Health inspection·August 19, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 8/17/25 at 8:20 AM, V7 LPN said R1 was on a pureed diet, and was able to feed himself. She said he was on a puree diet due to the weak muscles in this throat following a stroke. He was alert but non-verbal. He seemed to understand what was being said to him, and he knew he was not supposed to have solid foods. He would always be grabbing and sneaking food off of trays and hurry and stuff it in his mouth. V7 said R1 could propel the wheelchair himself with his left foot. She said sometimes the staff would take him out of the dining room and he would just go back in, and he would grab at food.On 8/17/25 at 11:00 AM, V5 CNA said R1 was alert and always did his own thing and did not like to listen. He did not speak; he used a lot of hand motions. She said R1 was on a puree diet, and he could feed himself, and he also had thickened liquids. He would try to take food mainly from the snack cart or food left on tables. We reminded the independent residents not to leave food behind. She said R1 was non-complaint with his puree diet and was quick to grab anything and try to eat. She said there was no special rules or procedures to ensure he left the dining room without grabbing food as he was leaving. She said it was just common knowledge among the aides to just keep an eye on him because of his behaviors of grabbing at food.On 8/17/25 at 11:20 AM, V6 CNA said she has witnessed R1 snatching food such as a pork tenderloin sandwich and a burger. She said R1 was able to feed himself and propel himself, and he did need to be watched when he was leaving the dining room. When he would get food he would stuff it in his mouth really fast because he knew he was not supposed to have it. V6 said on 8/9/25 she was in the dining room for the dinner meal and had her back turned while feeding other residents. She did not know where R1 was located at the time. She said call lights were going off on D wing, so her and V3 CNA decided to go check. She said as she was walking towards D wing she noticed R1 and he appeared to be choking. She began doing back thrusts and the Heimlich maneuver. She said it appeared bread and hot dogs were in his mouth. On 8/17/25 at 11:36 AM, V3 said she did see him once trying to take a sandwich off of another resident's tray. If he was leaving the dining room and seen a plate, he would try and take food. He wandered in his wheelchair and able to go wherever he wanted. She said the staff would monitor him but could not watch him 24/7. She said in the dining room there would be 2-3 aides sitting at a table assisting residents to eat. V3 said R1 would sit in the dining room closer to the B wing entrance and would take himself out of the dining room. Sometimes he would go around the short wall of the dining room or through it. There was no set process or procedure. V3 said she was walking with V6 towards D wing when they noted R1 to be choking and she assisted with resuscitation measures, but R1 expired. V3 said she was speaking with V4 LPN and heard her say she had just passed R1 and he had food in his mouth but did not do anything.On 8/17/25 at 12:30 PM, V4 said R1 was on a puree diet and had behaviors of taking food from the dining room tables. She did not see him before the choking incident on 8/9/25. She said R1 was able to move himself through the facility. There was no procedure or protocol in place at that time to ensure he got out of the dining room without stealing food from plates.On 8/17/25 at 2:30 PM, V1 Administrator said she was working as an LPN the night of the incident. She said during the meal service, she recalls R1 was in the dining room at his table near the entrance of B wing. He was eating his pureed diet and able to move himself around. V1 said she was at the nurse's station when she heard staff calling for help. She saw V3 and V6 giving back thrusts and performing the Heimlich maneuver, and it was not helping. She said you could tell his mouth was full of food, and as she was pulling it out, it appeared to be hot dogs and buns. V1 said 911 was called, and she continued efforts to get the food out. When the EMTs arrived, they tried to intubate him, but could not get the tube in, and R1 could not breathe. She said the EMTs tried for 40 minutes, but R1 expired. V1 said R1 was always trying to get food off plates in the dining room. Most of the time residents will yell out at the staff to alert (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146041 If continuation sheet Page 2 of 3 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 08/19/2025 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)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete us to him stealing food. She said none of the residents ever said anything. V1 said R1 was sat next to those residents needing fed, but he moved so fast. He must have picked up food while he was moving through the dining room. All of the CNAs are to be in the dining room and passing trays. During that time, R1 needed better supervision. Everyone is supposed to be monitored. Should have been watching (R1) and taking him out of the dining room. We did fail him somewhere, I guess.The facility's revised 8/11/25 policy for meal supervision and assistance documents The resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This includes: 1. Identifying hazards and risks 2. Evaluating and analyzing hazards and risks 3. Implementing interventions to reduce hazards and risks 4. Monitoring for effectiveness and modifying interventions when necessary.The immediate jeopardy that began on 8/9/25 was removed on 8/11/25 when the facility: Identified all residents who could potentially be affected by a choking incident from ingesting food not on their recommended diet, have adequate supervision in place during meals and while exiting the dining area. Care plans for residents with pureed and mechanical soft diets were reviewed for accuracy. Revisions were made to reflect all current supervision and safety interventions. The revisions were reviewed with staff involved in the care of each resident and updated on the staff assignment sheet and cheat sheets. The deficient practice was corrected on 8/11/25 after the facility: Audited care plans of all the residents requiring modified diets, and supervision while eating. All care plans have been reviewed and modified for accuracy. Environmental review of the dining room completed on 8/10/25 and table changes made as necessary as well as identified residents at risk, are now escorted from the dining room after meals. Residents on a pureed diet will be seated together for resident dignity and safety/supervision with a staff member assigned to their table. On 8/11/25 all licensed nursing staff were in-serviced on the facility policy for Meal Supervision and Incidents and Accidents. On 8/11/25 an emergency Quality Assurance and Performance Improvement (QAPI) meeting was held with the medical director. Hot Dogs will no longer be served in the building, and an adequate replacement has been implemented. Quality Assurance (QA) tools developed post QAPI to ensure quality and compliance. New staff will receive the education during their onboarding process. Event ID: Facility ID: 146041 If continuation sheet Page 3 of 3