Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Allure Of Moline during CMS and state inspections, most recent first.
The facility failed to honor several residents' expressed preferences not to be served meals on Styrofoam, instead providing lunch on Styrofoam plates with Styrofoam cups and plastic utensils despite residents stating they preferred ceramic or regular dishes and reporting this had occurred multiple times. Staff, including CNAs, confirmed that Styrofoam products were routinely used for room trays and sometimes in the dining rooms. The Administrator questioned the use of Styrofoam during an observed meal, and the DON acknowledged that using Styrofoam at mealtimes was a dignity issue inconsistent with the facility’s policy to promote and maintain residents’ dignity during meals.
Medication Storage and Administration Error: An LPN was observed carrying two medication cups and a drink in the dining room, then giving meds to two residents after first delivering a missed protein drink to another resident. The LPN stated the cups contained all of the two residents’ scheduled AM meds, while the Administrator stated meds should remain in the carts and nurses should pass only one resident’s medications at a time to avoid possible medication errors.
Failure to prevent resident-to-resident physical abuse involving two residents. One resident pushed another into a wall during a smoke break rush, and another resident lightly smacked a resident’s arm after becoming annoyed by his mumbling and noises. The Administrator confirmed both physical abuse allegations were substantiated.
A resident with left-sided hemiplegia following a CVA did not have her call light within reach while in bed, after a CNA reportedly removed it due to frequent use. Staff confirmed the resident could not access the call light on her own, and facility policy required it to be accessible for residents needing assistance.
A resident with dysphagia and moderate cognitive impairment, who required a pureed diet and close supervision, was left unsupervised in the dining room. The resident, known for taking food from others' trays, accessed and consumed solid foods, resulting in a fatal choking incident. Staff interviews revealed there was no formal supervision protocol in place to prevent such occurrences.
A resident who was alert, oriented, and dependent on staff for bathing was left exposed during a shower when a CNA failed to fully close the shower room door. The resident expressed discomfort with the lack of privacy, and staff interviews confirmed that facility policy requires doors to be closed during personal care to maintain dignity.
The facility did not ensure an RN was on duty for eight consecutive hours each day, as required, over multiple days. Staffing records and schedules showed repeated gaps in RN coverage, and leadership acknowledged ongoing recruitment challenges and selective hiring practices. This deficiency had the potential to impact all residents in the facility.
The facility did not provide required written notice of its bed hold policy to residents or their representatives when residents were transferred to the hospital. Medical records for several residents lacked documentation of this notification, and the Administrator confirmed that bed hold notices were not issued as required.
A resident receiving Lithium Carbonate had a physician's order for lithium levels to be checked every three months, but the facility did not document any lithium level checks after the initial test. The DON confirmed that no further monitoring was completed as required by the physician's order and facility policy.
The facility did not follow its abuse policy after a verbal altercation between two residents, as the incident was only noted in a care plan without a nursing progress note, investigation, or report to the state agency. The Administrator in Training was not informed, and required procedures for investigation and reporting were not followed.
The facility did not report an allegation of resident-to-resident verbal abuse, including threats of physical harm, to the Abuse Coordinator or the State Agency as required by policy. The incident was documented in a care plan after being discussed in a morning meeting, but no formal abuse report was made due to lack of communication among staff.
The facility did not investigate an alleged incident of resident-to-resident verbal abuse, despite its policy requiring immediate action and documentation. The event was only noted in a care plan after being discussed in a morning meeting, with no formal investigation or notification to the Abuse Coordinator.
A resident dependent on staff for hygiene did not receive scheduled showers as required by facility policy, with documentation showing missed showers and no record of refusals or care provided. The DON confirmed that the expected frequency of showers and documentation was not met, and the resident's family noted ongoing concerns about the resident's hair hygiene.
A CNA did not follow facility policy for catheter care by cleansing only the perineal area and omitting care to the meatus and catheter tube for a resident with an indwelling urinary catheter. Both the CNA and DON confirmed that full catheter care should include cleaning the meatus, perineal area, and catheter tube each time.
A resident with end stage renal disease did not consistently receive physician-ordered daily weights or scheduled doses of Lokelma to manage high potassium levels. Documentation showed missed weights and medication administrations over several weeks, despite facility policy and care plan requirements for daily monitoring and timely medication for dialysis care. The DON confirmed the missed care and cited issues with insurance and pharmacy supply for the medication.
A LPN administered insulin to a resident with Type 2 Diabetes Mellitus without wearing gloves, contrary to the facility's infection control policy requiring standard precautions for procedures involving potential exposure to blood or body fluids.
For approximately a month, 22 residents on one hall did not have access to hot or warm water in their rooms, requiring CNAs to obtain hot water from the nurses station for resident care. Both staff and residents reported the issue, and maintenance logs confirmed consistently low water temperatures well below policy standards. The problem began after new water pipes were installed, and despite internal checks and notifications, no external help was sought to resolve the deficiency.
A resident with a history of aggressive behavior and communication barriers physically struck another resident with severe cognitive impairment in the dining room. Staff intervened after the assault, and no injuries were found. The aggressive resident's care plan did not address his language needs, despite repeated incidents of escalating behavior and prior staff interventions.
A resident with multiple diagnoses was found with her morning medications left unattended at her bedside, as an LPN did not remain to observe her taking them. The resident was unaware the medications were there, and facility policy requires staff to observe medication consumption. The DON confirmed that medications should not be left on the table and that staff are to stay with residents until all pills are taken.
A resident reported being hit by a CNA with a chair, expressing feelings of being unsafe and frequently abused. Another CNA heard the resident's distress and reported it to an LPN. Despite these reports, the facility did not investigate the allegations or remove the CNA from duty, leading to a deficiency in handling abuse allegations.
The facility failed to maintain proper infection control, with fecal matter found on toilets and improper storage of soiled washcloths. Residents reported unsanitary conditions, confirmed by staff, indicating a lapse in adherence to infection prevention policies.
The facility failed to provide the required RN coverage for several days, affecting all 91 residents. The nursing schedule showed no RN coverage on multiple days, and limited hours on others. The DON confirmed the issue, citing difficulty in attracting RN applicants.
The facility failed to follow its Enhanced Barrier Protection and Contact Isolation Precautions policy, leading to infection control deficiencies. Staff did not consistently use required PPE, such as gowns and masks, during high-contact care activities for residents under isolation precautions. Observations showed staff performing care with only gloves, despite the need for additional protective equipment, as confirmed by the DON and other staff.
A resident with severe cognitive impairment tested positive for Covid-19, and the facility initiated isolation precautions. However, the resident's family was not informed of the positive test until two days later, contrary to the facility's policy requiring immediate notification of significant changes in condition. This delay was confirmed by the DON.
A CNA in the facility was found to have verbally abused and neglected residents, including making them wait unnecessarily and using derogatory language. Two residents reported the CNA's refusal to assist those not assigned to her and her inappropriate behavior towards confused residents. The facility's investigation confirmed these allegations, resulting in the CNA's termination.
The facility failed to provide written notice of transfer to three residents and their representatives, as required by their policy. The medical records showed that these residents were transferred to a local hospital, but there was no evidence of the required written notice. The Corporate Compliance Nurse confirmed the lack of documentation and notification.
A resident reported feeling intimidated and humiliated by a CNA who turned off the call light without addressing needs, changed the resident without communication, and got the resident up without consent. The resident expressed feelings of dread and belittlement, leading to the CNA's termination after an investigation confirmed mental and verbal abuse.
A resident with bipolar disorder and autistic disorder experienced theft and exploitation when the former BOM opened an account in the resident's name and withdrew $11,900 without consent. The resident was cognitively intact, and the facility's policy on misappropriation of resident property was violated. The former BOM's employment was terminated, and a police report was filed.
The facility failed to prevent verbal abuse by a Certified Nurse Aide (V5) who took away a resident's (R2) urinal, causing distress and leaving the resident in a wet bed. R2 and another resident (R7) reported that V5 often refused to help and made disparaging comments about their ability to care for themselves. The allegations were confirmed, and V5 was terminated.
A facility failed to ensure timely response to a resident's call light. A CNA was observed using her cell phone instead of responding to a resident with a leaking colostomy bag. The resident's care plan required prompt assistance due to visual/hearing impairments and a history of falls. The administrator acknowledged challenges in preventing staff from using cell phones during shifts.
Failure to Honor Resident Preferences Regarding Use of Styrofoam During Meals
Penalty
Summary
The facility failed to honor multiple residents' stated preferences not to be served meals using Styrofoam products, affecting 8 of 12 residents reviewed for dignity. During a lunch observation, several residents were served their meals on Styrofoam plates with Styrofoam cups and plastic utensils. One resident stated they had previously informed staff they did not like Styrofoam and preferred ceramic or regular dishes. Other residents commented that it would be nice to be served meals in regular dishes and reported that this was not the first time they had been served using Styrofoam products. Additional residents reported they had been served meals on Styrofoam in the past and expressed a preference for regular dishes. Staff interviews confirmed that Styrofoam products were used for residents who ate in their rooms and were also used at times in the dining rooms during meals and for room trays. The Administrator, who was present in the dining room during the observed lunch, questioned why Styrofoam products were being used and stated they should not be used, indicating awareness that regular dishes were expected. The DON acknowledged that using Styrofoam during meals was a dignity issue and emphasized that the facility was the residents' home and that regular dishes should be used at mealtimes. The facility’s policy on promoting and maintaining residents’ dignity during mealtimes states that residents are to be treated with respect and dignity in a manner that maintains or enhances quality of life and recognizes residents’ individuality and rights, which was not followed when residents’ expressed preferences regarding dishware were not honored.
Medication Storage and Administration Error
Penalty
Summary
The facility failed to securely store medications for two residents, R15 and R21, with the issue affecting medications stored on the E Hall cart for residents R5, R6, and R9 through R42. The facility’s undated Medication Storage document states that medications are to be stored in the pharmacy and/or medication rooms according to manufacturer recommendations and in a manner that ensures proper sanitation, temperature, light and ventilation, moisture control, segregation, and security. On 11/25/25 at 8:45 AM, an LPN was observed in the main dining room holding two clear medication cups with pills and a glass of tan-brown liquid. The LPN handed the liquid to one resident, then gave medications to R15 and another cup to R21. At 9:15 AM, the LPN stated she had forgotten to give a resident his protein drink, so she dropped that off and then administered R15 and R21’s medications. The LPN stated the medication cups contained all of R15 and R21’s scheduled 8:00 AM medications. R15’s MAR listed Gabapentin 100 mg, Aspirin 81 mg, Baclofen 10 mg, Multiple Vitamins with Minerals, Pepcid 20 mg, and Senna Tablet 8.5 mg. R21’s MAR listed Famotidine 20 mg, Lithium Carbonate 150 mg, Ascorbic Acid 500 mg, Aspirin 325 mg, Potassium Chloride 20 meq, Vitamin D3 2000 Units, Eye-Vites, and mucus relief 400 mg. At 10:00 AM, the Administrator stated that all medications should be kept in the carts and nurses should only pass one person’s medications at a time to avoid possible medication errors.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent abuse for two residents reviewed for abuse, involving resident-to-resident physical abuse. The facility’s undated Abuse, Neglect and Exploitation policy states it is intended to protect each resident’s health, welfare, and rights by preventing abuse, neglect, exploitation, and misappropriation of resident property. The facility’s Final Investigative Report dated 11/10/25 documented that one resident pushed another resident into a wall. On 11/25/25 at 2:30 PM, the resident who was pushed confirmed that he had been pushed by the other resident some time ago, but stated, “I ran into the wall.” He also stated he was relatively new to the facility and did not realize that when staff announced smoke break time, some residents would run for the door. The facility’s Final Investigative Report dated 11/24/25 documented that another resident struck a different resident on the arm. The investigation stated that the resident who was struck had a history of mumbling to himself and making random noises, which annoyed the other resident and led to the arm strike. Throughout the survey, the resident who was struck did not answer questions and was observed mumbling incoherently and making clicking noises. On 11/25/25 at 2:45 PM, the resident who struck him confirmed that he lightly smacked the other resident’s arm because those noises were annoying. On 11/26/25, the Administrator confirmed that both allegations of physical abuse were substantiated because they did happen.
Call Light Not Accessible for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident, who was unable to move her left side due to a cerebrovascular accident (CVA) and required substantial assistance for bed mobility, did not have her call light within reach while in bed. The resident reported that a CNA entered her room at night, took her call light away, and told her she was using it too much. Observations confirmed that the call light was placed on the nightstand, out of the resident's reach, and staff interviews corroborated that the resident could not have moved the call light herself due to her physical limitations. Staff interviews further revealed that the resident frequently used her call light for assistance, particularly at night, and facility policy required that the call light be accessible and secured for residents. The care plan for the resident specifically indicated the need to encourage her to use the call bell for assistance, given her self-care deficits. Despite these requirements, the call light was not accessible, resulting in a failure to accommodate the resident's needs and preferences as required.
Failure to Supervise Resident with Dysphagia During Meals Resulting in Fatal Choking Incident
Penalty
Summary
A deficiency occurred when a resident with dysphagia, who was on a pureed diet and required close supervision during meals, was left unsupervised in the dining room. The resident had a history of cerebral infarction, hemiplegia, aphasia, and moderate cognitive impairment, and was known to be at risk for choking and aspiration. Care plans and physician orders specifically indicated the need for supervision during meals and noted the resident's tendency to take food from other residents' trays, as well as attempts to eat nonfood items. On the day of the incident, the resident finished his pureed meal and was able to self-propel his wheelchair across the dining area. Staff interviews revealed that the resident was known for quickly grabbing and consuming food not on his prescribed diet, particularly when unsupervised or while leaving the dining room. Multiple staff members acknowledged that there was no formal process or procedure in place to ensure the resident did not access inappropriate foods when exiting the dining area. Supervision was described as informal, relying on staff awareness and reminders to other residents not to leave food unattended. During the incident, staff were occupied with other duties and did not notice the resident's movements. The resident was later found in distress, choking on solid food items such as bread and hot dogs, which were not part of his prescribed diet. Despite immediate intervention by CNAs, an LPN, and EMTs, the resident was unable to be resuscitated and expired. Staff interviews confirmed that the lack of a structured supervision protocol contributed to the resident's ability to access and consume hazardous foods, leading to the fatal choking event.
Failure to Ensure Privacy During Resident Shower
Penalty
Summary
A deficiency occurred when a resident was not provided privacy during a shower. On the observed date and time, the shower room door in the C hall was left halfway open while a resident, who was naked and covered in soap, was being assisted by a CNA. Both the resident and the CNA confirmed that the door should have been closed, and the resident expressed discomfort with the door being open. Interviews with facility staff, including the Administrator, another CNA, and the Assistant Director of Nursing, confirmed that facility policy requires the door to be closed during showers to maintain resident privacy and dignity. The resident involved had multiple medical diagnoses, including Parkinson's disease, osteomyelitis, COPD, diabetes, and other chronic conditions. She was alert, oriented, and dependent on staff for bathing and toileting. The facility's policy on promoting and maintaining resident dignity specifically states that staff must ensure privacy during care, including showers. The failure to close the shower room door resulted in a lack of privacy for the resident during personal care.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Professional Nurse (RN) for eight consecutive hours a day, seven days a week, as required. Review of the facility's daily staff posting sheets and monthly nursing schedule over a specified period revealed multiple days where there was no documented eight-hour RN assignment. The facility's own assessment tool indicated the necessity of appropriate staffing, including RNs, to meet resident care needs. During an interview, the Corporate Nursing Officer acknowledged ongoing difficulties in recruiting and retaining RNs, despite increased pay and incentives, and noted reluctance to hire certain available RNs due to concerns about their work history or reputation. This deficiency had the potential to affect all 99 residents residing in the facility, as documented in the facility's application for Medicare and Medicaid.
Failure to Provide Bed Hold Policy Notice at Time of Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives at the time of transfer to the hospital, as required by facility policy. Record review showed that four residents who were discharged or hospitalized on multiple occasions did not have documentation in their medical records indicating that they or their representatives received the bed hold policy notice. Specifically, the records for these residents lacked evidence of written notification at the time of each transfer for hospitalization or therapeutic leave. During an interview, the Administrator confirmed that bed hold notices were not given at the time of transfer and acknowledged that the facility was aware of this ongoing issue.
Failure to Monitor Lithium Levels as Ordered
Penalty
Summary
The facility failed to monitor blood levels of a psychotropic medication, Lithium Carbonate, as ordered by the physician for one resident. The resident had a physician's order for Lithium Carbonate 450 mg twice daily and for lithium levels to be checked every three months, starting from 2/5/2024. The last documented lithium level in the resident's medical record was from 11/5/2024, and as of 5/20/2025, there was no documentation of any subsequent lithium level checks. The Director of Nursing confirmed that the resident had not had their lithium level checked since the last recorded date, despite the standing order and facility policy requiring timely laboratory monitoring.
Failure to Implement Abuse Policy Following Resident Verbal Altercation
Penalty
Summary
The facility failed to implement and follow its Abuse, Neglect, and Exploitation policy for two of three residents reviewed for abuse. The policy requires immediate investigation and reporting of all alleged violations, including verbal altercations, to the Administrator and appropriate agencies within specified timeframes. However, a verbal altercation involving two residents was documented in a care plan, but there was no corresponding nursing progress note, abuse investigation, or report to the state agency. The Social Service Director noted the incident in the care plan after it was discussed in a morning meeting, but could not recall which nurse reported the incident, and there was no documentation of the event over the weekend when it occurred. The Administrator in Training, who serves as the facility's Abuse Coordinator, confirmed that she was not made aware of the incident and that no investigation or report was initiated. The lack of communication and documentation by nursing staff and the Social Service Director resulted in the failure to follow the facility's abuse policy, which mandates prompt investigation and reporting of all abuse allegations, including those involving verbal altercations between residents.
Failure to Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to both the facility's Abuse Coordinator and the State Agency for two of three residents reviewed for abuse. According to the facility's Abuse, Neglect and Exploitation policy, all alleged violations must be reported to the Administrator, state agency, and other required agencies within specified timeframes. In this case, a verbal altercation, including threats of physical harm, occurred between two residents. The incident was documented in one resident's care plan after being discussed in a morning meeting, but no abuse report was made to the Abuse Coordinator or the State Agency. The Social Service Director confirmed she documented the incident in the care plan based on information from a morning meeting but was not present during the weekend when the incident occurred and could not identify the reporting nurse. The Administrator in Training, who also serves as the facility's Abuse Coordinator, confirmed she was not informed of the incident and that no abuse report was submitted to the state agency. The lack of communication and failure to follow reporting procedures resulted in the deficiency.
Failure to Investigate Resident-to-Resident Verbal Abuse Allegation
Penalty
Summary
The facility failed to investigate an alleged incident of resident-to-resident verbal abuse involving two residents. According to the facility's Abuse, Neglect and Exploitation policy, any suspicion or report of abuse, including verbal altercations, requires an immediate investigation, including identifying and interviewing all involved parties and thorough documentation. However, for an incident involving a verbal altercation and threats of physical harm between two residents, there was no documentation of an abuse investigation, no nursing progress note detailing the event, and no evidence that the required investigative steps were taken. The care plan for one resident was updated to reflect the altercation, but this was based on information shared during a morning meeting and not on a formal investigation. The Social Service Director confirmed that the incident was reported after the weekend, but she did not know which nurse initially reported it, and there was no follow-up with the Abuse Coordinator. The Abuse Coordinator stated she was not made aware of the incident and would have expected to be notified to initiate an investigation. As a result, the facility did not respond appropriately to the alleged violation as required by its own policy.
Failure to Provide Scheduled Showers and Document Hygiene Care
Penalty
Summary
A resident who was dependent on staff for hygiene did not receive the required weekly showers as outlined in the facility's policy. The policy states that residents should be assisted with bathing to maintain proper hygiene, with showers provided according to a set schedule or upon request. Observation revealed the resident was in a high-back wheelchair, appeared pleasantly confused, and had oily, unwashed hair. The resident's family member reported that although the resident was scheduled for showers twice a week, the hair often appeared greasy and unwashed unless specifically requested or washed by the family member. Review of the resident's shower documentation for May showed showers were only recorded on three dates, with no documentation of any showers from May 10th to May 20th. The Director of Nursing confirmed that the resident should have received two to three showers during this period and that there was no documentation of refusals or showers provided. The expectation was that CNAs complete a shower sheet for each shower, and refusals should be documented in the notes, but neither was present for this resident during the specified timeframe.
Failure to Perform Complete Catheter Care per Facility Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to perform indwelling urinary catheter care according to facility policy for a resident with a urinary catheter. The facility's policy requires that catheter care be performed every shift and as needed, including cleansing the resident's meatus, perineal area, and the catheter tube itself. During an observed catheter care procedure, the CNA assisted the resident to stand and cleansed only the perineal area, omitting care to the meatus and the catheter tube. The CNA later confirmed that the meatus and catheter tube should have been cleansed during the procedure. The Director of Nursing (DON) also verified that proper catheter care for a male resident includes cleaning the meatus, perineal area, and catheter tube each time care is provided. This failure to follow established catheter care procedures was identified for one resident reviewed for urinary catheters out of a sample of 35.
Failure to Provide Prescribed Dialysis Medication and Daily Weights
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end stage renal disease who required hemodialysis. The resident had physician orders and a care plan specifying the need for daily weights and administration of Lokelma (sodium zirconium cyclosilicate) on specific days to manage high potassium levels. Documentation showed that the resident was not weighed on several ordered days in April and May, and multiple scheduled doses of Lokelma were not administered during this period. The medication was prescribed in response to a significantly high potassium level, and the care plan required close monitoring and collaboration with the dialysis center. The Director of Nursing confirmed that there were multiple missed daily weights and missed doses of Lokelma, citing issues with insurance coverage and pharmacy supply for the medication. The facility's own policy required timely medication administration and daily weights for residents receiving hemodialysis, as well as communication with the dialysis center regarding treatment orders and resident status. Despite these requirements, the resident did not consistently receive the prescribed medication or daily weights as ordered by the physician.
Failure to Use Gloves During Insulin Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to apply gloves during the administration of insulin to a resident with Type 2 Diabetes Mellitus. The facility's infection control policy requires staff to use standard precautions, including wearing personal protective equipment such as gloves, when there is potential exposure to blood or body fluids. During observation, the LPN prepared and administered five units of Humalog Insulin subcutaneously to the resident's left arm without donning gloves, then disposed of the used syringe. The LPN confirmed that gloves were not used during the procedure, which was not in accordance with the facility's infection control guidelines.
Failure to Maintain Safe Hot Water Temperatures in Resident Care Area
Penalty
Summary
The facility failed to provide hot water at comfortable temperatures for 22 residents residing on D-Hall. Certified Nurse Assistants (CNAs) and residents reported that there had been no hot or even warm water in any of the rooms on D-Hall for about a month. CNAs had to obtain hot water from the nurses station to clean residents in the mornings, and residents described the water from their bathroom sinks as cold and uncomfortable. Maintenance staff confirmed the issue, noting that water temperatures in resident rooms reached only 76 degrees Fahrenheit after several minutes, which is below the facility's policy for safe water temperatures. Maintenance logs showed a pattern of low water temperatures in D-Hall rooms over several weeks, with readings as low as 49 to 76 degrees Fahrenheit. The Maintenance Director acknowledged being informed of the problem by nursing staff one to two weeks prior and stated that the issue began after new water pipes were installed about a month ago. Despite checking equipment and notifying the Corporate Maintenance Director, no outside assistance had been called to address the ongoing lack of hot water. Facility policy requires maintaining appropriate water temperatures in resident care areas, but this standard was not met for the affected residents on D-Hall.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault involving a resident with Alzheimer's dementia and severe cognitive impairment and another resident with Paranoid Schizophrenia and moderate cognitive impairment. The incident occurred when one resident, who has a history of aggressive behavior and communication difficulties due to language barriers, became agitated and struck another resident in the dining room. Staff were present and intervened to separate the residents, but the assault had already occurred. The resident who was struck did not exhibit a reaction and was assessed with no injuries found. Prior to the incident, there were multiple documented episodes of the aggressive resident displaying escalating behaviors, including yelling, cursing, and attempts to strike other residents. Staff had to intervene on several occasions to prevent altercations. The care plan for the aggressive resident identified risks for verbal and physical aggression but did not address his communication or language needs, despite staff observations that language barriers contributed to his frustration. Both residents involved were assessed as being at moderate risk for mistreatment.
Failure to Observe Medication Administration
Penalty
Summary
A resident who was cognitively intact and had multiple diagnoses, including hypertension, anxiety, depression, and respiratory failure, was observed lying in bed with a cup containing five pills and three large chewable tablets on the bedside table. The resident was unaware that her morning medications were present and could not recall how long they had been there. The May 2025 Medication Administration Record indicated that her morning medications included duloxetine, loratadine, calcium, dronedarone, pregabalin, and calcium carbonate. An LPN reported that she had completed the medication pass, provided the resident with her medication cups, and instructed her to take them but did not remain to observe the resident consume the medications. The LPN acknowledged that she should have stayed to ensure the medications were taken. The DON confirmed that facility policy requires nurses to observe residents taking their medications and not to leave medications unattended. The facility's policy also specifies that staff must observe resident consumption of medication.
Failure to Investigate Alleged Abuse and Protect Resident
Penalty
Summary
The facility failed to investigate an allegation of potential physical abuse and ensure the alleged victim was protected from further abuse. A resident, identified as R4, reported that a CNA, referred to as V5, hit them with a chair while they were in the bathroom. R4 expressed feeling unsafe and stated that they were abused frequently without any intervention. Another CNA, V4, heard R4 yelling about being pushed down by V5 and reported this to an LPN, V3. Despite these reports, the facility did not conduct a thorough investigation into the allegations. The Administrator, V1, confirmed that no investigation was completed regarding the potential abuse reported by R4. Additionally, V1 did not remove V5 from their duties, although V3 was instructed to move V5 to a different hall. The lack of documentation and investigation into the abuse allegations, as well as the failure to protect the resident from further potential abuse, highlights a significant deficiency in the facility's handling of abuse allegations.
Inadequate Infection Control Measures
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as evidenced by the presence of fecal matter on toilets and improper storage of soiled washcloths. Observations revealed that three residents experienced unsanitary conditions in their shared bathrooms. One resident reported finding dirty washcloths with feces in the sink and fecal matter on the toilet, which was confirmed by a CNA. Another resident also reported similar issues, including dirty adult incontinent briefs on the floor and fecal matter on the bathroom walls. A housekeeper corroborated these findings, noting the frequent presence of soiled washcloths and briefs in resident rooms. The Director of Nursing acknowledged awareness of the issue, indicating that CNAs were not adequately cleaning up after themselves. The facility's Standard Precautions Infection Control Policy mandates that all staff assume residents may be infected or colonized with transmissible organisms, requiring adherence to standard precautions to prevent infection spread. However, the observed conditions and staff admissions suggest a failure to implement these policies effectively, leading to potential cross-contamination and compromised infection control.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required nursing coverage of a Registered Nurse (RN) for the period of July 8-17, 2024. This deficiency has the potential to affect all 91 residents residing in the facility. According to the facility's nursing schedule, there was no RN coverage on July 8, 9, 10, 15, 16, and 17, 2024. Additionally, on July 12, 2024, an RN was present for only 8 hours, and on July 13-14, 2024, an RN was present for only 4 hours each day. The Director of Nursing confirmed the lack of RN coverage during this period and acknowledged the facility's difficulty in attracting RN applicants, which has resulted in being cited for this deficiency.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Protection and Contact Isolation Precautions policy and procedures for five residents, leading to deficiencies in infection control practices. The Enhanced Barrier Precautions policy requires the use of personal protective equipment (PPE) such as gloves, gowns, and masks during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. However, observations revealed that staff did not consistently use the required PPE when entering rooms of residents under contact isolation or enhanced barrier precautions. For instance, a resident colonized with ESBL and under contact isolation had a sign on their door instructing staff to wear gloves, gowns, and masks, yet the PPE bin outside the room lacked isolation gowns. A CNA was observed inside the room without PPE and did not perform hand hygiene upon exiting. Similarly, another resident with a wound and an indwelling urinary catheter was under enhanced barrier precautions, but staff performed care activities wearing only gloves, neglecting to use gowns and masks as required. Additional instances included staff performing wound care and gastric tube management for residents under enhanced barrier precautions while only wearing gloves, despite the need for gowns and masks to prevent potential fluid splashes. These observations indicate a systemic failure to implement the facility's infection prevention and control policies, as confirmed by the Director of Nursing and other staff members.
Failure to Timely Notify Family of Resident's Covid-19 Diagnosis
Penalty
Summary
The facility failed to notify a resident's representative of a change in condition in a timely manner. The facility's policy requires informing the resident, consulting the resident's physician, and notifying the resident's family member or legal representative when there is a significant change in the resident's physical condition or when new treatment is required. In this case, a resident with severe cognitive impairment tested positive for Covid-19 on March 26, 2023, and isolation precautions were initiated. However, the resident's family was not informed of the positive Covid-19 test until March 28, 2024, as verified by the Director of Nursing. This delay in notification constitutes a failure to adhere to the facility's policy on notification of change.
Verbal Abuse and Neglect by CNA
Penalty
Summary
The facility failed to prevent verbal abuse and neglect of a resident, identified as R70, among a sample of 29 residents. The facility's policy, dated February 2023, mandates the protection of residents from abuse and neglect. However, during a group meeting, R70 reported that a Certified Nurse Aide (CNA), identified as V8, was hateful and refused to help residents, including making them wait unnecessarily. R70 also observed V8 telling confused residents to leave her alone. Another resident, R18, corroborated these claims, stating that V8 was rude, refused to assist residents not assigned to her, and used derogatory language towards confused residents. R70 provided a written statement on July 17, 2024, further detailing V8's inappropriate behavior, including refusing to help those in need and turning off call lights without returning to assist. The facility's incident log from July 16, 2024, confirmed the allegations, documenting that V8 was verbally inappropriate and abusive, creating an environment where residents might be afraid to ask for assistance. The investigation concluded that V8's actions were abusive, leading to her termination from the facility.
Failure to Provide Written Notice of Transfer
Penalty
Summary
The facility failed to provide written notice of transfer to three residents and their representatives, as required by their Notification of Change policy. The policy mandates that the facility must inform the resident, consult the resident's physician, and notify the resident's family member or legal representative when there is a change requiring such notification, including a transfer or discharge. Specifically, the medical records for three residents, identified as R41, R74, and R94, showed that they were transferred to a local hospital on different dates, but there was no evidence that the facility provided the required written notice of transfer to the residents or their representatives. On July 18, 2024, at 2:00 PM, the Corporate Compliance Nurse (V7) confirmed that the facility did not provide the necessary written notices of transfer for these residents. This lack of documentation and notification represents a failure to comply with the facility's policy and regulatory requirements for resident transfers.
Failure to Prevent Mental Abuse
Penalty
Summary
The facility failed to prevent mental abuse for one resident (R3) as evidenced by the actions of a Certified Nursing Assistant (CNA), identified as V5. According to the report, R3 reported an incident where V5 turned off the call light without addressing R3's needs, later returned to change R3 without any communication, and then proceeded to get R3 up without consent. R3 expressed feelings of intimidation, humiliation, and dread towards V5, describing the CNA as unprofessional and unapproachable. The incident was reported to the Administrator in Training, who confirmed that R3 felt belittled and humiliated by V5's behavior. R3's care plan was updated to reflect the risk for abuse and to encourage finding a trusted staff member to talk to without feeling humiliated. Further investigation revealed that V6, an LPN, also observed R3's distress and confirmed R3's negative feelings towards V5. V6 stated that R3 described V5 as cold, rude, and deflating, and mentioned that V5's behavior made R3 feel terrible. V6 did not report the issue earlier because V5 was not present at the time. The facility's policy on abuse, neglect, and exploitation was reviewed, which defines mental abuse as including humiliation, harassment, and threats of punishment or deprivation. The investigation concluded with the termination of V5, confirming the allegation of mental and verbal abuse.
Misappropriation of Resident Funds by Former BOM
Penalty
Summary
The facility failed to protect a resident with diagnoses of bipolar disorder and autistic disorder from theft and exploitation. The former Business Office Manager (BOM) opened an account in the resident's name and withdrew $11,900 without the resident's consent. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 15/15, experienced unauthorized transactions from their ABLE account to the BOM's personal electronic money account. The facility's policy on abuse, neglect, and exploitation clearly defines misappropriation of resident property, which was violated in this case. The facility's final report to the State Agency indicated that the investigation was ongoing and that the family was not cooperating with the staff. However, a police report was filed. The former BOM's employment was terminated after the incident was discovered. The resident's father reported the issue to the facility and subsequently filed a police report when he noticed the discrepancy in the account balance. The Regional Nurse confirmed that the former BOM should not have taken the resident's funds.
Failure to Prevent Verbal Abuse by Certified Nurse Aide
Penalty
Summary
The facility failed to prevent the verbal abuse of a resident (R2) by a Certified Nurse Aide (V5). According to the report, V5 instructed another Certified Nurse Aide (V6) to take away R2's urinal, which V6 refused to do. V5 then took the urinal herself, causing distress to R2. R2 reported that this was not the first time V5 had taken his urinal, and that V5 would often take it away if he asked for too much help during the night, leaving him in a wet bed. R2 also mentioned that V5 had previously refused to button his shirt and made disparaging comments about his ability to care for himself. Another resident (R7) corroborated R2's claims, stating that V5 often refused to help and made similar comments about their ability to perform self-care tasks. The facility's Abuse Investigation confirmed the allegations of verbal abuse, leading to the termination of V5. The investigation included interviews with other residents, which supported the claims against V5. Despite attempts to obtain a statement from V5, she did not provide any information or feedback, and all communication was handled through her union. The facility's policy on Abuse, Neglect, and Exploitation clearly defines verbal abuse and mandates protections for residents, which were not upheld in this instance.
Failure to Respond to Call Light in a Timely Manner
Penalty
Summary
The facility failed to ensure staff responded to a resident's request for assistance in a timely manner. The incident involved a resident with diagnoses including colostomy, cataracts, and glaucoma. On the specified date, two call lights were activated at the nurse's station, one of which was from the resident's room. A Certified Nurse Assistant (CNA) was observed sitting in the hallway near the resident's room, looking at her personal cell phone and not responding to the call light. When questioned, the CNA admitted she had not noticed the call light and promptly attended to the resident. The resident needed help with putting on socks and addressing a leaking colostomy bag, which had caused stool to leak through his pants. The resident expressed concern about missing his smoke break due to the delay in assistance. The CNA acknowledged that the call light had been on for at least five minutes and recognized that even this duration was too long when the resident had feces on his skin. The resident's care plan indicated a need for prompt response to all requests for assistance due to a history of falls and visual/hearing impairments. The facility's policy on call lights emphasized that all staff members are responsible for responding to activated call lights. The administrator acknowledged difficulties in ensuring staff refrain from using their cell phones while on duty and confirmed that the CNA in question had just started her shift and should have been attending to call lights instead of using her phone.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near East Moline
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hope Creek Nursing & Rehab | 0.9 mi | ★★★★★ | 6 | 0 |
| Silvis Center For Nursing Rehab & Care | 1.6 mi | ★★★★★ | 6 | 0 |
| Celebrate Sr Living Of Moline | 1.6 mi | ★★★★★ | 1 | 0 |
| Avenues At Quad Cities | 1.9 mi | ★★★★★ | 0 | 0 |
| The Vistas At Bettendorf | 3 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.