Based on interview and record review the facility failed to ensure that one resident (R1) is free from abuse in a sample of three residents reviewed for abuse. This failure caused R1 to be visibly soiled through outer clothes and to have an odor. Findings Include: The Facility's Abuse Reporting policy dated 8/11/2017 documents This facility will not tolerate resident abuse or mistreatment by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, resident representative, legal guardians, friends or other individuals. The Abuse Reporting policy documents For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or by deprivation by an individual, including a caretaker, of goods or services that are necessary to attain ore maintain physical, mental psychosocial well-being. Willful Abuse: as used in this definition of abuse, mean the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mental Abuse: Including, but not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Neglect/Mistreatment: means the failure to provide, or willful withholding of, adequate medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. A Complaint Form dated 5/22/24 documents that V9 (R1's Health Care Power of Attorney) complained that on the weekend of 5/17/24-5/19/24 she had stopped in and R1 smelled of urine and was not clean. The Follow Up section of the complaint documented Investigation and (State Agency) report completed. See (State Agency) final report. The Final Report for Allegation related to (R1) dated 5/27/24 documents that R1 is alert with confusion and has a BIMS (Brief Interview for Mental Status) score of 2 (out of possible 15/indicating R1 is severely cognitively impaired) She uses a (reclining padded wheelchair) for mobility that is propelled by staff. She is able to utilize her right arm and will often raise it in the air. She is able to utilize her right arm and will often raise it in the air. She is also able to reach and grasp with her right arm/hand. (R1) has a current care plan for crying/being tearful, verbal aggression (yelling and cursing), physical aggression (grabbing and hitting) and pushing herself out of her (reclining padded wheelchair). The Final Report for Allegation related to (R1) dated 5/27/24 documents The following was noted (On 5/19/24) at approximate 5:45 PM V6 (Registered Nurse) came in for her shift and went to check (R1) because she had her arm up in the air. According to staff (R1) sometimes does this to indicate a need, though not consistently due to her confusion. When (V6/RN) checked (R1) she noted her to be wet and soiled, and she was slid down in her wheelchair. (V6/RN) immediately went to get a CNA to assist her in changing (R1) and laying her down. At approximately 6:00 PM (V6/RN) and (V5 Certified Nurse Aide) took (R1) to her room, changed her and laid her down. (V6/RN) asked (V3/RN) why the resident was sliding down in her chair and soiled. (V3/RN)'s response was that (R1) was having behaviors of aggression toward the staff who provided cares. (V6/RN) stated upon interview that (R1) was having no behaviors at the time she interacted with (R1) and was not having behaviors when she and (V5/CNA) provided cares. V3/CNA) was assigned to (R1) on 5/19/24 stated during her interview that (R1) had been having behaviors of yelling and screaming that day and the day before. She states she had been told to make sure (R1) was safe and leave her alone when these behaviors were occurring due to her being physically aggressive and bruising staff when she grabs and holds on.(V4/CNA) sated she noticed (R1) was when she was in the TV area by the nurses' station at approximately 2:20 PM and had asked the nurses if they wanted her to attempt to change (R1) and lay her down. (V3/CNA) was told by (V3/RN) not change her at that time due to the behaviors (R1) was exhibiting. The Final Report for Allegation related to (R1) documents that it was clear that (V3/RN) was not understanding the appropriate response to resident behaviors and ensuring cares are completed even during the occurrence of behaviors. It also became clear that she was not being truthful about her instructions and response to staff in regard to (R1) on 5/19/24. On 6/7/24 at 12:42 V8 (Administrator on call at the time of allegation) stated that she reviewed the video of the areas in question regarding the allegation with R1 on 5/19/24. V8 confirmed that R1 remained in her (reclining padded wheelchair) with no toileting and/or changing of her incontinent brief from the time she got up on 5/19/24 until V6 (Registered Nurse) and V4 (Certified Nurse Aide) took her to her room and changed her around 6:00 PM. On 6/7/24 at 11:30 AM V3 (Registered Nurse) seemed confused when asked about the allegation regarding R1 at the facility on 5/19/24. V3 stated what weekend are you talking about? I wouldn't remember all the details of a busy weekend. When asked why she was terminated from the facility V3 stated Oh, that. I told them that I didn't want the (staff) to have to get beat up just to change (R1)'s pants. (R1) was being very resistive that day and would keep saying no. If (staff working at the time of the incident) thought they should have changed (R1) that is on them, not me. They know how to do their jobs. On 6/7/24 at 11:10 AM V4 (Certified Nurse Aide) stated On that day (5/19/24) (R1) was being a little resistive in the morning after breakfast. So I made sure she was dry and positioned and didn't push it with her. When I went back after lunch I noticed she was slid down in her (reclining padded wheelchair) with foot part over the couch cushions. At about 2:00 PM I asked (V3/RN) about it and she said that she couldn't get (R1) to quit trying to get out of her chair. I told her I would go lay (R1) down and change her and (V3/RN) stated 'No, she can just stay there until she calms down.' V4 stated (R1) can be mean and yell and she does pinch sometimes, but I have never had to leave her wet like that before. V4 stated that at that time, 2:00 PM, R1 was visibly soiled and needed changed. V4 stated that she believed that she could have given cares to (R1) without being physically harmed. V4 stated that at 2:00 PM R1 was not having behaviors that V4 could observe. V6 (Registered Nurse) written statement dated 5/21/24 documents When I had come in for work it was about 5:45 PM and (R1) was positioned against the blue sofa, her feet were kind of over the sofa-she looked like she was sliding out of her chair and there was urine and fecal matter on her. I just, how she was, it wasn't appropriate, and that's why I went to (V8/Administrator on call) about it. I said something to (V3/RN) about it because she was on that side, about her sliding down in her chair and she said she's been having behaviors and I said when I walked over she just grabbed my hand, she wasn't having any behaviors. She (V3/RN) didn't have an answer to that. On 6/7/24 at 2:00 PM V6 (Registered Nurse) confirmed that she came in on 5/19/24 around 5:45 PM and found R1 visibly soiled through her clothes with visible BM (Bowel Movement) and food on her clothes and she smelled. V6 confirmed that V3 (Registered Nurse) told her that R1 had been having behaviors that prevented the staff from giving cares. V6 stated I wasn't comfortable with that, so I reported it. I have never had to leave a confused resident in that state before. If (R1) is having behaviors like the grabbing and pinching if you approach her on her left side she cannot reach you. (R1)'s behaviors usually mean that she needs something. V6 stated that when she and V5 (Certified Nurse Aide) changed R1 that she had no behaviors and was not resistive. On 6/7/24 11:15 AM V5 (Certified Nurse Aide) stated when I came in on that day (5/19/24) (V6/RN) told me to clock in and help her lay (R1) down. At that time (around 6:00 PM) (R1) stunk, and you could see that she was wet and messy. I ended up soaking off some of the BM (Bowel Movement) because it was dried into her skin. On a scale of 0-10 with 10 being the worse, she was a ten plus. It was nasty and I would be upset if my loved one looked like that. We have been trained on how to deal with behaviors, so I don't understand why (R1) would have had to have been left that bad ever. She had no behaviors when we laid her down and she had no behaviors when I did the extensive clean up. On 6/11/24 at 9:15 AM V9 (R1's Health Care Power of Attorney) stated I stopped in on the weekend it was either 5/19 or 5/20 and (R1) looked awful. I had my granddaughter with me, and she usually climbs up in (R1)'s lap and hugs her and she would not even get close to her because she stunk so bad. The smell was awful. I did ask staff and they told me she had been being mean, which I know she does sometimes. But it did bother me enough that I went ahead and reported it because I've never seen her that smelly and gross before.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management for one of one resident (R41) reviewed for pain management in the sample of 24. This failure resulted in R41, who is a resident on hospice services with the diagnoses of malignant neoplasm of her right lung, cervix, trachea, and adrenal gland, refusing to get out of bed and reposition because of R41's extreme pain with any kind of movement. Findings include: The facility's Management of Pain policy, dated 5/29/18, documents, Our mission is to facilitate independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Promptly and accurately assessing and diagnosing pain; Encouraging residents to self-report pain; Increasing comfort and reducing depression and anxiety in residents; Monitoring treatment efficacy and side effects; Preventing and minimizing anticipated pain when possible; Using pain medication judiciously to balance the resident's desired level of pain relief with the avoidance of unacceptable adverse consequences. For the purpose of this policy, pain is defined as 'whatever the experiencing person says it is, existing whenever the experiencing person says it does.' Procedure: Residents and families will be asked to periodically measure satisfaction related to pain and its management. Physician Communication and Involvement-Pain will be assessed and managed in a timely fashion, especially if it is of recent onset. The physician will be notified of resident's complaint of pain when not relieved by medication as ordered by the physician. Thorough communication with the physician will ensure an appropriate pain management plan. On 12/06/22 at 02:17 PM, R41 was alert and oriented lying-in bed on her right side. R41 stated she has lots of pain from her lung cancer, kidney stones, and my leg issues. A few nights ago, the nurse (V9 Licensed Practical Nurse) would not give me my pain medicine for some reason. I put my light on around 11:00 p.m. and asked her for a pain pill. She told me I couldn't get it just yet because I still had an hour before I was due. I was ok with this no big deal. So, an hour went by she told me the same thing again. 1 am went by, 2 am went by 3 am went by, 4 am went by, 5 am went by and she never brought me pain medication. She was in the room at 6 am finally and I asked her where my pill was. She told me I was sleeping when she came in. If I was sleeping it wasn't very good. I was in so much pain all I could do was doze off not actually sleep. She treated me like a dog. I'm in pain and I asked for a pain pill, but she says I don't even look like I'm in pain. If I get off my routine of pain medication it throws it completely off, and then I have to start all over again to try and get it under somewhat control. Unable to contact nurse. R41 was unable to reference a date. R41's MDS (Minimum Data Set), dated 10/23/22, documents that R41 scored a 13 on her BIMS (Brief Interview for Mental Status) assessment signifying that R41 is cognitively intact. A facility Grievance/Complaint form, dated 12/6/22, documents, (R41) stated that (V9) did not give her PRN (as needed) pain meds over the weekend. Resident could not give exact time or date. The form also documents, Follow Up Action Taken: Upon investigation, interviewed V9. She stated on 12/5/22 at 3:00 a.m., R41 asked for a pain pill. V9 stated when she brought the pain pill to R41, she was sleeping at that time. V9 attempted to wake R41 by calling her name. R41 did not wake up. Approximately at 5:30 a.m., V9 stated CNAs (Certified Nursing Assistant) informed her R41 was asking for a pain pill. At that time V9 stated she was in another resident's room that was having an emergency. V9 instructed the CNAs to let R41 know she would be down with her pain medicine as soon as she was done helping the resident that was having the emergency. V9 then stated informed the oncoming nurse at 6:00 a.m. that the resident asked for pain medicine. R41 received pain medicine at 6:05 a.m. R41's Controlled Drug Receipt/Record Disposition Form, dated 11/30-12/7/22, documents that R41 received Norco 10/325 mg one tablet on 12/4/22 at 8:10 p.m., and the next dose was not administered until 12/5/22 at 6:05 a.m. R41's Physician's orders, dated 12/7/22, documents that R41 has the following orders: Morphine Sulfate Solution 100 mg (milligrams)/5 ml (milliliters). Give 0.25 ml orally every six hours as needed for mild pain; Norco 10-325 mg one tablet by mouth every four hours as needed for pain. R41's Care plan, dated 4/19/22, documents, I have altered respiratory status related to Lung Cancer. Intervention: Use pain management as appropriate. Monitor/document side effects and effectiveness. R41's History and Physical, dated 10/16/22, documents, Chief Complaint: Pain. History of Present Illness: R41 complains of diffuse pain and achiness especially in her back but seems to be generalized. She has known metastatic lung cancer. Not currently undergoing active treatment. Impression and Plan: Chronic pain. R41's Pain Assessment, dated 10/23/22, documents that R41 has frequent severe pain, and that she complains of pain daily. R41's Significant change MDS, dated [DATE], documents in Section J Health Conditions that R41 has frequent severe pain R41's Medicare Daily Progress note, dated 10/23/2022 at 11:33 a.m., documents, R41 refused to be repositioned in bed or get up for meals. R41 has been deciding if she wants hospice or not and R41 has decided that she does not want to treat lung cancer and prefers to have hospice services. R41's medical record has no documentation of physician follow up. R41's Medicare Daily Progress note, dated 10/26/2022 at 09:56 a.m., documents, As needed pain medications given with effectiveness noted, R41 states that she is still having pain. R41 refused to get up for AM meal. R41 is able to feed self but requires set up assistance. R41 has poor appetite and fluid intake and has been educated on coming to dining room but still refuses. R41 refused to go to appointment for renal scan. R41 has decided on hospice and hospice will be here today to evaluate R41. Staff offered to reposition R41 and R41 refused. R41's record documents she was admitted to Hospice on 10/27. R41's Nurses' note, dated 10/27/22 at 9:41 a.m., documents, R41 refuses to get up for meals despite staff encouragement. Staff offered to reposition R41, and she refused. R41 prefers to lay on right side despite being educated on skin breakdown. R41's Nurses' note, dated 10/27/2022 at 12:42 p.m., documents, R41 is admitted to hospice. New order to discontinue Norco 7.5 mg/325 mg every 4 hours as needed. Start Norco 10 mg/325 mg every 4 hours as needed. R41's Care plan, dated 10/28/22, documents, Terminal illness-admit to hospice due to Cancer diagnosis. Goal: Myself and my family's will be maintained, and I will be comfortable without observable indications of pain and/or other physical, mental, or psychological symptoms thru staff monitoring and intervention. Intervention: Provide Pain/Discomfort medications per physician order. Monitor effectiveness and side effects. Report changes in pain, uncontrolled pain, and adverse effects of medications to the physician. R41's Nurses' note, dated 10/28/22 at 9:35 a.m., documents, Refuses to get up for meals. R41 has poor appetite. R41's Hospice admission Orders, dated 10/28/33, documents that R41's primary diagnosis for admission to hospice is malignant neoplasm of R41's right lung. The orders also document R41's related diagnoses are malignant neoplasm of the adrenal gland, trachea, and cervix. R41's Nurses' note, dated 10/30/22 at 12:47 p.m., documents, R41 states pain is all over. R41's Behavior Note, dated 11/1/22 at 2:24 a.m., documents, No behaviors noted or reported from change in pain and anxiety meds. Continues asking for pain meds on same schedule as before. R41's Nurses' note, dated 11/3/22 at 8:28 p.m., documents, Maintaining comfort as much as possible. R41's Behavior note, dated 11/3/2022 at 02:30 a.m., documents, R41 received a 10-325 Norco at 01:00 a.m. and rang her call light at 02:30 a.m. asking for another pain pill. R41 stated, 'she would not tell anyone if I gave her another one early.' R41 was told that we would not be administering anything early to her. R41 has been increasing her requests for pain pills and at denials she continues to ask for other medications that have been discontinued or not available to her like Diazepam and oxycodone-acetaminophen. R41's Behavior note was signed by V9. R41's Behavior note, dated 11/3/2022 at 4:00 a.m., documents, R41 request another pain pill at 03:50 a.m. I told her it has been less than 4 hours since her last pill and this is her 3rd request since being administered a pain pill at 01:00 a.m. She stated, 'it was okay to give it to her early since it's only like 10 minutes early.' I told her it was more than an hour early and I would not be issuing her medications early. I also explained due to the increasing requests and attempts at bargaining for more pills we have to chart all of the attempt times as well and would not be going against the orders to give them early. When entering her room to answer the call light she was asleep and woke up when turned the call light off. R41's Behavior note was signed by V9. R41's Medical record has no documentation of R41's physician or hospice being notified of R41's requesting pain medication, on 11/3/22, prior to being scheduled due to pain not being controlled. On 12/08/22 at 9:54 AM, V2 (Director of Nursing) confirmed that V9 should have notified the physician or hospice of R41's increased pain, but V9 did not do that. R41's Nurses' notes, dated 11/6/22 at 6:29 p.m., documents, Appears in no pain. However, the note also documents, Requesting Norco when available. R41's Nurses' note, dated 11/8/22 at 10:48 a.m., documents, R41 refuses to get up for meals. R41's Nurses' notes, dated 11/9/22 at 9:16 a.m., document, R41 refused to get up for meal. R41's Nurses' notes, dated 11/11/22 at 6:26 p.m., documents, Comfort maintained as much as possible. R41's Nurses' note, dated 11/13/2022 at 09:21 a.m., documents, Resident refuses to get up for meals. She is a total staff assist for transfers, ADLs (activities of daily living), and tray set up. She is hospice status. Her pain is controlled with as needed pain medications. However, R4's Nurses' notes also documents, Resident refuses to be repositioned. Stating 'if I move, I hurt.' Staff will continue with current plan of care. R41's MAR (Medication Administration Record), dated 11/22, documents that R41's tolerable pain is a 4 (on a pain scale of 0-10). R41's Pain assessments document that 17 out of 30 days, R41's pain level exceeded her tolerable pain rating it from a 5-10 (on a pain scale of 0-10). The MAR also documents that R41 is being administered Norco 10-325mg on an average of daily two to four times a day with the exception of five days when R41 requested it one time during the day. In addition to the Norco, R41 was started on Morphine as needed 11/3/22, and R41 requested the Morphine (11/3-11/30/22) one time a day nine days and twice a day four days. On 12/08/22 at 12:08 PM, V8 (Certified Nursing Assistant) stated, (R41) complains a lot of being in pain. She doesn't show facial expressions of pain, but I'm not in her body so I don't know what she is feeling. When we provide incontinent care to R41, R41 cry's out and will be saying, 'Oh that hurts' the whole time especially if we have to roll her to her left side. On 12/08/22 at 9:54 AM, V2 (Director of Nursing) stat (R41) does have frequent pain. On 12/08/22 at 10:43 AM, V5 (MDS-Minimum Data Set Coordinator) stated, (R41) frequently requests a change in her pain medication or an increase. V5 also confirmed that a person can build up a tolerance to pain medication, and that R41 has active cancer. On 12/08/22 at 11:00 AM, V6 (Hospice Registered Nurse) was assessing R41. R41 stated, My pain is just all over. I'd say it's a 7 (scale of 0-10) right now. It's stabbing and aching. The main places it hurts are my kidneys and my lungs. My cancer is primarily in my lungs. I don't get out of bed because I hurt too much. I can't even move to roll over let alone get out of bed the pain is so bad. I can only lay in one position to help with the pain. My heart has also been fluttering and beating fast more lately. While R41 was speaking she was constantly fidgeting and facial grimacing throughout the conversation. V6 explained to (R41), Your pain is a vicious cycle. You hurt then you start getting anxious. If your pain isn't controlled, you get even more anxious and your pain keeps going up because your body is getting anxious and worked up. V6 also stated, I feel like (R41) would benefit from changing her Norco to something like Methadone because I feel that her body may have built up a tolerance and she needs a constant schedule to keep ahead of her pain. (R41) has lung cancer and has had multiple fractures so she for sure has pain. On 12/09/22 at 10:15 a.m., V1 (Administrator) stated that (R41) is on hospice for her diagnosis of cancer, but she feels that (R41) is just a pain medication seeker because she is always wanting more pain medications.