**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was free from mental abuse by depriving a resident their rights to private visitations (see F563 & F583) and isolating the resident from social interactions for staff convenience, causing the resident to experience ongoing feelings of being dull, bored, and frustrated which resulted in the resident expressing feelings of being a prisoner, for 1 (#78) of 13 sampled residents. Findings include. During an observation and interview on 5/17/25 at 2:00 p.m., resident #78 was sitting in the common area with another resident and NF3 and NF4. Resident #78 stated she had to visit with her friends in the common area because she was not allowed visitors in her room. (See F563 & F583) During an interview on 5/18/25 at 9:42 a.m., resident #78 stated she was not allowed to have visitors in her room. She stated the facility had been limiting her visitations for several months. She stated on several different occasions, while having visitors in her room, staff told her that she would need to move the visit out of her room to the common area. She stated she knew this was not right but had agreed to not having visitors in her room to keep the peace with the staff. She stated this restriction of not being allowed visitors in her room has caused her to feel dull, bored, and frustrated, and she stated she feels like a prisoner always being watched by staff. She stated the restriction on having visitors has been difficult because socialization was very important to her. Review of resident #78's Nursing Note, created by staff member E, dated 3/21/25, showed, Writer walked by and was rounding and saw resident and another resident family member [NF4] hugging on resident and tickling her. Advised resident that it was not ok. Resident family member then sat on bed and visited for remainder of evening. Review of resident #78 Electronic Health Record Summary Care Plan, with a care plan meeting dated 11/12/24, showed, Resident Preferences: entertainment activities, reading and socializing/chatting [coffee with [Name]/Trivia Facts] . Psychosocial/Mood: Able to express needs, feelings, thoughts, understands others and person/family visitation . : Activities: Goal: I will maintain my current level of socialization as evidenced by no complaints of isolation at monthly care plan meetings or quarterly. During an interview on 5/19/25 at 10:13 a.m., staff member H stated she was told by staff member E that resident #78 was not to have NF4 visit her in her room any longer, and they were to only visit in the common area. Staff member H stated she did not know everything that had happened to limit the resident's visits, but she knew resident #78 was very upset about it. During an interview on 5/19/25 at 10:22 a.m., staff member I stated she was informed by staff member E that resident #78 was not allowed to have visitors and, If you see any visitation in her room ask for it (visitors) to come out into a common area. Staff member I stated resident #78 Takes it upon herself that she runs the facility and encourages residents to come to her if they have any problems. Staff member I stated resident #78 can have visitors as long as it was not other resident family members or other residents. During an interview on 5/19/25 at 10:45 a.m., staff member J stated staff member E had directed her to only allow resident #78 to have visitors in the common room. During an interview on 5/19/25 at 10:55 a.m., staff member G stated resident #78 was no longer allowed to have certain visitors in her room. During an interview on 5/19/25 at 11:06 a.m., NF1 stated she was asked to attend a meeting with resident #78, staff member E, and staff member F, regarding resident #78's visitation rights. She stated she was told by staff member E that the resident was having visitors in her room, and she was getting those visitors riled up about the care at the facility. NF1 stated when meeting with staff members E and F, and resident #78, it was discussed that resident #78 was not allowed to have certain visitors in her room, and she would have to meet those visitors in the common area. NF1 stated resident #78 verbally agreed during that meeting to not have certain visitors in her room, and she agreed to meet those visitors in the common area. During an interview on 5/19/25 at 11:21 a.m., NF3 stated they have been friends with resident #78 for many years. She stated they were told by facility staff that NF4 could no longer visit resident #78 in her room. She stated the facility had never spoken to her, or NF4, about the incident which resulted in NF4 not being able to visit resident #78 in her room. NF3 stated that one day NF4 came to her and told her that staff had told him he was no longer allowed to visit resident #78 in her room, and they could only visit in the common area. She stated that NF4 was visibly upset and sad that he was no longer allowed to visit resident #78. She stated resident #78 had also expressed to her that she was upset that NF4 could no longer visit her in her room. During an interview on 5/19/25 at 12:09 p.m., staff member E stated they have had problems with resident #78 in the past telling them that she would shut them down and speak negatively about the facility. She stated they have had problems with other family members speaking with resident #78 in her room and the resident gets riled up. She stated that resident #78 was told that she was not allowed to have visitors in her room other than her family, because if resident concerns came up about the facility, they needed to know about it so they could fix it. Staff member E stated she was not aware of any concerns which were brought up during resident #78's private visits in her room that the facility was not aware. Staff member E stated there were no safety concerns between resident #78 and NF4 visiting each other. She stated they would just sit in her room all day and were being negative about the facility. She stated resident #78 agreed during a visit with NF1, staff member F, and herself that she would limit her visits with certain individuals to the common area so staff could observe. During an interview on 5/19/25 at 12:37 p.m., staff member F stated for resident #78 there had been concerns about her having a lot of complaints and telling other residents and/or their visitors about those complaints. So, staff member E decided that if she was going to have visitors they would have to meet in a common area and not her room. He stated it seemed like resident #78 was creating more issues with family members bringing them into her negativity. He stated most of her complaints had to do with food but was not aware of any concerns which were not shared with the facility. Staff member F stated he recalled a meeting between himself, resident #78, staff member E, and NF1, regarding the resident not having visitors in her room. He stated she had agreed that she would no longer have visitors in her room. He stated this meeting was not documented at the time and they did not provide resident #78 with anything in writing about limiting her visits to the common areas or their rationale to why her visits should be limited to the common area. Review of resident #78's Patient Relations Worksheet, with a received date of 5/19/25 at 3:20 p.m., showed: - Comments/Abstract: [Resident #78] said she is not allowed visitors in her room. - Referral Data: [Resident #78] is asked that if she has any visitors that are not her immediate family, they need to visit in the common areas. There was a meeting with [Resident #78, staff member E, NF1, and staff member F] that this message was relayed. - Interview Data: [Staff member E] reports that [Resident #78] had another resident's grandson visiting and was touching [Resident #78]. [Resident #78] reported that she is fine with the grandson touching her. [Resident #78] has had the grandson in her room on several previous occasions along with family members of other residents. [Resident #78] often seeks out other residents and/or family members to air her grievances while also discussing issues in resident council. Review of the facility's policy and procedure titled, Resident Abuse/Neglect Allegations, Senior Services, with a last reviewed date of 6/2024, showed: .Definitions: Mental Abuse - any act which results or has the potential to result, in mental impairment of the resident's intellectual or psychological functions including but not limited to, humiliation, harassment, threats, punishment, or deprivation . Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm . II. All employees are trained upon hire and annually regarding abuse, neglect and how to deal with work-related stresses, i.e., catastrophic reactions involving residents . Review of the facility's policy and procedure titled, Patient Rights and Responsibilities, with a review date of 8/2022, showed: .IV. Senior Care Registration: . 2. To be free from abuse and neglect (verbal, sexual, physical [and] mental abuse . 4. To voice concerns without fear of being punished [and] to express any complaints you have about your care or treatment . 11. To have private visits and to have visitors at any time, as long as you wish to see them [and] as long as the visit doesn't interfere with the provision of care and privacy rights of others .

Based on observation, interview, and record review, the facility failed to consistently assess, measure, and monitor a resident's pressure ulcer; and failed to ensure wound dressings were provided as ordered by the physician, and failed to ensure sufficient wound documentation was completed, to prevent the progression of a worsening Stage III pressure ulcer for 1 (#75). This deficient practice had the potential to cause worsening wounds and infection for the resident; and the facility failed to ensure 1 (#7) of 13 sampled residents properly received perineal care to prevent the occurrence of a wound related to the use of an indwelling catheter. Findings include: 1. During an interview on 5/17/25 at 3:57 p.m., resident #75 stated she had recently returned to the facility after being admitted to the hospital with sepsis. She stated she was very susceptible to developing infections. Resident #75 stated she developed a pressure ulcer on the back of her right upper thigh from not being cleaned, and the area was getting moist. She stated the pressure ulcer developed after she was re-admitted to the facility. She stated she had Addison's disease which caused her skin to be very sensitive and prone to skin breakdown. She stated staff would not listen to her regarding how to apply the wound dressing, and then the dressing would roll up and frequently come off. She stated she was worried the wound had become bigger and staff were not consistent with changing the dressing. She stated she was to be seen at the Wound Clinic once a month, and she was supposed to have the dressing changed every other day. During an observation on 5/18/25 at 4:17 p.m., staff member C provided wound care and a dressing change for resident #75. Resident #75 had an oval shaped wound located on the back of her right upper thigh. The wound was approximately 3 cm x 2 cm in size and was red and beefy in appearance. A. Assess, Measure and Monitor Pressure Ulcer During an interview on 5/18/25 at 4:17 p.m., staff member C stated staff member D provided weekly wound care at their facility on Thursdays. She stated if a wound dressing needed to be changed sooner, or more frequently during the week, staff would perform the dressing changes. Staff member C stated she did not measure or assess the wound when she performed dressing changes for resident #75 because staff member D assessed and measured the resident's wounds when she did her weekly rounds. Staff member C stated she could usually tell if resident #75's wound had worsened when she provided the dressing change. During an interview on 5/19/25 at 4:52 p.m., staff member B stated the facility had a wound care nurse that came to the facility at least once a week, on Thursdays, to provide wound care for the residents with wounds. She stated the wound care nurse would assess, measure, and provide dressing changes during that visit. During an interview on 5/20/25 at 8:35 a.m., staff member D stated she provided wound care for residents at the facility every week on Thursdays. She stated she started at this facility early in the morning each Thursday. She stated she also rounded, everyday, Monday through Friday. Staff member D stated she did not take measurements of a resident's wound every time she provided wound care, but would take a picture of the wound, which was uploaded into the resident's record. She stated she did try to obtain measurements of the wound at least once a week. Staff member D stated resident #75 was usually in bed or asleep when she was there to do her wound care, and the resident would tell her to come back later. She stated she sometimes did not return later, so she would notify the nurse on duty, so the staff could provide the resident's wound care. Staff member D stated she had not had a recent opportunity to assess, measure, or monitor resident #75's right leg wound. She stated she believed resident #75 had a recent Wound Clinic visit which showed her wound was slightly worse. Staff member D stated after reviewing resident #75's medical record, she did not think resident #75's dressing changes were being completed, consistently. During an interview on 5/20/25 at 9:07 a.m., resident #75 stated she had not seen staff member D every week. She stated staff member D only came to her room in the early mornings to do wound care. She stated she was usually asleep or still in bed when staff member D wanted to do her wound care, and she did not want to get up that early. She stated she would ask staff member D to come back later, but she never returned later. Resident #75 stated staff member D only did wound care in the mornings. If you did not get up while she was there, so she could do the wound care, staff member D would say you refused, and would not return later in the day to try and do the wound care. Review of resident #75's Nurse Progress Note, dated 4/21/25, showed, Resident has pressure sore that continues to be open from chronically. [sic] Measurement 0.5 cm x 0.3 cm x 0.1 cm. Resident had prior dressing on from 4/16 from hospital. Wound bed was beefy red, surrounding skin purple in color. Resident had dressing redressed cleansed with [normal saline] and skin prep to surrounding and replaced with foam dressing. [sic] Review of resident #75's Physician Wound Clinic Progress Note, dated 4/22/25, showed, Wound Length: 0.5 cm, Width:0.4 cm, Depth: 0.1 cm, Pressure Stage: 3 . Note: This patient returns today. Her right posterior thigh pressure ulcer appears to be improved and there is no slough. Will continue with barrier cream as well as Xeroform, No Sting Sacral Opti foam gentle which will be changed every other day and will see her back in a month. Review of resident #75's Physician Wound Clinic Progress Note, dated 5/19/25, showed, Wound Length: 2.7 cm, Width: 2 cm, Depth: 0.2 cm, Stage: 3 . Right posterior thigh wound is slightly larger. I debrided it as noted above. Will continue to with the barrier cream, Xerofoam No Sting and sacral Opti foam gentle. I will see her back in one month and she will have this changed every other day . A review of resident #75's Medical Record, Wound Care Notes, Progress Notes, and Flowsheets, from 4/21/25 to 5/20/25, did not reflect the resident's wound was assessed, measured or monitored from 4/22/25 to 5/19/25. Wound Clinic Physician Progress Notes showed resident #75's Stage 3 pressure injury went from improving on 4/22/25 to a worsening Stage 3 Pressure Injury on 5/19/25. A review of the facility's policy and procedure titled, Wound Assessment, with an effective date of 11/2024, showed: Document: A. Location . B. Dimensions .C. Type of wound . D. Description of Wound . E. Presence of undermining or tunneling . F. Wound base condition and color . G. Drainage . H. Condition of surrounding skin . I. Signs and symptoms of infections . J. Wound assessments are to be completed on admissions .b. Senior Services - wound assessments and measurements are completed weekly. K. Skin assessments are completed quarterly for long term residents. A review of the facility's policy and procedure titled, Wound Management, with an effective date of 5/2024, showed, .IX. Monitor healing: A. Measure, Assess, and photograph the wound on admission. B. assess the wound with each dressing change. C. Measure wounds 2 times a week, Mondays and Thursdays. D. If ulcer does not exhibit healing, reassess treatment plan. B. Provide Wound Dressing Changes/Documentation During an interview on 5/18/25 at 4:17 p.m., staff member C stated resident #75's dressing was to be changed every three days or as needed. She stated the nursing staff were expected to change the dressing as ordered on the days the wound care nurse was not able to change the dressing. During an interview on 5/19/25 at 4:52 p.m., staff member B stated the facility had a wound care nurse that came to the facility at least once a week, on Thursdays, to provide wound care for the residents with wounds. She stated the wound care nurse provided dressing changes during that visit. She stated the nurses were also responsible for providing dressing changes as ordered by the physician and as needed. During an interview on 5/20/25 at 8:35 a.m., staff member D stated resident #75 was to have the dressing changed on her right leg pressure ulcer every other day. She stated she had not been able to provide dressing changes for resident #75 for a couple of weeks. She stated when she provided a dressing change it was documented in the resident's electronic record. Staff member D stated she did not see that resident #75's dressing changes were being documented, and it looked like the dressing changes were not being done consistently. During an interview on 5/20/25 at 8:45 a.m., staff member C stated the dressing changes for resident #75's wound were to be documented under the flowsheet. She stated she believed the dressing changes were being completed as ordered, but they were not being consistently documented. During an interview on 5/20/25 at 9:07 a.m., resident #75 stated she had not seen staff member D every week. She stated the nurses did not regularly change the dressing to her pressure ulcer. She stated the dressing often slipped or rolled up and would fall off when she transferred. She said they did not always put a new dressing on right away. A review of resident #75's Wound Clinic Physician Progress Notes, showed resident #75's Stage 3 pressure injury went from improving and measuring 0.5 cm x 0.4 cm, on 4/22/25, to a worsening Stage 3 Pressure Injury measuring 2.7 cm x 2 cm on 5/19/25. Review of resident #75's Work Task History for Treatment Orders and Treatment Administration Record (TAR), dated 4/18/25 to 5/18/25, showed, Apply/change dressing every other day. A review of the TAR showed the resident dressing changes were completed on the following dates: 4/23/25, and not documented on the following dates: 4/27/25, 5/3/25, 5/7/25 and 5/11/25, and skipped on the following dates: 4/21/25, 4/25/25, 4/29/25, 5/1/25, and 5/9/25. The resident's wound care orders were changed on 5/19/25. A review of resident #75's Medical Record, Wound Care Notes, Progress Notes, and Flowsheets, from 4/21/25 to 5/19/25, showed the wound care and dressing changes were completed and documented for one day, on 4/23/25. Review of resident #75's Active Physician Orders, dated 5/19/25, showed, Apply/change dressing every third day. Comments: cleanse with [normal saline] pat dry, no-sting barrier to surrounding intact skin, apply Xeroform to wound bed, cover with foam dressing. Change every 3rd day and as needed if soiled or removed. 2. During an interview on 5/17/25 at 4:30 p.m., resident #7 stated he had a catheter that had leaked for months on and off. Resident #7 stated staff would change the catheter, but it would often still leak. Resident #7 also stated he had sores on his privates. He stated he had told the staff about his sores, but he felt they did not listen, and he often felt they did not do perineal care correctly. He stated, You'd think they'd do this (clean) every night automatically. He stated some staff would clean twice a day but sometimes they would not at all. Resident #7 stated he asked a staff member in the past to change his brief, and the staff responded with You're okay to him. During an interview on 5/19/25 at 9:27 a.m., resident #7 stated he was uncircumcised, and when staff completed perineal care, they often forgot to pull the foreskin back to properly clean the area. He stated this was where the sore was. During an interview and observation on 5/19/25 at 1:52 p.m., staff member S stated it looked like resident #7 had been sitting in that chair [wheelchair] too long because resident #7's buttocks had looked red. Staff member S stated, Oh my goodness when they observed the wound underneath the uncircumcised skin on resident #7's foreskin. Staff member S did not have anything to measure the wound with but guessed on the measurements of 0.5 cm x 0.2 cm x 0.1 cm depth. Staff member S stated they thought resident #7's wound could have been from his catheter that was removed less than a month ago. Staff member S was unaware resident #7 had a wound at all. The wound bed was observed to be superficial and pink. The wound edges were light pink, and the overall wound size was less than an inch in length. The wound was the size and shape of the catheter tubing where the foreskin rested on the tubing. During an interview on 5/20/25 at 9:01 a.m., staff member D stated they had not known about resident #7's wound, and stated there was now an order for a dressing change to be done daily. Staff member D stated resident #7 had gotten his catheter removed 4/28/25. They stated there was a possibility he got a device related wound, but staff member D was unsure due to the peculiar spot. Staff member D stated, It looks like it was a little larger (in the past), and had been healing along the margins (sides of the wound). Staff member D stated it was concerning resident #7 had a wound, and was not notified. Staff member D stated it was hard to help if they did not know about it. A request was made for #7's Wound cares/task check off, etc. related to [resident #7]'s private area wound prior to 5/19/25. During an interview on 5/20/25, staff member E stated not having information regarding resident #7's wound. Review of resident #7's EHR Skin Assessment, located in the Flowsheets, with a date of 5/17/25, showed: WDL (within defined limits).