Health inspection·November 20, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to perform hand hygiene and follow Physician treatment orders for one of four Residents (R12) and follow Physician treatment orders, prevent a worsening pressure ulcer and prevent a newly acquired pressure ulcer for one of four Residents (R3) reviewed for pressure ulcers in a sample size of 46. This failure resulted in R3 developing a new in-house pressure ulcer to the left Ischium, a new in-house stage 4 pressure ulcer to right Ischium and increasing in size in stage 4 pressure ulcers to right and left heels.Findings include: Residents Affected - Few The Facility Wound Treatment Management Policy, dated 2025, documents: to promote healing of various types of wounds, it is the policy of the Facility to provide evidence-based treatments in accordance with current standards of practice and physician orders; wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing; dressings will be applied in accordance with manufacturers recommendations; treatments will be based on etiology of wound, characteristics of wound, location of wound and goals/preferences of resident/representative, guidelines for dressing selection; treatments will be documented on the Treatment Administration Record; and effectiveness of treatments will be monitored through ongoing assessment of the wound and lack of progression towards healing, changing characteristics and goals/preferences. 1.R3's Physician Order Sheet/POS, dated 11/20/25, documents R3 admitted to the facility on [DATE] and diagnoses including Hypertension, Osteoarthritis, Type Two Diabetes with Foot Ulcer, Anemia, Polyneuropathy, Peripheral Vascular Disease, Venous Insufficiency, Pressure Ulcer of the Left Heel and Pressure Ulcer of the Right Heel. R3's 11/20/25 POS documents: follow-up with wound clinic (10/14/25); supplement for wound healing (11/11/25); send to Emergency Department for evaluation of Altered Mental Status (11/19/25); Left Heel and Right Heel cleanse (Normal Saline) and medicated dressing (Calcium Alginate with Silver) daily (11/4/25); and Left Ischium and Right Ischium cleanse (Normal Saline) and medicated dressing (Calcium Alginate with Silver) daily (11/4/25). R3's POS dated 11/20/25, does not document pressure ulcer interventions. R3's current Care Plan documents: pressure ulcers to the Left Heel, Right Heel, Left Ischium and Right Ischium; Venous Ulcers of the Left Dorsal Foot, Right Leg and Right Second Toe; liquid protein supplement (11/5/25); monitor/document location, size and treatment of skin injury and report abnormalities, failure to heal and signs and symptoms of infection to the doctor; apply stock moisture barrier cream as needed; use pressure relieving devices as appropriate; dietary supplements as ordered and dietician consult as needed to address skin issues; administer treatments as ordered; wound Page 1 of 3 145027 145027 11/20/2025 Allure of the Quad Cities 833 Sixteenth Avenue Moline, IL 61265

F 0686 physician (VOHRA) to assess and treat weekly; and weekly treatment documentation to include measurement of each area of skin breakdown. Level of Harm - Actual harm Residents Affected - Few On 6/26/25 R3's Wound Evaluation and Management Summary documents: Pressure Ulcer of the Left Heel [(Site Two), duration 30 days] measuring 1.5 cm by 3.6 cm by 0.4 cm with moderate serous drainage; Pressure Ulcer of the Right Heel [(Site Four), duration 45 days] measuring 4.7 cm by 13 by 0.4 cm; and surgical debridement of the Right Heel. On 11/18/25 R3's Wound Evaluation and Management Summary documents increased wound size: Stage Four Pressure Ulcer of the Left Heel [(Site Two), duration 175 days] measuring 2.9 by 3.5 cm by 0.3 cm with heavy serous drainage; Stage Four Pressure Ulcer of the Right Heel [(Site Four), duration 190 days] measuring 12.0 cm by 16.0 by 0.4 cm; and Stage Four Pressure Ulcer of the Right Ischium [(Site 14), duration 30 days] measuring 2.3 cm by 2.1 cm by 0.1 cm. The Wound Evaluation and Management Summary documents to elevate legs and off-load wounds and does not document any additional interventions. R3's Skin Documentation Log, dated 10/1/25 through 11/4/25, documents increased wound size: Right Heel Pressure Ulcer (Site Four), duration 148 days, measuring 6.0 centimeters/cm by 6.5 cm by 0.4 cm (10/7/25); 5.0 cm by 6.5 cm by 0.4 cm (10/24/25); 6.0 c by 6.5 cm by 0.4 cm (10/21/25); 7.0 cm by 6.0 cm by 0.40 cm (10/28/25); and 10.0 cm by 8.0 cm by 0.4 cm (11/4/25). R3's Skin Documentation Log, dated 10/2/25 through 11/4/25, documents increased wound size: Left Heel Pressure Ulcer [(Site Two), duration 133 days] measuring 2.6 cm by 3.2 cm by 0.4 cm (10/7/25); 2.0 cm by 2.6 cm by 0.4 cm (10/14/25); 3.0 cm by 3.0 cm by 0.4 cm (10/21/25); 3.0 cm by 3.0 cm by 0.4 cm (10/28/25) and 3.0 cm by 3.0 cm by .04 cm (11/4/25). R3's Skin Documentation Log, dated 10/2/25 through 11/4/25, documents: a new Left Ischium Pressure Ulcer [(Site 12), duration 8 days] measuring 2.0 cm by 2.0 cm by 0.1 cm (10/14/25); measuring 1.8 cm by 1.8 cm by 0.1 cm (10/21/25); 2.70 cm by 1.2 cm by 0.1 cm (10/28/25); and 1.90 cm by 1.0 cm by 0.1 cm (11/4/25). R3's Skin Documentation Log, dated 10/2/25 through 11/4/25, documents: a new Right Ischium Pressure Ulcer [(Site 13), duration 12 days] measuring 4.0 cm by 2.3 cm by 0.1 cm (10/14/25); measuring 1.4 cm by 0.9 cm by 0.1 cm (10/21/25); 1.2 cm by 0.7 cm by 0.1 cm (10/28/25); and 0.9 cm by 0.7 cm by 0.1 cm (11/4/25). R3's Treatment Administration Record/TAR, dated 10/1/25 through 11/19/25, does not document treatment administration on 10/1/25 through 10/14/25 (Left Ischium and Right Ischium); does not document 10/16/25 and 10/27/25 treatment (Left Heel, Right Heel and Right Ischium); does not document treatment administration on 10/27/25 (Left Ischium); does not document treatment administration on 10/10/25 and 10/13/25 (Left Heel, Right Heel, Right Ischium and Left Ischium); and does not document pressure ulcer interventions. On 11/18/25 at 1:52 pm, R3 did not have pressure reducing devices on the bed or chair. On 11/19/25 at 12:15 pm, R3 was unavailable for interview. V1 (Administrator) stated, (R3) got sent out to the hospital and got admitted . On 11/20/25 at 12:45 pm, V4 (Wound Nurse/Assistant Director of Nursing) stated, (R3) was high risk 145027 Page 2 of 3 145027 11/20/2025 Allure of the Quad Cities 833 Sixteenth Avenue Moline, IL 61265

F 0686 Level of Harm - Actual harm for skin breakdown upon admission because (R3) had other diabetic and venous ulcers. (R3) did acquire some of these pressure ulcers after admission. V4 verified that pressure ulcer preventions were not documented in the medical record and the Treatment Administration Record does not document the entirety of completion of all pressure ulcer treatments for the time period of 10/1/25 through 11/20/25. Residents Affected - Few 2. R12's current Physician Order Sheet, documents to cleanse wound to the left medial foot with normal saline, then apply medi-honey (medicated ointment) to the wound bed, then cover with a dry dressing daily and as needed. This form also documents to cleanse R12's right lateral foot with normal saline, apply a collagen sheet (medicated sheet), and cover with a bordered foam daily and as needed. On 11/19/25 at 11:45am, V8, Registered Nurse, used hand sanitizer and applied gloves. V8 applied a medicated pad to R12's right heel. V8 did no cleanse R12's wound before applying the medicated pad. V8 left the room to gather supplies for R12 wound on her right lateral foot. V8 used hand sanitizer then applied gloves. V8 lifted the dressing to look at R12's wound. V8 then attempted to reapply the dressing to the wound. V8 then removed the dressing and applied a clean dry dressing. V8 stated that she did not cleanse R12's wounds nor did she apply any medications. V8 also stated that R12 did not have a wound on her left foot. V8 verified that she did not change her gloves or perform hand hygiene during wound care. V8 also stated that R12's left foot wound care was not done at all and her right foot wound care was not done as ordered. On 11/19/25 at 2:20pm, V4, Assistant Director of Nursing/Treatment Nurse, stated that V8 needed to redo R12's treatment as ordered, not just cover it up with a dry dressing. V4 also stated that R12's wound should have been done as ordered. 145027 Page 3 of 3