**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure physical and psychosocial care interventions were implemented and modified to meet a resident ' s activities of daily living needs and failed to exhaust all available remedies as evidenced by the deterioration of a resident ' s physical status resulting in death for 1 (Resident #1) of 8 sampled residents. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. The IJ began on 08/19/2024 when maggots were observed to be imbedded in the body of Resident #1 by staff providing care, and pain was identified by the resident as the rationale for refusal of additional assessment and care. The Administrator and Nurse Consultants were notified of the IJ on 11/27/2024 at 11:07 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 12/09/2024 at 9:13 AM. The IJ was removed on 12/10/2024 at 3:32 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Findings include: A review of a facility policy titled, Resident Rights, revised on 11/22/2016, indicated facility staff were trained on resident rights and involved in the implementation of the policy and procedure. Residents have a right to be informed of their health, medical condition and treatment, participate in or refuse treatment, be advised of alternative care and treatments and their consequences. Residents have the right to 15. Receive adequate and appropriate medical care, nursing care, protective and support services, and personal cleanliness in a safe and clean environment. , 22. Be transferred or discharged only for medical reasons, for your welfare or that of others . , 33. Be free from physical abuse and neglect . A review of a facility policy titled, Abuse, Neglect, Misappropriation and Exploitation Investigation and Reporting Policy, revised 10/18/2022, indicated, The Facility will endeavor to protect residents from maltreatment, which means adult abuse, sexual abuse, neglect, misappropriation of resident property, and exploitation of residents. It recognizes resident rights to be free from physical, verbal, or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints as defined by federal regulation. Section II - Staff training and competency included in-service training programs that addressed resident rights, abuse policy including definitions and terminology, recognizing signs and symptoms of abuse, how and when and to whom allegations of mistreatment, neglect, and abuse will be reported, investigations on injuries of unknown origin. Section III - Identifying, investigating, and reporting, general policy included, all alleged, witnessed, or suspected resident maltreatment, including abuse and neglect shall be immediately reported to the Administrator or immediate supervisor and investigated by Facility management. All facility personnel, including all employees and any physician, owner, and Administrator, must immediately report all incidents of alleged, witnessed, or suspected resident maltreatment, including abuse and neglect, to the Administrator, or the Administrator ' s Designee who will report events as required by State law or regulation. When determining whether to report an incident, the definitions of abuse and neglect shall be considered. Any person in the facility suspecting the facility Administrator of any form of resident maltreatment or failing to report resident maltreatment is encouraged to go to the DON, consultant, or the State Agency. The Administrator or designee will immediately conduct an investigation of all incidents of alleged, witnessed, or suspected resident maltreatment. All alleged, witnessed, or suspected incidents must be reported according to state and federal law, within time restrictions required by law. All alleged violations are to be reported immediately but no later than 2 hours after allegation is made, to the Administrator, State Agency, local law enforcement, physician, coroner, State Registry, and resident ' s responsible party or emergency contact. Section IX - Definitions included Neglect, An act or omission by a caregiver responsible for the care and supervision of an endangered person or an impaired person constituting the negligent failure to: 1. Provide necessary treatment, rehabilitation, care, food, clothing, shelter, supervision, or medical services to an endangered person or an impaired person; , and 4. Provide goods or services to a long-term care facility resident necessary to avoid physical harm, mental anguish, or mental illness. Impaired person - A long-term care facility resident is presumed to be an impaired person. A Policy and Procedure was requested for catheters. The Administrator provided policy statement, We do not have a policy on urinary catheters. On 11/25/2024 at 12:25 PM, the Administrator stated the facility did not have a policy for wound care. The Medical Director was an independent contractor, and the facility did not have a job description for the Medical Director. Review of the job description for Administrator indicated the position was to manage and direct the day-to-day operations of the facility, and to learn and implement state and federal regulations. Responsibilities of the position included resident safety, reviews complaints and grievances, maintain written policies and procedures, assist department head with eliminating and correcting problem areas. Review of the job description for the Director of Nursing (DON) indicated the position responsibilities included assuring resident safety, day to day operation and management of the nursing department and working closely with the Administrator regarding coordination of resident services and functions of the nursing department. Review of the job description for the Assistant Director of Nursing (ADON) indicated the position responsibilities included assuring resident safety and day-to-day operations of the nursing department, meeting with team members regarding coordination of resident services. Review of the job description for the Charge Nurse indicated the position responsibilities included assuring resident safety; perform nursing services for the comfort and well-being of the residents; check residents daily to determine status, assess, record, and report changes in residents ' condition to supervisor and attending physician; complete treatment orders; complete skin audits; identify nursing problems and respond and initiate immediate action; communicate problems to DON; provide emergency care to residents; assess resident needs and provide input for care. Review of the job description for the Treatment Nurse indicated the position responsibilities included assuring resident safety; completing treatment orders; assist and complete skin audits; safety of residents; identify safety hazards and special nursing problems and initiate immediate action; communicate problems and needs in nursing department; assess and report changes in resident condition and take follow-up action as necessary; provide emergency care to residents; assess resident ' s needs and provide input. Review of the job description for Certified Nursing Assistant (CNA) indicated the position responsibilities included assuring resident safety; identify resident problems and concerns and report them immediately to charge nurse or a licensed nurse; report changes in residents ' condition. A review of the Medical Director Retainer Agreement with an effective date 01/01/2018, indicated the duties of the Medical Director included guidance and oversite in the development and implementation of resident care policies that reflect current standards of practice; responsible for coordination of medical care in the facility; identifying, evaluating, and resolving medical and clinical concerns and issues affecting resident care, medical care or quality of life or were related to the provision of services by physicians and other licensed health care practitioners. Medical care through medical doctors, Advanced Practice Registered Nurse (APRN) ' s, and telehealth services provided by the contracted provider limited liability company. A review of the medical director statement, provided by the Administrator, dated 12/11/2024, indicated the physician designated as the Medical Director was not the physician named as the Medical Director in the Medical Director Retainer Agreement, as the agreement was between the limited liability company providing a Medical Director and the facility and not with the individual provider. A review of the admission Assessment Communication, dated 05/17/2024 indicated Resident #1 was a hospital referral for possible long-term care (LTC) placement. Nursing information included Resident #1 required maximum assistance of two for rolling over in bed and moving from a laying to sitting position; required assistance with oral hygiene; maximum assistance toileting and perineal care, incontinent at times; mechanical lift for transfers and no restrictions on ambulation; cognitive status was alert and oriented; had a sacral decubitus ulcer; required a wheelchair; had a mood disorder and was receiving medication. A review of the Level I Preadmission Screen, also known as the DMS-787, with a completion date of 05/17/2024, indicated Resident #1 had a diagnosable major mental disorder indicated as panic or other severe anxiety disorder. A review of the Report of Disability Examination, also known as the DCO-0107S, with a signed date of 06/07/2024, indicated Resident #1 had a medical history that included severe morbid obesity, unspecified mood disorder, and chronic pain. Further review indicated Resident #1 had pain with movement classified as 10 on a scale of 1-10, 10 being the worst Medications listed included a serotonin reuptake inhibitor (antidepressant), a selective serotonin reuptake inhibitor (antidepressant), two blood pressure medications, a muscle relaxant, oral opioid (pain reliever), opioid analgesic patch, and three medications for elevated blood sugar. A check box response to the question, Has the patient followed treatment recommendations? was No. Comments indicated Multiple instances - refusal of Care. A review of the Medical Review Team (MRT) Social Report for Adults, also known as the DCO-0108S, with an application date of 03/19/2024 indicated Resident #1 ' s illness, injury, or conditions limiting ability to work or perform household activities included chronic pain described as constant pain with treatment that included wound care and pain medication. MD #1 and APRN #11 were listed as physicians seen by Resident #1 in the past year, and Resident #1 was hospitalized from [DATE] to 05/20/2024. A review of the Hospital Medical Discharge Summary, with a discharge date d of 05/20/2024, indicated Resident #1 had morbid obesity, was chronically bedbound related to deconditioning and not moving much, surgically implanted catheter, poor social living scenario, and chronic pain. A note dated 5/7/24 indicated resident continued to refuse physical therapy and turning and there was a high concern for continued decline with refusal to comply. A note on 5/8/24-5/19/24 indicated Resident #1 had not been compliant with any activity. Instructions included wound care to perineal and gluteal area. A review of the admission Agreement, signed by Resident #1 on 05/20/2024, indicated due diligence would be used by the facility to obtain the services of a physician when the resident ' s condition required such medical attention and would attempt to obtain the services of another physician if resident ' s personal physician was unavailable. Further, the facility would obtain, at the discretion of the physician or the facility, ancillary services, such as physician or ambulance services, deemed necessary for the health and welfare of the resident. A review of the Acknowledgment of Receipt of Advanced Directive Information-Resident, signed by Resident #1 on 05/20/2024 indicated Resident #1 chose to have continued administration of all possible medical treatment, as ordered by the physician, to prolong life to the greatest extent possible without regard to condition, chance of recovery, or expense. A review of the Capacity Verification, dated 05/20/2024 did not indicate a capacity (an individual ' s mental or physical ability) and was signed by the resident and an unidentified facility representative. A review of the admission Record, indicated the facility admitted Resident #1 on 05/20/2024 with diagnoses that included pressure ulcer of the sacral region, type 2 diabetes mellitus, malaise (an indefinite feeling of debility or lack of health often indicative of or accompanying the onset of an illness), morbid obesity, mood affective disorder, and chronic pain. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2024, indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #1 ' s mood interview, sections C through I were not completed related to negative symptom responses to the first two questions, and a total mood severity score indicated 00. Resident #1 had impairment of bilateral lower extremities, used a wheelchair for mobility, was dependent on staff for toileting and dressing; required substantial/maximal assistance with oral hygiene and personal hygiene; required setup/cleanup assistance with eating; and refused shower/bathing self. Resident #1 was dependent on staff to roll left and right, refused to sit up, refused to transfer to a chair, refused to use wheelchair, and refused to transfer for a tub or shower. Resident #1 had an indwelling urinary catheter and was continent of bowel. Active diagnoses were identified as diabetes mellitus, morbid obesity, mood affective disorder, and chronic pain described as occurring frequently and not interfering with daily activities. Prognoses of life expectancy of less than 6 months indicated no. Skin condition indicated a stage IV (most severe stage, significant tissue loss, damage extends through all layers of skin exposing muscle, tendon/bone, high risk of infection) pressure ulcer was present on admission and Resident #1 was at risk of developing pressure ulcers. Resident #1 medications received included an antidepressant and opioid. Resident #1 had a goal to remain in the facility and not return to the community. Care areas identified included activities of daily living (ADL) functional/rehabilitation potential; urinary incontinence and indwelling catheter; falls; nutritional status; dehydration/fluid maintenance; pressure ulcer; psychotropic drug use; and pain. A review of the significant change MDS, with an ARD of 08/23/2024, indicated changes from the admission MDS included the following: Resident #1 exhibited behavior described as worsening for rejection of care occurring daily. Resident #1 refused shower/bathe, dressing, rolling left or right in bed, and any transferring; required supervision with oral hygiene. Resident #1 was always incontinent of bowel. Pain was described as effecting sleep, interfering with therapy activities, and day to day activities almost constantly, and rated as a 10 on a scale of 0-10 with 10 being the worst pain imagined. Resident #1 did not receive scheduled pain medication. Medications included an antibiotic. Care areas identified included cognitive loss/dementia and behavioral symptoms. A review of Resident #1 ' s care plan with a resolved date of 10/22/2024, indicated Resident #1 ' s code status as full code, indicating wanting cardiopulmonary resuscitation. Interventions included providing the opportunity for resident to discuss feelings and ask questions related to end of life decisions and review code status; and a change in code status to do not resuscitate (DNR) with interventions that included checking for resident signature on consent form; verify physician order; review code status with resident annually and as needed; acknowledge right to revoke DNR status; and a. Resident #1 was placed on contact isolation on 08/21/2024 due to wound and wound myiasis (a parasitic infection that occurs when fly larvae [maggots] burrow into the skin of a live animal and feed on its tissue) related to refusal of wound care. Interventions included pest control with a fly light trap, treatment of myiasis as ordered by physician, and wound care as ordered by physician resident refused; and b. Resident #1 had an ADL self-care performance deficit related to chronic pain, refusing ADL care, turning, wound treatment, incontinent care and catheter care. Interventions included, resident was totally dependent on 2 staff for bathing/showering, mobility, dressing, toileting, transferring with mechanical lift, was bedfast, used bedrails for independence with turning and positioning, dependent on 1 staff for personal and oral hygiene, required skin inspection and was to be observed for redness, open areas, scratches, cuts, bruises and report changes to nurse; and c. Resident #1 exhibited behaviors that included rejection of care with interventions that included providing staff training on behaviors, notification to the physician of changes in behavior, and administering and monitoring effectiveness of medications; and d. Resident #1 was resistant to care evidenced by refusal of care, to be repositioned, refused skin assessments and treatments. Interventions included allowing Resident #1 to make decisions about treatment to provide sense of control, educate on outcome of non-compliance, encourage participation during care activities, clearly explain care activities prior to contact, negotiate ADL care times to allow resident participation, change approach if Resident #1 becomes agitated and notify charge nurse of situation; and e. Resident #1 had no impaired cognitive function/dementia based on BIMS score of 15, would remain oriented to person, place, situation and time, and would maintain current level of decision-making ability. Interventions included engaging in pleasant topic conversation prior to initiating care; and f. Resident #1 was receiving opioid pain medication therapy with interventions that included administering medication as ordered by physician and monitoring side effects of the medication; and g. Resident #1 had antidepressant medications related to affective mood disorder with interventions that included administering medications as ordered and monitoring side effects and effectiveness every shift. A black box medication warning indicated observation and monitoring for suicidality, unusual changes in behaviors, and clinical worsening; and h. Resident #1 had a mood problem related to mood affective disorder with interventions that included behavioral health consults, monitoring for irritability, mood changes, and agitation; and i. Resident #1 had chronic pain with interventions to anticipate need for pain relief, evaluate effectiveness of interventions, monitor for non-verbal pain, mood/behavior changes and review impact on functional ability and impact on cognition; and j. Resident #1 had a pressure ulcer to coccyx/sacrum and potential for development of pressure ulcers and refused treatment that included wound care, turning and repositioning, wound assessments per protocol and full skin assessments. Goals included healing of the pressure ulcer, remain free of infection, and maintain or develop clean intact skin. Interventions included administration of medication and treatments as ordered, educating resident on causes of breakdown and frequent positioning; and k. Resident #1 had an indwelling catheter. Interventions included changing catheter as ordered, resident refused catheter changes and care; monitor and report signs and symptoms of urinary tract infection, that included foul smelling urine, altered mental status, change in behavior. Resident #1 refused a follow up urology appointment. A review of Order Summary Report, with active orders as of 10/01/024, indicated Resident #1 had an order to admit to LTC (long term care); a pain assessment every shift with a start date of 05/20/2024; treatment of coccyx wound daily and as needed with a start date of 05/23/2024; an antidepressant daily for mood affective disorder, with a start date of 05/21/2024; oral opioid pain medication every 4 hours as needed for severe pain with a start date of 07/26/2024; an opioid pain medication every 4 hours as needed for pain; an antidepressant at bedtime for mood affective disorder, with a start date of 05/20/2024. A review of the Nsg [Nursing] Admit/Readmit/Quarterly Assessment, dated 05/20/2024 indicated a skin assessment integrity comment, Stage four noted to resident ' s coccyx with wet to dry treatment in place. Sensory Perception indicated Resident #1 ' s ability to meaningfully respond to pressure related discomfort was slightly limited, was able to respond to verbal commands, cannot always communicate discomfort or the need to be turned OR has some sensory impairment limiting the ability to feel pain or discomfort in 1 or 2 extremities. Resident was bedfast and had very limited mobility and was unable to make changes independently and was at moderate risk for dehydration. Cognition did not identify current psychiatric diagnoses or behavioral problem. Neurological assessment indicated resident was alert and oriented to person, place, time, and situation and was verbally appropriate. Resident #1 indicated pain occurred frequently in the last 5 days affecting sleep and day to day activities, and current pain was severe and rated it a 10 on scale of 0-10. No behaviors were documented. A review of the Nsg Admit Skin Audit, dated 05/20/2024 indicated Resident #1 had bruising to right and left antecubital areas related to IV sticks, dry skin, a stage 4 wound to coccyx (Stage 4 indicates full thickness tissue loss with exposed bone, tendon, or muscle.). A review of the Nsg Functional Abilities and Goals-Admission, with an effective date of 05/20/2024 indicated Resident #1 had bilateral lower extremity impairment, required a wheelchair for mobility and was dependent for manual wheelchair use, required substantial/maximal assistance with personal hygiene, was dependent for toileting, dressing, rolling left and right, sitting to lying, lying to sitting, transferring from chair to bed and bed to chair, refused to stand from seated position, and refused shower/bathing. On 05/21/2024 Resident #1 was seen by APRN #11 for hospital follow up. Reviewed problems included type 2 diabetes mellitus (DM), morbid obesity, anxiety, panic disorder with agoraphobia, depressive disorder, chronic pain, pressure injury of buttock, open wound of buttock, and pain in right hip joint. History of present illness (HPI) included urinary catheter surgically implanted, denied depression. Physical examination revealed morbid obesity and limited ambulation. Psychiatric mental status was normal mood and lethargic; was oriented to time, place, and person. Musculoskeletal revealed limited range of motion (ROM) and right hip pain. Assessment plan included: DM, chronic pain continue opioid; depressive disorder continue antidepressant. Open wound of buttock was not assessed. On 05/23/2024, Resident #1 was seen by APRN #4 for open wound assessment. Reviewed problems included unstageable pressure injury, open wound of buttock with complication, pain right hip joint. HPI included reported stage 4 pressure ulcer to coccyx, present on arrival to facility. Visit was first wound care visit. APRN #4 indicated they were unable to access Stage 4 pressure ulcer to coccyx and other unknown wounds as patient currently refuses to turn for full body skin assessment. Resident reported due to pain, would turn once per day when goes to the bathroom. Review of system (ROS) indicated unable to assess wounds. Orders given for wound care, if unable to perform tele visit at time of turning. On 05/26/2024, Resident #1 was seen via telemedicine by APRN #22 for report of change in condition, HPI indicated expired opioid order, pressure ulcer required dressing change, and pain at wound site during wound care. ROS included mental status as active and alert. The Assessment/Plan was chronic pain with a change in opioid medication. Review of a Progress Note, dated 05/26/2024, indicated Resident #1 refused to be cleaned and refused wound care more than one time daily, and stated would allow nurse to provide care at a later time. At 10:00 PM staff notified LPN #32 Resident #1 did not want care provided. A review of Nsg Weekly Skin Audit, dated 05/27/2024, indicated skin was intact, no wounds with narrative note that stated, Resident refuses any and all skin audits. Review of a Progress Note, dated 05/29/2024 at 5:26 PM indicated an odor in Resident #1 ' s room suspected coming from wound. The former Assistant Director of Nursing (F-ADON) entered Resident #1 ' s room and was aware of incontinent bowel, care was attempted and resident refused to allow staff to complete incontinent care and wound care. Feces were in wound dressing, resident was advised of risk of not allowing care, resident reported that (pronoun) did not care about wound becoming infected and would rather lay in feces than to be moved. On 05/29/2024, Resident #1 was seen by Primary Care Physician (PCP) as new admission. The problem list included morbid obesity, heart failure, DM type 2, hypertension, malaise, mood affective disorder, and chronic pain. HPI included incontinent of bladder, continent of bowel, mood stable without behavioral problems, and was compliant with medications and care. Functional assessment indicated one person assist for ADLs and transfers. ROS included no anxiety or depression. Assessment/Plan included depressive disorder - continue antidepressant, impaired ADLs - assist and monitor, degenerative joint disease (DJD) - continue pain control with opioid, assist with ADLs and monitor, moderate to severe frailty syndrome - bedbound, assist with ADLs and monitor, sarcopenia (muscle loss) - assist with ADLs and monitor, poly-pharmacy - educate on medication interaction/adverse effects and monitor for adverse effects. Review of a Progress Note, dated 05/30/2024 at 4:43 PM indicated Resident #1 continued to refuse incontinent care and wound care, and stated, I would rather lay here and die, than to let you move me. A review of Medication Administration Record (MAR), for May 2024 (05/20/52024 through 05/31/2024) indicated Resident #1 had pain documented 9 times above a level of 0, with medication administered. A review of Treatment Administration Record (TAR), for May 2024 indicated Resident #1 refused to allow wound care 05/23/2024, 05/24/2024, 05/26/2024, 05/27/2024, 05/30/2024, and 05/31/2024. No as needed (PRN) wound care was documented. A review of Nsg Weekly Skin Audit, dated 06/03/2024, narrative note indicated Resident refuses all cares, an (sic) treatments. On 06/03/2024 Resident #1 was seen by APRN #11 for follow-up on chronic pain. HPI indicated follow up for sacral ulcer, refusing bed and incontinence changes, wound care and repositioning related to pain. ROS revealed psychiatric mental status was active and alert and normal mood, oriented to time, place, and person. Assessment/Plan indicated chronic pain, continue oral opioid and PCP ordered opioid transdermal patch. On 06/03/2024 Resident #1 was seen by PCP for acute visit for toenail care. ROS and Exam indicated skin had no rash, itching or skin changes and was warm dry (W/D) and intact. Assessment and plan included pressure ulcer on coccyx - resident does not want to be rolled due to pain. Continue facility wound care and Monitor for infection . DJD indicated staff reporting refusal of care due to pain; resident reports pain in hips, back and bilateral knees, educated on taking medication to stay ahead of pain, resident reported still has pain 40 minutes after taking medication; educated on importance of care compliance; opioid patch ordered for pain. Review of a Progress Note, dated 06/02/2024 at 3:20 PM and 11:29 PM indicated Resident #1 refused incontinent and wound care. On 06/03/2024 at 2:22 PM, Resident #1 refused 3 attempts at shower to be given. On 06/04/2024 at 4:25 AM, indicated Resident #1 rejected care. At 3:27 PM, Resident #1 continued to reject care related to incontinence and positioning. On 06/05/2024 at 12:41 AM, Resident #1 rejected care, to be changed, and was laying in stool. On 06/05/2024 at 7:39 PM, Resident #1 refused shower. On 06/06/2024 at 11:37 AM, Resident #1 continued to refuse care, showers, incontinent care and wound treatment. On 06/06/2024 at 7:37 PM, Resident #1 continued to refuse care, laying in feces. On 06/07/2024 at 6:39 PM Resident #1 continued to refuse incontinent care and personal care, CNA offered bed bath resident became angry and threw dinner tray stating, I hate this (explicit word) place and the people here, when CNA stated they would get assistance to provide bath. Resident #1 refused positioning, incontinent care, or other ADL assistance. On 06/08/2024 at 6:03 PM Resident #1 allowed partial bed bath and refused to be turned off back to allow for wound assessment or care. On 06/12/2024 at 09:15 AM, Resident #1 refused 3 attempts to give shower. On 06/15/2024 at 3:56 PM, Resident #1 had no shower given. On 06/16/2024 at 01:09 AM, Resident #1 continued to refuse care. On 06/16/2024 at 3:33 PM, Resident #1 refused laxative and stated has bowel movement (BM) once a week and intentionally does not eat much so does not produce much waste. On 06/17/2024 at 02:06 AM, Resident #1 continued to refuse care. On 06/17/2024 at 10:23 AM, Resident #1 continued to refuse care, was currently lying in feces, refuses to allow staff to clean, and stated what is the point anyway. On 06/17/2024 at 1:14 PM, F-ADON spoke with Resident #1 regarding continued refusal of care. Resident #1 became upset and asked to be left alone. A review of a PCP note indicated on 06/17/2024, Resident #1 was seen for an acute visit for toenail care. HPI indicated mood stable with no behavioral problems and was compliant with care. Exam included a psychiatric evaluation that described Resident #1 as calm, cooperative, alert and oriented (AO) x 3 (indicating person, place, situation), and followed commands. The Assessment/Plan indicated the facility was unable to access the wound due to refusal because the resident did not want to be rolled. Staff reported refusal of all care. Options were provided if the resident continued to refuse care, which included comfort care and transfer to another facility. Continue facility wound care. The opioid patch dose was increased and an oral opioid medication was added. Review of a Progress Note, dated 06/19/2024 at 11:50 AM, indicated Resident #1 continued to refuse perineal care and repositioning. On 06/19/2024 at 12:41 PM, Resident #1 refused 3 attempts to provide shower. On 06/20/2024 at 04:01 AM, Resident #1 continued to refuse perineal and other care. On 06/21/2024 at 12:47 AM, [TRUNCATED]

F686 J Based on interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure care and services were provided to prevent new pressure ulcer development and promote healing of existing pressure ulcers including admission and ongoing wound care assessments, appropriate and alternative interventions, and resident understanding of consequences of refusal; specifically no surgical interventions under anesthesia were offered, no intravenous pain medication was offered, no anti-anxiety medication was offered, the Medical Director was not made aware of or involved in care, interventions, or resident education; the Administrator did not participate in resident communications or bedside care plan meetings, no one-on-one in person counseling was sought out, behavioral history or symptoms were not used in interventions, no attempt at a competency evaluation for mental instability was made for 1 (Resident #1) of 8 residents reviewed for wound care services to treat, heal, and prevent pressure injuries. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 05/23/2024, when Resident #1 began refusing wound and incontinence care due to pain, and the facility did not provide effective interventions to alleviate the symptoms. The Administrator and Nurse Consultants were notified of the IJ on 11/27/2024 at 9:56 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 12/09/2024 at 9:13 PM. The IJ was removed on 12/10/2024 at 5:30 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Findings include: On 11/25/2024 at 12:25 PM, the Administrator stated the facility did not have a policy for wound care. The Medical Director was an independent contractor, and the facility did not have a job description for the Medical Director. A review of the facility ' s undated policy titled Resident Rights, indicated, residents had a right to; receive information in a language the resident understands, receive adequate and appropriate medical care, nursing care, protective supportive services, and personal cleanliness in a safe and clean environment, be advised by a physician or appropriate medical staff of alternative courses of care and treatments and their consequences. A review of a facility policy titled, Infection Prevention and Control Program, dated 11/22/2017, indicated the medical director was responsible for overseeing the management of an outbreak. Review of the job description for Administrator revealed the position was to manage and direct the day-to-day operations of the facility, and to learn and implement state and federal regulations. Responsibilities of the position included resident safety, reviews complaints and grievances, maintain written policies and procedures, assist department head with eliminating and correcting problem areas. Review of the job description for the Director of Nursing (DON) revealed the position responsibilities included assuring resident safety, day to day operation and management of the nursing department and working closely with the Administrator regarding coordination of resident services and functions of the nursing department. Review of the job description for the Assistant Director of Nursing (ADON) revealed the position responsibilities included assuring resident safety and day-to-day operations of the nursing department, meeting with team members regarding coordination of resident services. Review of the job description for the Charge Nurse revealed the position responsibilities included assuring resident safety; perform nursing services for the comfort and well-being of the residents; check residents daily to determine status, assess, record, and report changes in residents ' condition to supervisor and attending physician; complete treatment orders; complete skin audits; identify nursing problems and respond and initiate immediate action; communicate problems to DON; provide emergency care to residents; assess resident needs and provide input for care. Review of the job description for the Treatment Nurse revealed the position responsibilities included assuring resident safety; completing treatment orders; assist and complete skin audits; safety of residents; identify safety hazards and special nursing problems and initiate immediate action; communicate problems and needs in nursing department; assess and report changes in resident condition and take follow-up action as necessary; provide emergency care to residents; assess resident ' s needs and provide input. Review of the job description for Certified Nursing Assistant (CNA) revealed the position responsibilities included assuring resident safety; identify resident problems and concerns and report them immediately to charge nurse or a licensed nurse; report changes in residents ' condition. A review of a document titled Medical Director Retainer Agreement with an effective date 01/01/2018 stated, the Medical Director ' s services included working with the facility in identifying, evaluating, and resolving medical and clinical concerns and issues affecting resident care, medical care, or quality of life; or related to the provision of services by physicians and other licensed health care practitioners. A review of the admission Record, indicated the facility admitted Resident #1 on 05/20/2024 with diagnoses that included chronic pain, unspecified mood disorder, morbid obesity, malaise (general sense of unwell, often with fatigue, diffuse pain, or lack of interest in activities), and congestive heart failure. On 05/31/2024 a diagnosis stated, procedure and treatment not carried out because of patient ' s decision for unspecified reasons. On 06/28/2024 a diagnosis stated, pressure ulcer of sacral region, unstageable. On 08/22/2024 a diagnosis stated, wound myiasis (a parasitic infection where fly larvae [maggots] infest and feed on living tissue in wounds). A review of the Nursing Admit Skin Audit dated 05/20/2024 at 10:11 PM, indicated a stage 4 pressure injury to the coccyx with a wet to dry dressing in place (Stage 4 pressure injuries involve full thickness tissue loss with exposed bone, tendon, or muscle.). A review of an Advanced Practice Registered Nurse (APRN) #4 note, dated 05/23/2024 at 9:55 AM, revealed Resident #1 had a medical history of anxiety, morbid obesity, panic disorder with agoraphobia (a fear of places and situations that might cause panic, helplessness, or embarrassment), depressive disorder, insomnia, chronic pain, pressure injury of the buttocks, open wound of the buttocks with complications, pain in the right hip joint. A review of the Level I Preadmission Screen, also known as the DMS-787, with a completion date of 05/17/2024, revealed Resident #1 had a diagnosable major mental disorder indicated as panic or other severe anxiety disorder. A review of Resident #1 ' s hospital records dated 05/20/204 revealed, Resident #1 became very angry when wound care was attempted, screamed out in pain, and yelled Everybody leave the room right now! I am tired of everyone hurting me! When staff attempted to clean stool off, Resident #1 responded I don ' t care, just leave me alone! Hospital records also indicated chronic narcotic use for pain related to multiple joint arthritis especially of the hips and knees, bed bound mobility since November 2023, a risk for falls related to behavior with interventions including appropriate de-escalation techniques, diversion activities, and a sitter, a coping problem possibly related to grieving, lack or control, altered self-image, depression, noncompliance, or impaired social functioning. A review of a hospital record, with a printed date of 05/20/2024, revealed social determinants of health included social isolation. Plan revealed treatment of chronic sacral decubitus ulcer. A review of the admission Agreement, signed by Resident #1 on 05/20/2024, revealed due diligence would be used by the facility to obtain the services of a physician when the resident ' s condition requires such medical attention and would attempt to obtain the services of another physician if resident ' s personal physician was unavailable. Further, the facility would obtain, at the discretion of the physician or the facility, ancillary services, such as physician or ambulance services, deemed necessary for the health and welfare of the resident. A review of the Acknowledgment of Receipt of Advanced Directive Information-Resident, signed by Resident #1 on 05/20/2024 indicated, Resident #1 chose to have continued administration of all possible medical treatment, as ordered by the physician, to prolong life to the greatest extent possible without regard to condition, chance of recovery, or expense. A review of the Capacity Verification, dated 05/20/2024 did not indicate a capacity (an individual ' s mental or physical ability) and was signed by the resident and an unidentified facility representative. The admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2024, revealed Resident #1 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #1 ' s mood interview was reported as no symptoms present for little interest or pleasure in doing things and feeling down, depressed, or hopeless. Resident #1 was reported to have no behavioral symptoms physical, verbal, or otherwise and no behaviors of refusal of care. A stage 4 pressure ulcer was identified that was present on admission and Resident #1 was at risk of developing pressure ulcers. Skin and ulcer treatments identified were pressure reducing device for the chair, pressure reducing device for the bed, and ulcer care. A review of Resident #1 ' s Care Plan, last modified on 10/25/2024, revealed Resident #1 became agitated and distressed when out of bed due to pain, self-directed activities like television programs, writing letters, balloon toss, Bible reading, inspirational music were initiated with activities to boost Resident #1 ' s self-esteem. The goals included making eye contact, making a verbal response, reaching for items, smiling, and engaging in activities. Resident #1 had a self-care deficit related to pain and refused wound care interventions, skin assessments, urinary catheter care, bowel incontinence care, and turning. Interventions included assistance of two staff members for bathing and turning, and staff was to inspect skin for redness, open areas, scratches, cuts, and bruises. The goal was for Resident #1 to maintain current level of care. Resident #1 was care planned for an antidepressant for mood disorder interventions included an antidepressant with a black box warning to caregivers for appropriate monitoring and close observation for clinical worsening, suicidality, or unusual changes in behavior. Resident #1 was only care planned for behavioral health interventions of medication and no counseling or therapy sessions. Resident #1 had a wound infestation (maggots) related to refusal of wound care. Resident #1 had contact isolation due to wound and wound myiasis (a parasitic infection that occurs when fly larvae [maggots] burrow into the skin of a live animal and feed on its tissue) related to refusal of wound care. Interventions included pest control with a fly light trap, treatment of myiasis as ordered by physician, and wound care as ordered by physician, resident refused. Resident #1 was on narcotic pain medication therapy. Interventions included narcotic pain administration as ordered and monitor for respiratory side effects; the goal was Resident #1 will be free from any discomfort or adverse side effects from pain medication. A review of Order Summary Report, with active diagnoses as of 10/01/024, revealed Resident #1 had a pain assessment every shift with a start date of 05/20/2024; treatment of coccyx wound daily and as needed with a start date of 05/23/2024; an antidepressant daily for mood affective disorder, with a start date of 05/21/2024; oral opioid pain medication every 4 hours as needed for severe pain with a start date of 07/26/2024; an opioid pain medication every 4 hours as needed for pain; an antidepressant at bedtime for mood affective disorder, with a start date of 05/20/2024. A review of the Nsg [Nursing] Admit/Readmit/Quarterly Assessment, dated 05/20/2024 revealed a skin assessment integrity comment, Stage four noted to resident ' s coccyx with wet to dry treatment in place. Sensory Perception indicated Resident #1 ' s ability to meaningfully respond to pressure related discomfort was slightly limited, was able to respond to verbal commands, cannot always communicate discomfort or the need to be turned OR has some sensory impairment limiting the ability to feel pain or discomfort in 1 or 2 extremities. Resident was bedfast and had very limited mobility and was unable to make changes independently and was at moderate risk for dehydration. Cognition did not identify current psychiatric diagnoses or behavioral problem. Neurological assessment indicated resident was alert and oriented to person, place, time, and situation and was verbally appropriate. Resident #1 indicated pain occurred frequently in the last 5 days effecting sleep and day to day activities, and current pain was severe and rated it a 10 on scale of 0-10. No behaviors were documented. A review of a Progress Note on 05/20/2024 at 4:42 PM, revealed Resident #1 was admitted via stretcher from the hospital. Resident #1 refused to allow staff to perform a skin assessment stating they only wanted to be changed once a day and would not allow staff to perform anything else. Former-Assistant Direct of Nursing (F-ADON) was made aware and after encouragement the resident allowed a limited viewing. On 05/22/2024 at 4:07 PM, there were multiple attempts to complete the admission skin audit were refused by Resident #1. The hospital reported at time of discharge Resident #1 had a stage 4 pressure ulcer to the coccyx and a Deep Tissue Injury (DTI) to the right calf. A review of a Progress Note dated 05/23/2024 at 11:22 AM revealed, the floor nurse and APRN #4 attempted wound assessments. Resident #1 refused care, stating they only get turned once a day because they can ' t turn more than once, and it would be after they had a bowel movement. APRN #4 reviewed hospital records and noted refusal of care history. No new or alternative interventions were offered to Resident #1 ' s refusal. A review of a Progress Note dated 05/23/2024 at 2:04 PM revealed, the F-ADON attempted multiple times with staff to provide wound care. It was stated Resident is own responsible party. No new or alternative interventions were offered to Resident #1 ' s refusal. A review of a Progress Note dated 05/26/2024 at 1:20 AM revealed, Resident #1 ' s chronic opioid pain medication was stopped, floor nurse reported no agitation or anxiety just refusal of care. A review of a Progress Note dated 05/26/2024 at 1:12 PM revealed, Resident #1 called nurse into the room to discuss a plan for staff care. Resident #1 stated while in the hospital a pain pill would be provided and 45 mins later, they would call the nurse to provide peri care and wound care at the same time. Resident #1 only wanted to turn once a day. Resident #1 was informed the chronic opioid pain pill had been stopped yesterday and there were no current orders, nurse stated they would contact the provider. A review of a progress note dated 05/26/2024 at 2:08 PM revealed, a new order had been placed for a replacement opioid pain medication, but not Resident #1 ' s chronic opioid pain medication. A review of a progress note, dated 05/26/2024 at 11:43 PM, revealed Resident #1 stated they did not allow day shift to provide wound care due to pain. Resident #1 suggested the nurse complete it after medication pass, but later stated they were going to bed. No alternative interventions were offered to Resident #1 ' s refusal. A review of a progress note, dated 05/28/2024 at 6:33 PM, revealed Resident #1 refused all wound care after medicated twice with replacement opioid pain medication stating it was still too painful. No alternative interventions were offered to Resident #1 ' s refusal. A review of a progress note, dated 05/29/2024 at 5:26 PM, revealed the charge nurse reported to management an odor in Resident #1 ' s room suspected causes was the Resident ' s wound. Resident #1 was medicated with replacement opioid pain medication prior, then staff attempted to perform incontinence care and wound care. Resident # 1 agreed but started to complain of pain while on their left side and requested to be left alone. Resident #1 was advised of feces still on their body and the wound and the risk of refusal could lead to infection and sepsis. Resident # 1 was advised they need to roll on the right side and stated, due to the pain they would rather lie in feces than be rolled. Resident #1 refused care without any alternative pain medication or anti-anxiety medication offered. Former-Director of Nursing (F-DON), Administrator, and APRN notified. It was stated Resident was their own responsible party. A review of a progress note, dated 05/30/2024 at 4:43 PM, revealed Resident #1 refused wound assessment, wound care, and incontinence care by nurse and APRN, cited as too painful to even move and stated, I would rather die, than to let you move me. Risk of infection and death explained and Resident #1 verbalized understanding. No alternative intervention, no anti-anxiety medication offered to Resident #1 ' s refusal. A review of a progress note, dated 06/02/2024 at 3:20 PM, revealed Resident #1 allowed staff to pull them up in the bed but screamed and said it hurt. Resident #1 continued to refuse incontinence and wound care, stating it ' s too painful. A review of a progress note, dated 06/03/2024 at 3:20 PM, revealed Social Services Director (SSD), F-DON, and APRN held a care plan meeting at Resident #1 ' s bedside. Resident #1 stated such unbearable pain with attempts to roll, F-DON advised the wound needed to be cleaned to help with infection. Resident #1 verbalized understanding but stated they couldn ' t handle the pain. Resident #1 stated replacement narcotic pain medication helped with soreness but didn ' t come close to touching the pain in their hips and knees when rolling. APRN discussed other possible medications and methods, Resident #1 stated they were open to trying something different. A review of Resident #1 ' s June Medication Administration Record (MAR) revealed a new order for a transdermal opioid pain patch was started on 06/04/2024 at 8:00 AM. A review of a progress note, dated 06/06/2024 at 11:37 AM, revealed Resident #1 continued to refuse all care including bathing, incontinence care, and wound care stated it was too difficult and painful to roll back and forth. Staff offered a mechanical lift; Resident #1 stated it was too painful as well. A review of a progress note, dated 06/07/2024 at 3:15 PM, revealed the SSD contacted the Regional Ombudsman to help facilitate care with Resident #1. SSD stated the facility was looking at issuing a 30-day discharge notice. A review of a progress note, dated 06/07/2024 at 6:39 PM, revealed Resident #1 continued to refuse all incontinence care and personal care related to pain management. Resident continued complaint of pain which interferes with activities of daily living (ADL ' s), personal care, and inability to turn for wound care. Resident #1 became angry with bedside nursing staff and threw the diner tray down. Resident #1 stated I hate this [expletive] place and the people here, [pronoun] hurts too much to turn, and Resident #1 stated they would need to be put out to have wound care performed. APRN aware of Resident #1 ' s continued refusal of care. Resident is own responsible party was documented. No alternative intervention offered, no alternative plan of care for surgical wound debridement under anesthesia suggested, no anti-anxiety medication offered, no escalation to Medical Director, or visit from the Administrator. A review of a progress note, dated 06/17/2024 at 10:23 AM, revealed Resident #1 was laying in feces and refused to allow staff to roll them and provide care. Resident #1 stated its too painful and what ' s the point anyway. No alternate pain medication or route was sought out, no anti-anxiety medication was offered, the Medical Director was not contacted, and the Administrator did not attempt to assist with the resident. A review of a progress note, dated 06/17/2024 at 1:14 PM, revealed Resident #1 continued to refuse care related to pain from osteoarthritis. Resident #1 reported increased pain since hospitalization in November, the new order for (Name Brand) opioid transdermal pain patch was not helping. Resident #1 reported none of the pain medications were helping the pain. Resident #1 was told if they continued to refuse care other housing options would be sought out. Resident #1 stated they liked the facility and did not wish to leave, then became upset, didn ' t want to finish the conversation, and asked to be left alone. A review of Primary Care Physician (PCP) ' s 06/17/2024 visit note revealed, Resident #1 ' s Mood was stable without behavioral problems noted antidepressant medication was continued with no change, the facility had not been able to assess the wound related to resident refusals, education was provided on wound care, options of comfort care measures, or transferring facilities were offered to Resident #1. No indication of intravenous (IV) pain medication, no anti-anxiety medication, no surgical consult for wound debridement under anesthesia or consult to the Medical Director was noted. Resident #1 reported to PCP the (Name Brand) opioid transdermal pain patch was not touching his pain. A review of a progress note, dated 06/17/2024 at 2:41 PM, revealed Resident #1 ' s replacement opioid pain medication was increased. A review of a progress note, dated 06/17/2024 at 2:42 PM, revealed Resident #1 ' s (Name Brand) opioid transdermal pain patch was increased. A review of a progress note, dated 06/18/2024 at 10:21 AM, revealed Resident #1 told the Regional Ombudsman they liked the facility and refused care related to chronic pain issues. Ombudsman indicated with continued refusal a new placement, or a discharge would happen. No alternative approach or intervention was indicated. A review of a progress note, dated 06/21/2024 at 00:47 AM, revealed Resident #1 continued to refuse care, and when asked to rate their pain, indicated it was fine and not the problem the nurse should be concerned about. No other problem was identified by the resident, no further investigation was done by staff to find out, no counselor was consulted, and the medical director was not notified. A review of a progress note, dated 06/21/2024 at 12:54 PM, revealed the nurse offered Resident #1 an unscheduled pain pill to premedicate for wound care. Resident #1 responded by lowering their eyes and voice and stated, I ' m perfectly fine right now. Before the nurse could get a response out Resident #1 with eyes closed and head down, held their hand up and repeated, I ' m perfectly fine right now. A review of a progress note, dated 06/21/2024 at 3:27 PM, revealed Resident #1 ' s room had a smell indicating they had a bowel movement. Resident #1 refused attempted to remove the soiled brief, assess their skin, change them, or provide pain medication. Resident #1 would dismiss staff from room when something disagreeable is said. A review of a progress note, dated 06/22/2024 at 10:48 AM, revealed a foul odor was observed in Resident #1 ' s room and the sitting area outside the room. The nurse attempted to provide an extra pain medication, and to attempt wound care. Resident #1 closed their eyes, held up their hand, and stated, Why would you think we are doing it this afternoon?! I ' ve told you people until I ' m blue in the face, I will have to be unconscious for that! What does it take to get through?! Nurse educated Resident #1 on infection risk and sepsis from sitting in stool. Resident #1 responded, I know, [Nurse Name], I know. And I ' m not dealing with the pain, I ' ve already told you. The Medical Director was not made aware of the situation or the Resident #1 ' s request, the Administrator did not engage in any communication with the resident, and no surgical consult was attempted for wound debridement under anesthesia, no anti-anxiety medication was suggested. A review of a progress note dated 06/23/2024 at 1:11 PM revealed, Resident #1 had a bowel movement, was sitting in it, and refused care from staff. The nurse reported Resident #1 Shuts down when staff attempt to provide care. Resident closes eyes as if to ignore us and would dismiss staff from room when they disagreed or became frustrated. The Medical Director was not made aware of the situation or the Resident #1 ' s request, the Administrator did not engage in any communication with the resident, and no surgical consult was attempted for wound debridement under anesthesia, no anti-anxiety medication was suggested. A review of PCP ' s 06/26/2024 at 2:22 PM visit note revealed Resident #1 antidepressant medication was continued with no change, the facility had not been able to assess the wound related to resident refusals, education was provided on wound care, options of comfort care measures, or transferring facilities were offered to Resident #1. Resident #1 was indicated to have degenerative joint disease in multiple sites and refusing to turn for incontinence care or wound care related to pain, plan was continued replacement opioid pain medication as ordered. A depression assessment tool was used to assess Resident #1 for depression results were as follows; Resident #1 indicated feeling little interest or pleasure in doing things several days a week, feeling down, depressed or hopeless several days a week, feeling tired or having little energy several days a week, poor appetite or overeating several days a week, feeling bad about yourself or that you are failure or have let down your family several days a week, trouble concentrating on things, such as reading the newspaper or watching television several days a week, moving or speaking so slowly that other people could have noticed or so fidgety or restless that you have been moving a lot more, several days a week. Resident #1 indicated several days a week these problems made it difficult to do work, take care of things at home, or get along with other people. Resident #1 responded not at all to thoughts that you would be better off dead, or thoughts of hurting yourself in some way. The depression score was 9. Results were changed from Resident #1 ' s MDS admission assessment 30 days ago which had a 0 depression score identified. A review of a document titled (Medical Group Clinic), Patient consent for Care Management Services signed and dated by Resident #1 on 05/20/2024 indicated, Resident #1 signature agreed to services by the facility employed medical group which included consulting with relevant specialist about your health care . (Medical Group Clinic) will continue to be your primary care provider and will coordinate your care with other providers. A review of a progress note dated 06/26/2024 at 3:15 PM revealed, nurse advised Resident #1 their Primary Care Physician (PCP) was in the facility and wanted complete a wound assessment and send the resident to the emergency room (ER) for evaluation and treatment. Resident #1 was sitting in stool complained of a stomachache, refused care from staff, refused wound assessment from the PCP, and refused transfer to the ER. A review of the Order Summary Report, of discontinued orders, with an order date of 06/26/2024, revealed a psych referral, for 1 day, one time only for refusing care. The end date was 06/27/2024, the order status was completed. No follow through of this order. Resident #1 did not see anyone until second order was placed by APRN #11 on 07/07/2024. A review of a progress note, dated 06/27/2024 at 8:10 AM, revealed PCP discontinued Resident #1 ' s (Name Brand) opioid transdermal pain patch per the resident ' s request and ordered a consult to pain management. A review of the document Informed Consent to Refuse Treatment and/or Services dated 06/26/2024 at 2:53 PM indicated, the facility had offered Resident #1 daily wound care to the coccyx, repositioning, incontinence care, bathing, skin and wounds assessments, body audits, bariatric bed, specialty mattress, and a trapeze bar. The treatments and services were recommended for Resident #1 health and well-being and benefits included wound healing, achieving/maintaining good skin integrity, preventing/decreasing chances of pneumonia, deep view thrombosis, more wounds, infection, and possible death. Risk that might be reasonably expected as a result of refusing treatment and services included worsening of wound with new wounds, pneumonia, deep vein thrombosis, infection, sepsis, and even death could occur. The document is signed by Resident #1, witnessed by the F-ADON, and signed by the PCP. The Medical Director was not aware and did not sign, the Administrator did not sign, and no noted conversation was had regarding the resident ' s new depression symptoms, no surgical consult was attempted for wound debridement under anesthesia, no anti-anxiety medication was suggested. A review of Resident #1 ' s admission Record from 05/20/2024 indicated 06/26/2024 was Resident #1 ' s 57th Birthday. No notation was made, no notes from the Activity Director or SSD, no indication the facility noticed. A review of a progress note, dated 06/28/24 at 3:24 AM, revealed Resident #1 had the (Name Brand) narcotic transdermal pain patch discontinued because they wanted to look at other means of pain control. Resident continued to take all medications and was tolerating well. A review of a progress note dated 06/29/2024 at 7:55 AM, stated, Advised nurse to try to determine reason for rejection of care. Determine if changes need to be made for those that are providing care such as have male aides working with the resident during care. Modify the plan of care. No indication of any findings or modified interventions noted, no suggestions for anti-anxiety medication, no counseling suggested, no contact to the Medical Director, and no visit from the administrator was made. A review of a (Medical Group) note, dated 07/03/2024 at 12:52 PM, revealed Resident #1 was seen by APRN #11, findings included a history of obesity (02/19/2024), anxiety (03/25/2024), panic disorder with agoraphobia (a fear of places and situations that might cause panic, helplessness, or embarrassment) (02/19/2024), depressive disorder (02/19/2024), insomnia (05/21/2024), chronic pain (02/16/2024), pressure injury of the buttock (02/28/2024), unstageable pressure injury (05/23/2024), muscle weakness (02/19/2024), open wound of the buttocks with complications (03/29/2024) pain in the right hip joint (03/21/2024). Resident #1 refused to allow staff to turn them, had a wound and refuses wound APRN to assess related to pain and the pain medication had been changed. There[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a newly admitted resident, who continued to refuse activity of daily living (ADL) care and assistance, and assessment and treatment for pressure wounds, and all available remedies were provided to ensure the resident's mental and psychosocial health did not continue to deteriorate for 1 (Resident #1) of 8 residents reviewed for mental and psychosocial health, as evidenced by the failure to ensure a newly admitted resident's wounds were assessed, monitored, and treated to prevent death. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.40 (Behavioral Health) at a scope and severity of J. The IJ began on 06/03/2024, when Resident #1 began refusing wound care, and the facility failed to provide effective interventions to alleviate declines in the resident's mental and psychosocial health that would potentially allow staff to provide needed care. The Administrator and Nurse Consultants were notified of the IJ on 11/27/2024 at 9:56 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 12/09/2024 at 9:13 PM. The IJ was removed on 12/10/2024 at 5:30 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Findings include: A review of a facility policy titled, Resident Rights, revised on 11/22/2016, indicated facility staff were trained on resident rights and involved in the implementation of the policy and procedure. Residents have a right to be informed of their health, medical condition and treatment, participate in or refuse treatment, be advised of alternative care and treatments and their consequences. Residents have the right to 15. Receive adequate and appropriate medical care, nursing care, protective and support services, and personal cleanliness in a safe and clean environment. 22. Be transferred or discharged only for medical reasons, for your welfare or that of others . 33. Be free from physical abuse and neglect . On 11/25/2024 at 12:25 PM, the Administrator stated the facility did not have a policy for wound care, the Medical Director was an independent contractor, and the facility does not have a job description for the Medical Director. Review of the job description for Administrator described the position was to manage and direct the day-to-day operations of the facility, learn and implement state and federal regulations. Responsibilities of the position included resident safety, reviews complaints and grievances, maintain written policies and procedures, assist department head with eliminating and correcting problem areas. Review of the job description for the Director of Nursing (DON) described the position responsibilities included assuring resident safety, day to day operation and management of the nursing department and working closely with the Administrator regarding coordination of resident services and functions of the nursing department. Review of the job description for the Assistant Director of Nursing (ADON) described the position responsibilities included assuring resident safety and day-to-day operations of the nursing department, meeting with team members regarding coordination of resident services. Review of the job description for the Charge Nurse described the position responsibilities included assuring resident safety; perform nursing services for the comfort and well-being of the residents; check residents daily to determine status, assess, record, and report changes in residents' condition to supervisor and attending physician; complete treatment orders; complete skin audits; identify nursing problems and respond and initiate immediate action; communicate problems to DON; provide emergency care to residents; assess resident needs and provide input for care. Review of the job description for the Treatment Nurse described the position responsibilities included assuring resident safety; completing treatment orders; assist and complete skin audits; safety of residents; identify safety hazards and special nursing problems and initiate immediate action; communicate problems and needs in nursing department; assess and report changes in resident condition and take follow-up action as necessary; provide emergency care to residents; assess resident's needs and provide input. Review of the job description for Certified Nursing Assistant (CNA) described the position responsibilities included assuring resident safety; identify resident problems and concerns and report them immediately to charge nurse or a licensed nurse; report changes in residents' condition. A review of the Medical Director Retainer Agreement with an effective date 01/01/2018 described, the duties of the Medical Director included guidance and oversite in the development and implementation of resident care policies that reflect current standards of practice; responsible for coordination of medical care in the facility; identifying, evaluating, and resolving medical and clinical concerns and issues affecting resident care, medical care or quality of life or were related to the provision of services by physicians and other licensed health care practitioners. Medical care through medical doctors, Advanced Practice Registered Nurse (APRN)'s, and telehealth services provided by the contracted provider limited liability company. A review of the medical director statement, provided by the Administrator, dated 12/11/2024, described the physician designated as the Medical Director, was not the physician named as the Medical Director in the Medical Director Retainer Agreement, as the agreement was between the limited liability company and the facility and not with the individual provider. A review of the admission Assessment Communication, dated 05/17/2024, revealed Resident #1 was a hospital referral for possible long-term care (LTC) placement. Nursing information included Resident #1 required maximum assistance of two for rolling over in bed and moving from a laying to sitting position; required assistance with oral hygiene; maximum assistance toileting and perineal care, and was incontinent at times; mechanical lift for transfers and no restrictions on ambulation; cognitive status was alert and oriented; had a sacral decubitus ulcer (pressure ulcers that appear on the skin over a bony region of the spine called the sacrum); required a wheelchair; had a mood disorder and was receiving medication. A review of the Level I Preadmission Screen, also known as the CMS-787, with a completion date of 05/17/2024, indicated Resident #1 had a diagnosable major mental disorder indicated as panic or other severe anxiety disorder. A review of the Report of Disability Examination, also known as the DCO-0107S, with a signed date of 06/07/2024, indicated a medical history that included severe morbid obesity, unspecified mood disorder, and chronic pain. Pain with movement classified as 10 on a scale of 1-10, 10 being the worst. Medications listed included a serotonin reuptake inhibitor (antidepressant), a selective serotonin reuptake inhibitor (antidepressant), two antihypertensives, a skeletal muscle relaxant, oral opioid, opioid analgesic patch, and three medications for elevated blood sugar. A check box response to the question, Has the patient followed treatment recommendations? was No. Comments indicated Multiple instances - refusal of Care. A review of the Medical Review Team (MRT) Social Report for Adults, also known as the DCO-0108S, with an application date of 03/19/2024 indicated Resident #1's illness, injury, or conditions limiting ability to work or perform household activities included, chronic pain described as constant pain with treatment that included wound care and pain medication. MD #1 and APRN #11 were listed as physicians seen by Resident #1 in the past year, and Resident #1 was hospitalized from [DATE] to 05/20/2024. A review of the Hospital Medical Discharge Summary, with a discharge date d of 05/20/2024, indicated Resident #1 had morbid obesity, was chronically bedbound related to deconditioning and not moving much, implanted catheter, poor social living scenario, and chronic pain. A note dated 5/7 indicated resident continued to refuse physical therapy and turning and there was a high concern for continued decline with refusal to comply. A note on 5/8-5/19 indicated Resident #1 had not been compliant with any activity. Instructions included wound care to peri and gluteal area. A review of the admission Agreement, signed by Resident #1 on 05/20/2024, indicated due diligence would be used by the facility to obtain the services of a physician when the resident's condition requires such medical attention and would attempt to obtain the services of another physician if resident's personal physician was unavailable. Further, the facility would obtain, at the discretion of the physician or the facility, ancillary services, such as physician or ambulance services, deemed necessary for the health and welfare of the resident. A review of the Acknowledgment of Receipt of Advanced Directive Information-Resident, signed by Resident #1 on 05/20/2024 indicated, Resident #1 chose to have continued administration of all possible medical treatment, as ordered by the physician, to prolong life to the greatest extent possible without regard to condition, chance of recovery, or expense. A review of the Capacity Verification, dated 05/20/2024 did not indicate a capacity and was signed by the resident and an unidentified facility representative. A review of the admission Record, indicated the facility admitted Resident #1 on 05/20/2024 with diagnoses that included pressure ulcer of the sacral region, Type 2 diabetes mellitus, malaise, morbid obesity, mood affective disorder, and chronic pain. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/27/2024, indicated Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #1's cognitive patterns for the BIMS score were based on the ability to repeat three words on first attempt; correct response to the current year; correct response to the current month, within five days; correctly identify the day of the week; and recall the words sock, blue, and bed with no cueing. Resident #1's mood interview, sections C through I were not completed related to negative symptom responses to the first two questions, and a total severity score indicated 00. Social isolation indicated Never. Section E - Behavior indicated Resident #1 had no physical, verbal, or other behavioral symptoms that included self-injury, throwing or smearing food or bodily wastes, and verbal/vocal symptoms. No refusal of care was indicated. Resident #1 indicated it was very important to take care of personal belongings, choose type of bathing, choose bedtime, have family or a close friend involved in discussions about care, have reading materials, listen to music, and go outside for fresh air. Resident #1 had impairment of bilateral lower extremities, used a wheelchair for mobility, was dependent on staff for toileting and dressing; required substantial/maximal assistance with oral hygiene and personal hygiene; required setup/cleanup assistance with eating; and refused shower/bathing self. Resident #1 was dependent on staff to roll left and right, refused to sit up, refused to transfer to a chair, refused to use wheelchair, and refused to transfer for a tub or shower. Resident #1 had an indwelling catheter and was continent of bowel. Active diagnoses were identified as diabetes mellitus, morbid obesity, mood affective disorder, and chronic pain described as occurring frequently and not interfering with daily activities. Prognoses of life expectancy of less than 6 months indicated no. Skin condition indicated a stage IV pressure ulcer (most severe stage, significant tissue loss, damage extends through all layers of skin exposing muscle, tendon/bone, high risk of infection) was present on admission and Resident #1 was at risk of developing pressure ulcers. Resident #1 medications received included an antidepressant and opioid. Resident #1 had a goal to remain in the facility and not return to the community. Care areas identified included activities of daily living (ADL) functional/rehabilitation potential; urinary incontinence and indwelling catheter; falls; nutritional status; dehydration/fluid maintenance; pressure ulcer; psychotropic drug use; and pain. A review of the significant change MDS, with an ARD of 08/23/2024, indicated changes from the admission MDS included the following: Resident #1 exhibited behavior described as worsening for rejection of care occurring daily. Resident #1 refused shower/bathe, dressing, rolling left or right in bed, and any transferring; required supervision with oral hygiene. Resident #1 was always incontinent of bowel. Pain was described as effecting sleep, interfering with therapy activities, and day to day activities almost constantly, and rated as a 10 on a scale of 0-10 with 10 being the worst pain imagined. Resident #1 did not receive scheduled pain medication. Medications included an antibiotic. Care areas identified included cognitive loss/dementia and behavioral symptoms. A review of Resident #1's care plan with a resolved date of 10/22/2024, indicated Resident #1's code status as full code, wanting cardiopulmonary resuscitation. Interventions included providing the opportunity for resident to discuss feelings and ask questions related to end of life decisions and review code status; and a change in code status to do not resuscitate (DNR) with interventions that included checking for resident signature on consent form; verify physician order; review code status with resident annually and as needed; acknowledge right to revoke DNR status; and a. Resident #1 had contact isolation due to wound and wound myiasis (a parasitic infection that occurs when fly larvae [maggots] burrow into the skin of a live animal and feed on its tissue) related to refusal of wound care. Interventions included pest control with a fly light trap, treatment of myiasis as ordered by physician, and wound care as ordered by physician resident refused; and b. Resident #1 had an ADL self-care performance deficit related to chronic pain, refusing ADL care, turning, wound treatment, incontinent care and catheter care. Interventions included, resident was totally dependent on 2 staff for bathing/showering, mobility, dressing, toileting, transferring with mechanical lift, was bedfast, used bedrails for independence with turning and positioning, dependent on 1 staff for personal and oral hygiene, required skin inspection and was to be observed for redness, open areas, scratches, cuts, bruises and report changes to nurse; and c. Resident #1 exhibited behaviors that included rejection of care with interventions that included providing staff training on behaviors, notification to the physician of changes in behavior, and administering and monitoring effectiveness of medications; and d. Resident #1 was resistant to care evidenced by refusal of care, to be repositioned, refused skin assessments and treatments. Interventions included allowing Resident #1 to make decisions about treatment to provide sense of control, educate on outcome of non-compliance, encourage participation during care activities, clearly explain care activities prior to contact, negotiate ADL care times to allow resident participation, change approach if Resident #1 becomes agitated and notify charge nurse of situation; and e. Resident #1 had no impaired cognitive function/dementia based on BIMS score of 15, would remain oriented to person, place, situation and time, and would maintain current level of decision-making ability. Interventions included engaging in pleasant topic conversation prior to initiating care; and f. Resident #1 was receiving opioid pain medication therapy with interventions that included administering medication as ordered by physician and monitoring side effects of the medication; and g. Resident #1 had antidepressant medications related to affective mood disorder with interventions that included administering medications as ordered and monitoring side effects and effectiveness every shift. A black box medication warning indicated observation and monitoring for suicidality, unusual changes in behaviors, and clinical worsening; and h. Resident #1 had a mood problem related to mood affective disorder with interventions that included behavioral health consults, monitoring for irritability, mood changes, and agitation; and i. Resident #1 had chronic pain with interventions to anticipate need for pain relief, evaluate effectiveness of interventions, monitor for non-verbal pain, mood/behavior changes and review impact on functional ability and impact on cognition; and j. Resident #1 had a pressure ulcer to coccyx/sacrum and potential for development of pressure ulcers and refused treatment that included wound care, turning and repositioning, wound assessments per protocol and full skin assessments. Goals included healing of the pressure ulcer, remain free of infection, and maintain or develop clean intact skin. Interventions included administration of medication and treatments as ordered, educating resident on causes of breakdown and frequent positioning; and k. Resident #1 had an indwelling catheter. Interventions included changing catheter as ordered, resident refused catheter changes and care; monitor and report signs and symptoms of urinary tract infection, that included foul smelling urine, altered mental status, change in behavior. Resident #1 refused a follow up urology appointment. A review of Order Summary Report, with active orders as of 10/01/024, indicated Resident #1 had a pain assessment every shift with a start date of 05/20/2024; treatment of coccyx wound daily and as needed with a start date of 05/23/2024; an antidepressant daily for mood affective disorder, with a start date of 05/21/2024; oral opioid pain medication every 4 hours as needed for severe pain with a start date of 07/26/2024; an opioid pain medication every 4 hours as needed for pain; an antidepressant at bedtime for mood affective disorder, with a start date of 05/20/2024. A review of the Order Summary Report, of discontinued orders, with an order date of 06/26/2024, indicated a psych referral, for 1 day, one time only for refusing care. The end date was 06/27/2024, the order status was completed. A review of the Order Summary Report, of discontinued orders, with an order date of 07/07/2024, indicated a referral to mental health clinic for depression, one time only for 4 days. The end date was 07/12/2024, the order status was completed. A review of the Order Summary Report, of discontinued orders, with an order date of 08/22/2024, indicated an antiparasitic medication, 4 tablets by mouth one time a day for 3 days related to wound myiasis. The end date was 08/29/2024, the order status was completed. A review of the Nsg (Nursing) Admit/Readmit/Quarterly Assessment, dated 05/20/2024 indicated a skin assessment integrity comment, Stage four noted to residents (sic) coccyx with wet to dry treatment in place. Sensory Perception indicated Resident #1's ability to meaningfully respond to pressure related discomfort was slightly limited, was able to respond to verbal commands, cannot always communicate discomfort or the need to be turned OR has some sensory impairment limiting the ability to feel pain or discomfort in 1 or 2 extremities. Resident was bedfast and had very limited mobility and was unable to make changes independently and was at moderate risk for dehydration. Cognition did not identify current psychiatric diagnoses or behavioral problem. Neurological assessment indicated resident was alert and oriented to person, place, time, and situation and was verbally appropriate. Resident #1 indicated pain occurred frequently in the last 5 days affecting sleep and day to day activities, and current pain was severe and rated it a 10 on scale of 0-10. No behaviors were documented. A review of the Nsg Admit Skin Audit, dated 05/20/2024 indicated Resident #1 had bruising to right and left antecubital areas related to IV (intravenous needle) sticks, dry skin, and a stage 4 wound to coccyx. A review of the Nsg Functional Abilities and Goals-Admission, with an effective date of 05/20/2024 indicated Resident #1 had bilateral lower extremity impairment, required a wheelchair for mobility and was dependent for manual wheelchair use, required substantial/maximal assistance with personal hygiene, was dependent for toileting, dressing, rolling left and right, sitting to lying, lying to sitting, transferring from chair to bed and bed to chair, refused to stand from seated position, and refused shower/bathing. A review of the Nsg Functional Abilities and Goals-Interim, with an effective date of 08/19/2024 indicated Resident #1 had no functional impairment of the upper extremities, had bilateral impairment of the lower extremities, utilized no devices for mobility, required substantial/maximal assistance with personal hygiene, was dependent with toileting hygiene, and refused shower/bathing, dressing, mobility that included rolling left and right, sit to lying and lying to sitting on side of bed, sit to standing, chair to bed and bed to chair transfer, toilet transfer, tub/shower transfer, was not assessed for walking or use of wheelchair. A review of Medication Administration Record (MAR), for May 2024 (05/20/52024 through 05/31/2024) indicated Resident #1 had pain documented 9 times above a level of 0, with medication administered. A review of Treatment Administration Record (TAR), for May 2024 indicated Resident #1 refused to allow wound care 05/23/2024, 05/24/2024, 05/26/2024, 05/27/2024, 05/30/2024, and 05/31/2024. No as needed (PRN) wound care was documented. A review of MAR, for June 2024 indicated Resident #1 had an opioid transdermal patch applied 06/03/2024 every 72 hours with a dosing change on 06/18/2024. Refused urinary catheter to be changed on 06/30/2024. Refused weekly weight on 06/05/2024, 06/12/2024, and 06/18/2024. Pain was assessed 24 times above a level of 0, with medication administered. A review of TAR, for June 2024 indicated Resident #1 refused wound care 29 days. No PRN wound care was documented. Psych referral was documented as done on 06/28/2024. A review of MAR, for July 2024 indicated Resident #1 had pain was assessed 14 times above a level of 0, with medication administered. A review of TAR, for July 2024 indicated Resident #1 refused wound care 30 days. No PRN wound care was documented. A review of MAR, August 2024 indicated Resident #1 refused urinary catheter to be changed on 08/31/2024, antiparasitic tablets administered on 08/23/2024, 08/24/2024, and 08/25/2024; was received a diuretic daily for fluid overload on 08/20/2024 through 08/31/2024. Pain was assessed 20 times above a level of 0, with medication given. An antibiotic was administered three times a day for 7 days for wound myiasis. A review of TAR, August 2024 indicated Resident #1 refused wound care to coccyx for 31 days and had a new order for wound care on bilateral lower extremities and refused care. No PRN wound care was documented. A review of MAR, September 2024 indicated Resident #1 had catheter changed however, progress notes documented refusal of care and did not address the catheter. Pain was assessed 25 times above the level of 0, medication was not administered 5 times for pain levels of 9/10, 6/10, 6/10, 6/10, and 4/10, due to blood pressure being below 100 systolic. A review of TAR, September 2024 indicated Resident #1 refused wound care to coccyx and wound care to bilateral lower extremities for 30 days. A review of MAR, October 2024 indicated Resident #1 began intermittent refusal of oral medications. Pain was assessed 32 times above the level of 0, with medication administered. A review of TAR, October 2024 indicated Resident #1 refused wound care to coccyx and wound care to bilateral lower extremities for 23 days. On 05/21/2024, Resident #1 was seen by APRN #11 for hospital follow up. Reviewed problems included Type 2 diabetes mellitus (DM), morbid obesity, anxiety, panic disorder with agoraphobia, depressive disorder, chronic pain, pressure injury of buttock, open wound of buttock, and pain in right hip joint. History of present illness (HPI) included Urinary catheter surgically implanted, denies depression. Physical examination indicated morbid obesity and limited ambulation. Psychiatric mental status was normal mood and lethargic; was oriented to time, place, and person. Musculoskeletal indicated limited range of motion (ROM) and right hip pain. Assessment plan included: DM, chronic pain continue opioid; depressive disorder continue antidepressant. Open wound of buttock was not assessed. On 05/23/2024, Resident #1 was seen by APRN #4 for open wound assessment. Reviewed problems included unstageable pressure injury, open wound of buttock with complication, pain right hip joint. HPI included reported stage 4 pressure ulcer to coccyx, present on arrival to facility. Visit was first wound care visit. unable to access Stage 4 pressure ulcer to coccyx and other unknown wounds as patient currently refuses to turn for full body skin assessment. Resident reported due to pain, would turn once per day when goes to the bathroom. Review of system (ROS) indicated unable to assess wounds. Orders given for wound care, if unable to perform tele visit at time of turning. On 05/26/2024, Resident #1 was seen via telemedicine by APRN #22 for report of change in condition, HPI indicated expired opioid order, pressure ulcer required dressing change, and pain at wound site during wound care. ROS included mental status as active and alert. Assessment/Plan was chronic pain with a change in opioid medication. On 05/29/2024, Resident #1 was seen by PCP as new admission. The problem list included morbid obesity, heart failure, DM type 2, hypertension, malaise, mood affective disorder, and chronic pain. HPI included incontinent of bladder, continent of bowel, mood stable without behavioral problems, and was compliant with medications and care. Functional assessment indicated one person assist for ADLs and transfers. ROS included no anxiety or depression. Assessment/Plan included depressive disorder - continue antidepressant, impaired ADLs - assist and monitor, degenerative joint disease (DJD) - continue pain control with opioid, assist with ADLs and monitor, moderate to severe frailty syndrome - bedbound, assist with ADLs and monitor, sarcopenia (muscle loss) - assist with ADLs and monitor, poly-pharmacy - educate on medication interaction/adverse effects and monitor for adverse effects. On 06/03/2024, Resident #1 was seen by APRN #11 for follow-up on chronic pain. HPI indicated follow up for sacral ulcer, refusing bed and incontinence changes, wound care and repositioning related to pain. ROS indicated psychiatric mental status was active and alert and normal mood, oriented to time, place, and person. Assessment/Plan indicated chronic pain, continue oral opioid and PCP ordered opioid transdermal patch. On 06/03/2024, Resident #1 was seen by PCP for acute visit for toenail care. ROS and Exam indicated skin had no rash, itching or skin changes and was warm dry (W/D) and intact. Assessment and plan included pressure ulcer on coccyx - resident does not want to be rolled due to pain. Continue facility wound care and Monitor for infection. DJD indicated staff reporting refusal of care due to pain; resident reports pain in hips, back and bilateral knees, educated on taking medication to stay ahead of pain, resident reported still has pain 40 minutes after taking medication; educated on importance of care compliance; opioid patch ordered for pain. On 06/17/2024, Resident #1 was seen by PCP for acute visit for toenail care. HPI indicated mood stable with no behavioral problems and was compliant with care. Exam included psychiatric evaluation described as calm, cooperative, alert and oriented (AO) x 3 (indicating person, place, situation), and follows commands. Assessment/Plan indicated facility was unable to access wound due to refusal, resident does not want to be rolled. Staff reported refusal of all care. Provided options if continued refusal of care that included comfort care and transfer to another facility. Continue facility wound care. Opioid patch dose increased; oral opioid medication added. On 06/26/2024, Resident #1 was seen by PCP for annual wellness visit. ROS indicated no joint pain, joint swelling, or restricted movements. Psychiatric indicated no anxiety or depression. Physical findings included, psychiatric as calm, cooperative, AOx3, and followed commands. Assessment indicated normal routine history and physical senior citizen (65-80). (Resident #1 was [AGE] years old.) A PHQ (patient health questionnaire) -9 score (screening, diagnosing, monitoring, and measuring severity of depression) was performed with a score of 9.0 indicating mild depression. Counseling/Education included nutritional needs, resident verbalized/demonstrated understanding of medical condition and disease process, educated on proper diet, proper use of medications and hygiene. Plan indicated wound had not been assessed due to resident refusal due to pain when rolled, staff reported refusal of all care. Continue facility wound care, monitor for infection, Not knowing what the wound looks like, send to emergency room (ER) for evaluation, referred to psych for evaluation. DJD indicated resident refused care due to pain, refused to allow staff to change after incontinent episode, refused wound care, resident refused PRN medications for pain, stated hurts too much to roll over for care. Opioid patch discontinued. Medication continued for depressive disorder. Review of Informed Consent to Refuse Treatment and /or Services, dated 06/26/2024 indicated Resident #1 signed the informed consent, at 2:53 PM, that outlined the PCP orders for daily wound care to coccyx, turning and repositioning, incontinent care, bathing, skin/wound assessments, body audits, bariatric bed, specialty mattress, and trapeze bar. Resident provided with the benefits and results of refusal up to and including death. Review of a Progress Note, dated 06/29/2024 at 07:55 AM, indicated Resident #1 rejected care and the nurse was advised to try to determine reason care rejected such as staff providing care being changed to male aides and to modify care plan as necessary. On 07/03/2024 Resident #1 was seen by APRN #11 for anxiety. Resident refused repositioning, refused wound care evaluation by APRN care, and stated it was related to severe pain. PCP previously adjusted pain medication. No trends/patterns documented; no pain assessment performed; a Yes response to Has there been a recent workup related to this issue to rule out medical delirium was documented with no response to description of workup or diagnosis. ROS revealed resident had fatigue. Physical exam revealed psychiatric ment[TRUNCATED]