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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 145027 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145027 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of the Quad Cities 833 Sixteenth Avenue Moline, IL 61265 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)