Health inspection·March 11, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to investigate an allegation of potential physical abuse and ensure the alleged victim was protected from further abuse for one of three residents (R4) reviewed for abuse in the sample of three. Residents Affected - Few Findings include: The Facility's Abuse, Neglect and Exploitation, not dated, documents abuse, neglect or exploitation occur. Written procedures for investigations include Identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence), investigating different types of alleged violations, identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and providing complete and thorough documentation of the investigation. On 3/11/2025 at 10 AM, R4 stated, (V5 CNA/Certified Nursing Assistant) opened my bathroom door, I was standing in front of the toilet and (V5) took a chair and hit me with it. R4 stated The chair hit me on the back of my legs. I do not feel safe here, and I am abused all the time, and no one does anything about it. On 3/11/2025 at 1:39 PM, V4 (CNA/Certified Nursing Assistant) stated on 3/9/2025, V4 heard yelling coming from R4's room. V4 stated R4 was yelling That effing (CNA/V5) pushed me down! V4 stated she then wheeled R4 sitting in his wheelchair down to V3 (LPN/Licensed Practical Nurse) and reported to V3 what R4 said to her. On 3/11/2025 at 2:09 PM, V3 (LPN/Licensed Practical Nurse) stated, V1 (Administrator in Training) instructed him to move V5 (CNA) from B Hall. V3 confirmed he moved (V5) to another hall. On 3/11/2025 at 12:18 PM, V5 stated on 3/9/2025 around 5:30PM R4 had his call light on, and V5 stated I went to check R4's call light and when I entered R4's bathroom, R4 was standing up, pulling his briefs up in front of the toilet. Then R4 shouted 'Get the F out!' and I left. V5 stated I stood in the hall and heard 'Don't hit me with that chair!' and that was when I went back in to see R4 sitting in his chair, screaming at me that I hit him with his wheelchair. On 3/10/2025, V1 (Administrator) current abuse allegations in the last 6 months have no documentation of an investigation being completed regarding R4's report of potential abuse. On 3/11/2025 at 2:20 P.M, V1 (Administrator) confirmed she did not complete an abuse investigation Page 1 of 3 146041 146041 03/11/2025 Allure of Moline 430 South 30th Avenue East Moline, IL 61244

F 0610 regarding V4's report of R4's potential abuse. V1 also confirmed she did not remove V5 (CNA) from work. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 146041 Page 2 of 3 146041 03/11/2025 Allure of Moline 430 South 30th Avenue East Moline, IL 61244

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure toilets were clean and free of fecal matter and failed to remove and store soiled wash clothes in a safe manner to prevent potential cross contamination. The failure effected three of three residents (R1, R2, R3) reviewed for infection control in a sample of three. Residents Affected - Few Findings include: The facility's Standard Precautions Infection Control Policy, not dated, documents All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors. Policies and procedures have been established for containing, transporting, and handling resident-care equipment and instruments/devices that may be contaminated with blood or body fluids. Personnel are trained in the use of these procedures. Policies and procedures have been established for routine and targeted cleaning of environmental surfaces as indicated by the level of resident contact and degree of soiling. Personnel are trained in the use of the procedures. On 3/10/2025 at 9:50 AM, R1 stated there have been several times that he has went to use the bathroom and there have been dirty wash clothes with feces on them sitting in the sink, or dirty gloves. R1's room had feces on the back of the toilet, R1 stated this happens all the time, the CNAs (Certified Nursing Assistants) do not care. On 3/10/2025 at 10:30 AM, the back of R3's toilet seat had brown fecal matter smeared on it, the brown fecal matter was spread all along the curved back part of the toilet seat about 4 inches in length, the washcloth on the sink was wet and off-white laying on the left side of the resident's sink. On 3/10/2025 at 10:40 AM, V7 (CNA/Certified Nursing Assistant) confirmed R3's bathroom had fecal matter spread along the back portion of the toilet seat, 4 inches in length, and that there was a wet, off white wash cloth laying on the left side of the sink. On 3/10/2025 at 11:10 AM, R2 stated she has gone into her bathroom and found dirty wash clothes with fecal matter all over them in the sink, and dirty adult incontinent briefs with fecal matter on the floor next to the trash can. R2 stated she has seen fecal matter splattered on the walls in the bathroom as well. R2's toilet had brown fecal matter on the seat. On 3/10/2025 at 12:43 PM, V11 (Housekeeper) stated, some days when she enters a resident's room, there will be dirty wash clothes with brown fecal matter, dirty briefs in the garbage cans or next to the garbage can. V11 stated residents are grouped two residents to one room that share a bathroom, and the room next to them share the same bathroom. On 3/11/2025 at 2:20 PM, V2 (Director of Nursing) stated that she was aware CNAs (Certified Nursing Assistants) were leaving dirty wash clothes in resident's rooms, and not cleaning up after themselves. 146041 Page 3 of 3