Allure of Geneseo

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safety of a resident by ensuring the shower room door was closed for 1 of 3 residents (R1) reviewed for safety and supervision. This failure resulted in R1 wandering into the shower room and experiencing a slip and fall to the floor and sustaining a laceration to her head and a right femoral fracture.

Inspectors wroteBased on record review and interview, the facility failed to ensure V5/Dietary Manager possesses the Food Handler Certification or Certified Food Protection Manager certification. This failure has the potential to affect all 62 residents residing in the facility. The facility's Dietary Manager Job Description, not dated, documents: QUALIFICATIONS: Food Handler Certification or Certified Food Protection Manager certification required. The Centers for Medicare and Medicaid Services, Form 671-Long-term Care Facility Application for Medicare and Medicaid, signed 1/13/26, by V1/Administrator, document 62 residents reside in the facility. During the initial kitchen tour, on 1/13/26, at 9:00 a.m., V5 confirmed since being hired, as the Dietary Manager, in October 2025, he has yet to obtain the certification required in the facility's job description.

Inspectors wroteBased on interview and record review, the facility failed to implement antibiotic stewardship by failing to ensure infection surveillance was thoroughly conducted, met the required criteria for antibiotic use and obtain/review culture results to track and trend infections for nine of nine residents (R1, R7, R8, R29, R53, R68, R71-R73) reviewed for antibiotic stewardship in the sample of 71.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication for one (R8) of six residents reviewed for unnecessary medications in a sample of 71.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate catheter care and failed to provide privacy/dignity of one (R53) resident of five residents reviewed for urinary catheters in a sample of 71.

Inspectors wroteBased on interview, observation and record review, the facility failed to conduct hand hygiene and change gloves per standards of care and don personal protective equipment (PPE) correctly for two of three residents (R40 and R47) reviewed for infection prevention practices in a sample of 71.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess a resident with new onset pain, failed to document the new onset pain, and the facility failed to ensure the resident's provider received notification of new onset pain. This applies to 1 of 3 residents (R1) reviewed for injuries of unknown origin in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened food items were dated upon opening and ensure areas in the kitchen were clean. This failure has the potential to affect all 63 residents currently residing in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to maintain a resident's dignity by ensuring clothing attire was clean and free of debris for one resident (R47) reviewed for dignity in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply physician-ordered compression stockings for one of one resident (R31), with a known history of acute/chronic heart failure, reviewed for edema, in a sample of 33.

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to ensure residents were provided range of motion exercises and contracture alleviation devices to prevent further decline in range of motion and care plan and assess a resident's contracture for three of three residents (R6, R7, R27) reviewed for limitations in range of motion in the sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a nebulizer mask and nebulizer tubing was changed every 72 hours and stored in a bag between uses and ensure oxygen tubing was changed every seven days for one of one resident (R57) reviewed for respiratory care in a sample of 33.

Inspectors wroteBased on observation, interview and record review facility staff failed to disinfect a shared glucometer between resident use for three of three residents (R6, R11 and R25) reviewed for infection control, in a sample of 33. The (undated) facility policy, Glucometer Disinfection directs staff, The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. The facility will ensure blood glucometer's will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. The glucometer's will be disinfected with a wipe pre-saturated with an EPA (Environmental Protection Agency) registered healthcare disinfectant that is effective against HIV (Human Immunodeficiency Virus), Hepatitis C and Hepatitis B virus. [...]

Inspectors wroteBased on interview and record review the facility failed to provide the resident/resident representatives with a written notice of transfer. This has the potential to affect all 63 resident's residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the bed hold policy for facility residents discharging to the hospital. This failure has the potential to affect all 63 residents currently residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to serve drinks at palatable temperatures. This failure has the potential to affect all 59 resident who currently reside in the facility. Findings Include: The Facility's Record of Food Temperatures Policy dated 01/01/2024 documents Hot foods will be held at 135 degrees Fahrenheit or greater. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. Place cold menu items such as ham salad or egg salad over an ice bath in a pan (preferably on a separate cart) and not beside a heated steam table. Resident Council Meeting Minutes dated December 2023 documents The food is sometimes cooled off by the time it gets to the rooms. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide safe mechanical lift transfer for one resident (R26) of 15 residents reviewed for falls and failed to supervise for three residents (R22, R25, R26) requiring supervision during meals of nine residents in the sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure privacy during incontinent care for one resident (R26) of 15 residents reviewed for privacy in the sample of 27.

Inspectors wroteBased on interview and record review the facility failed to refer one resident (R20) for a Preadmission Screening and Resident Review (PASARR) after onset of new possible serious mental illness of five reviewed for PASARR in a total sample of 27. Findings Include: The Facility's Resident Assessment-Coordination with PASARR Program policy dated 01/01/2024 documents This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. [...]

Inspectors wroteBased on interview, and record review the facility failed to obtain a PASARR (Preadmission Screening and Resident Review) Level I prior to admission to the facility and failed to request or obtain a PASARR Level II Screening for two (R10 and R22) of five residents reviewed for PASARR Screenings in the sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to assist two residents (R25, R26) at risk of malnutrition and who require assistance with meals of nine residents reviewed for nutrition in the sample of 27.

Inspectors wroteBased on observation, interview and record review the facility failed to have any indication for use for an antipsychotic medication for one resident (R20) of five reviewed for psychotropic medication use in a total sample of 27. Findings Include: The Facility's undated Use of Psychotropic Medications documents Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. R20's Medical Record documents R20 was admitted on [DATE] with diagnosis of CVA (Cerebral Vascular Accident) with hemiparesis. R20's history and physical dated 5/18/2020 from V6 (Attending Physician) that document Psychiatric/Behavioral: Negative for behavioral problems. [...]