 12:04 p.m., the Director of Quality stated they could not locate an assessment and consent form for the use of the positioning rails for Resident #4. 2. Resident #19 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis. Resident #19's quarterly resident assessment, dated 07/02/24, documented the Resident had severe cognitive impairment and required extensive assistance with transfers. On 07/18/24 at 9:18 a.m., the DON stated Resident #19 had the bed rails since admission. There was no documentation the facility assessed the Resident prior to the use of bed rails and no documented order for the bed rails. On 07/18/24 at 10:31 a.m., the DON stated there was no physician's order, consent, or an assessment for the use of the positioning bed rails for Resident #19.

Based on observation, record review, and interview, the facility failed to ensure: a. food items were labeled, dated and stored according to facility policy; b. proper food handling practices were followed to prevent the outbreak of foodborne illness; c. that staff changed gloves between task and according to facility policy; d. proper sanitization pratices or safety of the residents according to facility policy; e. hot food temperatures were documented according to facility policy. Findings: The DON reported 101 residents resided in the facility. a. The facility's policy Food and Supply Storage revised 1/24, read in part Cover, label and date unused portions and open packages. On 07/15/24 at 7:11 a.m., Dietary Aide #1 reported that all food items should be dated, labeled and stored. On 07/15/24 at 7:12 a.m., Dietary Aide #1 reported the tater tots, chicken tenders and bread should be dated, labeled and stored. On 07/12/24 at 7:18 a.m., Dietary Aide #1 reported it was bowl of sausages on the counter uncovered. b. The facility's policy Food Handling Guidelines undated, read in part Foods should be held hot for service at a temperature of 135 degree Fahrenheit or higher. On 07/12/24 at 8:00 a.m., Dietary Aide #1 reported the bacon temperature was 125 degrees. On 07/12/24 at 8:01 a.m., Dietary Aide #1 reported the temperature of the bacon was not acceptable, its supposed to be 135 degrees. c. A facility's policy Food Handling Guidelines revised 1/24, read in part Single use disposable gloves are worn when preparing foods that will not be cooked again (ready-to-eat foods) and while serving food. Gloves are to be placed over clean hands. Gloves are changed between tasks or if punctured or ripped. On 07/12/24 at 7:15 am., Dietary Aide #2 cracked eggs, handed silverware and condiments to resident, wiped counter and cooked eggs in skillet. On 07/12/24 at 7:15 am, Dietary Aide #2 reported they were supposed to change gloves between task. d. A facility's policy Sanitation and Infection Prevention/Control/ Dishwater Temperatures revised 1/24, read in part Final Rinse Sanitizer Solution Concentration 50-100 parts per million (ppm) sodium hypochlorite(chlorine) on dish surface in final rinse (minimum of 100 degree Fahrenheit). Each work area shall be equipped with sanitizing solution. Final rinse sanitizer concentration during each period of use. On 07/12/24 at 7:40 a.m., Dishwasher #1 reported the sanitizer solution bucket was empty and no parts per million (ppm) could be measured. On 07/12/24 at 7:41 a.m., Dishwasher #1 reported that the warewasher is supposed to have sanitizer solution in use to have clean dishes. e. A facility's policy Food Handling Guidelines undated, read in part Temperatures of hot food in service will be documented. On 07/12/24 at 8:04 a.m., no temperatures of hot food was documented; On 07/12/24 at 8:05 a.m., the Dietary Aide reported the hot food temperature log has not been documented.

Based on observation and interview, the facility failed to ensure call devices were accessible to residents for two (#17 and #58) of 28 resident observed for call lights in the memory care unit. The DON identified 101 residents resided in the facility. Findings: A Call Light Answering Policy and Procedure, dated 02/20/24, read in part, BVC recognizes that residents may call for assistance frequently. It is the responsibility of the team to answer the call for service. 1. Resident #37 admitted on [DATE] with diagnoses which included dementia and heart failure. A quarterly assessment, dated 04/16/24, documented the resident was dependent on staff for assistance with their ADLs. On 07/15/24 at 7:25 a.m.,the call light cord was observed hanging over the head of the bed. The call light was not accessible to Resident #37 2. Resident #58 admitted on [DATE] with diagnoses which included diastolic (congestive) heart failure and Alzheimer's disease. A quarterly assessment, dated 06/06/24, documented the resident required supervision or touching assistance with their ADLs. On 07/15/24 at 7:18 a.m., two call light cords were observed hanging over the foot of the bed of the empty bed in the room. Resident #58 was observed to be lying in his bed with neither call light accessible. On 07/15/24 at 7:26 a.m., CNA #1 stated Resident #58's call light cord was not within reach of the resident. On 07/15/24 at 7:28 a.m., CNA #1 stated Resident #37's call light cord was not within reach of the resident. On 07/19/24 at 9:18 a.m., the DON stated call devices should be within reach at all times.

Based on observation and interview, the facility failed to promote resident dignity by staff standing over a resident while assisting them to eat. The DON identified 101 residents resided in the facility. Findings: Resident #76 admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease. A quarterly assessment, dated 04/04/24, documented the resident's cognition was severly impaired and they required supervision or touching assistance with eating. On 07/15/24 at 8:08 a.m., LPN #1 pulled a chair over to a table near the TV in the dining area. LPN #1 began assisting Resident #76 with his meal. LPN #1 was standing while they assisted Resident #76 with their meal. On 07/15/24 at 8:23 a.m., LPN #1 continued to assist Resident #76 with their meal. LPN #1 continued to stand while assisting. 07/15/24 at 9:09 a.m., LPN #1 stated they were standing while assisting Resident #76 with their meal. They stated that was not the policy, per policy staff should be seated when assisting residents with their meals. On 07/19/24 at 9:14 a.m., the DON stated staff should be siting when assisting residents with meals.

Based on observation, record review, and interview, the facility failed to ensure a resident had a physician order and an assessment to self-administer medications for one (#1) of one sampled resident reviewed for self-administration of medications. The DON identified 101 residents resided in the facility. Findings: The Baptist Village Communities Self-Administration of Medications policy, dated 02/20/24, read in part, .The interdisciplinary team will assess the resident to determine if self-administration of medication is clinically appropriate, safe, and feasible. The policy also read, .A physician's order will be obtained and recorded in the chart. The order also will include which specific medications can be kept at the beside. On 07/15/24 at 8:34 a.m., A bottle of saline nasal spray was observed on Resident #1's nightstand. The Resident stated they self-administered the nasal spray at night. There was no documentation the resident had physician orders to self-administer medications or for the use of the nasal spray. On 07/18/24 at 11:56 a.m., LPN #2 stated Resident #1 did not have a physician order or an assessment for the self-administration of the saline spray they observed in the Resident's room. On 07/19/24 at 7:53 a.m., the DON stated a self-administration evaluation and a physician order was needed for medications at bedside.

Based on record review and interview, the facility failed to accurately complete a quarterly assessment for one (#45) of 21 sampled residents for accurate MDS assessments. The DON identified 101 residents resided in the facility. Findings: The Facility's Comprehensive Care Plan Policy and Procedure, dated 02/20/24, documented the facility must conduct initially and periodically a comprehensive, accurate, standardized assessment. Resident #45 admitted to the facility on [DATE] with diagnoses which included parkinsonism and psychotic disorder with hallucinations. A physician's order, dated 02/19/24, documented to administer 34 mg of Nuplazid (antipsychotic medication) at bedtime. An admission assessment, dated 03/01/24, document Resident #45 had not received antipsychotic medications. The Feburary MAR documented the Nuplazid had been administered each day of the look back period. On 07/19/24 at 11:11 a.m., MDS Coordinator #1 stated the admission assessment did not document Resident #45 had taken an antipsychotic. On 07/19/24 at 11:12 a.m., MDS coordinator #1 stated the resident had received the Nuplazid during the look back period. They stated the admission assessment had not been coded correctly.