Inspection·May 7, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent resident to resident physical assault for one resident (R5) of four residents reviewed for abuse in the sample of 27. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2025 documents: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Physical abuse includes, but is not limited to hitting, slapping, punching, biting and kicking. Final Incident Investigation Report dated 4/21/25 indicates R6 reached out and struck R5; residents separated immediately. R6 placed on 1:1 supervision until transported out of the facility to a behavioral hospital for evaluation. Nurse Note dated 4/15/2025 at 4:34pm indicates R6 argued and attempted to strike R16. Staff removed R16 to de-escalate the situation when he heard resident R5 talking to himself. R6 assumed R5 was talking about him and R6 began to yell and struck R5 on the arm. Staff intervened and separated both residents. On 5/7/25 at 11:00am V9, CNA (Certified Nurse Assistant) stated (on 4/1/5/25) she was sitting down D-Hall when she heard R6 shouting from the dining room. V9 stated as she responded to the dining room, she saw V11, LPN (licensed Practical Nurse) moving R16 away from R6 and then witnessed R6 hit R5 with his fist before she could get to R5 to remove him from proximity to R6. V9 stated because of her angle, she could see R6 strike R5 but could not see exactly where R6 made contact with R5's body. V9 stated somewhere around (R5's) chest or arm. V9 stated that she then pulled R5 away from R6 as R5 was in a wheelchair and R6 was standing. V9 stated R5 did not have any reaction to being struck by R6 and no injuries were found after R5 was assessed. V9 stated R6 continued yelling, shouting and cussing which is (R6's) usual behavior. V9 stated she believes R6's primary language is Spanish and that he gets easily frustrated when he isn't understood. V9 stated she accompanied R6 to the hospital (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 4 Event ID: 146041 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 146041 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Allure of Moline 430 South 30th Avenue East Moline, IL 61244 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)