Health inspection·September 19, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **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 transferred in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a fractured right ankle. This past non-compliance occurred from 8/21/25 to 8/29/25.The findings include:R1's admission record shows she was admitted to the facility on [DATE] with multiple diagnoses including muscle weakness. The 9/4/25 quarterly facility assessment shows R1 to have severe cognitive impairment. The same assessment showed impaired functional abilities to both lower extremities and requires a wheelchair for mobility. She was dependent on 2 or more staff for transfers to and from the chair/bed. The assessment defines dependent as the helper does all of the effort. The resident does none of the effort to complete the activity.R1's progress notes of 8/22/25 at 1:29 PM, documents the nurse was notified of the resident's right ankle being swollen and bruised. The notes show hospice was notified on 8/21/25 and was prescribed an antibiotic for cellulitis due to ankle being warm to touch and red. Upon assessing resident ankle, it had localized swelling and bruising to the right foot/ankle. Hospice notified again and stated they would order an x-ray.The 8/24/25 x-ray report documents a fracture involving the lateral and medial malleoli with mild displacement. The joint alignment is maintained. There is associated soft tissue swelling. The conclusion of the report shows acute ankle fractures.On 9/19/25 at 12:45 PM, V5 Certified Nursing Assistant (CNA) said R1 requires a mechanical lift, she cannot stand. She said there is always 2 staff when using the lift, one is needed to help guide the resident, or just in case anything goes wrong. And the other person operates the lift. V5 said R1 cannot get up on her own. Sometimes she will get a little anxious and move around in her bed, but that is all.On 9/19/25 at 9:17 AM, R1 was sitting up in a geriatric chair. Her right foot was wrapped with an elastic bandage and a support boot. Her eyes were closed and had no sign of discomfort.On 9/19/25 at 1:40 PM, V1 Administrator in training stated it was reported to her R1 had an acute ankle fracture of unknown origin. She stated there had been no fall or incident reported related to R1 to explain the fracture. V1 stated during her investigation she discovered V6 CNA was working on 8/20/25 on R1's hallway and already had been suspended due to an inappropriate transfer using the stand lift. She said while V6 was on suspension, this incident arose, and she called V6 to question her about R1 and her transfers. V1 said R1 should be transferred with 2 staff using the mechanical lift, and V6 reported she transferred R1 by standing her up by herself and attempted to pivot her into bed. V1 said that is when she concluded V6 had caused the fracture to R1s ankle. V1 said V6 reported to her she did not ask anyone for assistance; she took it upon herself to transfer the resident independently. She should have used the mechanical lift and asked for help. V1 said she interviewed the staff on duty with V6 and none assisted her with any transfers, and she had not asked for help. V1 said V6 was immediately terminated.The facility's undated policy for safe resident handling/transfers documents it is the policy of this facility to ensure that Page 1 of 3 145027 145027 09/19/2025 Allure of the Quad Cities 833 Sixteenth Avenue Moline, IL 61265

F 0689 Level of Harm - Actual harm Residents Affected - Few residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. 3. Mechanical lifting equipment or other approved transferring aids will be used based on the residents needs to prevent manual lifting except in medical emergencies. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. Prior to the survey date of 9/19/25, the facility had taken the following actions to correct the noncompliance:1. Corrective action for residents identified in the deficiency. A. The CNA that transferred the resident improperly is no longer a certified nurse's assistant at the facility. B. Hospice ordered a portable x-ray on 8/22/25, it was done the same day. The results were shared on 8/24/25 and showed a fracture of the right lateral and medial malleoli with mild displacement. Her ankle was immobilized and elevated per orders and medications given per orders. 2. Identifying other residents with potential for being affected and corrective action. Any resident that needs transfer assistance have the potential to be affected, but no others were identified at the time. 3. Systemic changes to reasonably assure deficiency does not recur. A. In-service was conducted by the administrator with nursing staff on 8/28/25 which included the facilities policy and procedure for safe resident handling/transfer. 4. The DON or designee will conduct QA (Quality Assurance) study to determine 1) does the resident need assistance with transferring, and 2) was the resident transferred safely and per the care plan. The QA study will be completed 5 days a week for 2 weeks, twice weekly for 2 months and weekly for 1 month. Audit results will be forwarded to the facility quarterly QAPI committee for review. 145027 Page 2 of 3 145027 09/19/2025 Allure of the Quad Cities 833 Sixteenth Avenue Moline, IL 61265

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident's medication was available for 1 of 3 residents (R2) reviewed for medication administration in the sample of 3.The findings include:R2 September Treatment Administration Record (TAR) shows he was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus without complications, non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, and cellulitis.The TAR shows an order for triamcinolone Acetonide external cream 0.1%, apply to RLE (right lower extremity) open area topically every day shift for wound care.On 9/19/25 at 11:00 AM, V9 Registered Nurse was asked to provide the triamcinolone cream applied to R2's legs. She began searching the medication cart, and the treatment cart and said there was none in stock. She said she applied the antifungal cream instead. She could not recall when she had used the triamcinolone. V9 said it should be in the medication cart and applied every day to his right leg for cellulitis. V9 looked in the pharmacy orders and said the last time the cream was ordered was May 2025. She said the triamcinolone cream was being used to prevent infection and the derma fungal cream she was using was not the same thing. On 9/19/25 at 11:10 AM, V9 presented a tube of cream labeled Derma Fungal, Miconazole Nitrate 2%, and was used to treat athletes' foot, jock itch and ring worm. On 9/19/25 at 11:23 AM, V3 Director of Nursing (DON) said the triamcinolone cream comes from the pharmacy and is a steroid cream. The nurses should be re-ordering though the computer. She said the anti-fungal cream would not be effective for R2's wound care. The nurses should not have been documenting the cream as applied if it was not available. The antifungal cream is not an appropriate substitution for triamcinolone cream. They should have contacted pharmacy and if they could not get it, they should have let us know. and not just use something random.The order summary for R2s triamcinolone cream shows the last re-order date was 6/17/25.The facility's undated policy for medication administration policy documents: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 10. Ensure that the six rights of medication administration are followed: b. Right drug. 11. Review medication administration record (MAR) to identify medication to be administered. 12. Compare medication source with MAR to verify resident name, medication name, form, dose, rout, and time. 145027 Page 3 of 3