Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Avenues At Quad Cities during CMS and state inspections, most recent first.
The facility failed to obtain physician orders, follow discharge care plans, and provide written 30-day notices for multiple facility-initiated discharges. Several residents with complex medical needs and their families were not properly informed or prepared for transfers, resulting in confusion, distress, and inadequate documentation of discharge planning or resident-specific needs.
The facility did not provide required written notice, documentation, or statements of appeal rights to multiple residents and their representatives prior to facility-initiated discharges. Residents and families were informed of discharges by phone with little notice, and there was no evidence of discharge meetings, physician orders, or proper documentation in medical records. Facility leadership confirmed that written notices and required notifications were not issued, and the Ombudsman was not informed.
A resident with a history of mental health issues and previous elopement incidents eloped from a facility at night during freezing temperatures. The facility failed to conduct a new elopement risk assessment or develop a comprehensive care plan addressing the resident's exit-seeking behaviors. Despite the resident's history of wandering and refusal of medications, there was no documentation of interventions to prevent future elopements, and the physician was not notified of the incident.
The facility failed to provide adequate night shift staffing, with only one CNA and one nurse for over 30 residents, despite the need for two CNAs to assist residents requiring mechanical lifts. A resident reported delays in care, and the DON acknowledged staffing challenges due to limited agency staff availability.
The facility's assessment failed to include the Infection Preventionist position or duties, despite its role in infection prevention and control for 31 residents. The Administrator acknowledged the omission, noting the position's importance in nursing services.
The facility failed to maintain documentation for its QAPI program, potentially affecting all 31 residents. The last QAPI program was implemented in February 2023, and the facility could not provide current evidence of an ongoing program. The administrator, new to the position, confirmed the lack of a current QAPI plan.
The facility failed to develop and implement plans of action to improve residents' quality of care and quality of life as part of its QAPI program. The facility's QAPI plan outlines a proactive approach to continual improvement, but no QAPI plan or PIP was conducted in the last year. The administrator confirmed that the last QAPI/PIP program was implemented in early 2023, and no current projects were underway.
The facility failed to implement an ongoing infection prevention and control program, lacking a designated Infection Preventionist and necessary surveillance. The DON confirmed no formal infection control in-services or monitoring since the last IP left. Additionally, the water management plan was not followed, with the Maintenance Director unaware of the program and lacking training, contributing to ineffective management of waterborne pathogens.
The facility failed to implement a system to monitor antibiotic use, lacking a designated Infection Preventionist and proper oversight. Despite policies emphasizing antibiotic stewardship, no tracking or surveillance was conducted from April to July, potentially affecting all residents.
The facility lacks a Certified Infection Preventionist, affecting all 31 residents. The previous Infection Preventionist left, and the DON who took over was not certified. The current DON is also uncertified, and no certification for the previous DON was found.
The facility failed to document the administration or refusal of Influenza and Pneumococcal vaccinations for several residents and lacked a system for tracking immunizations. The new Administrator and DON were unaware of who was responsible for the vaccination program, as the previous Infection Preventionist had left the facility. No tracking records were found, and resident MARs lacked vaccination information.
The facility failed to maintain an effective infection control program, lacking a surveillance system for communicable diseases and proper training on Transmission-Based Precautions. Gaps in infection tracking and a lack of formal in-services since the departure of the Infection Preventionist were noted, affecting all 31 residents.
A facility failed to provide a resident or their representative with a copy of the bed hold policy upon discharge to a hospital for end-of-life care. The facility's policy requires this notice to be given at discharge or within 24 hours, but there was no documentation to confirm this occurred. The DON confirmed the oversight.
The facility failed to conduct new Level I PASRR screenings for two residents who stayed beyond the validity of their initial screenings. The Social Service Director was unaware of the responsibility for managing the PASRR process, leading to a lack of updated screenings in the residents' medical records.
A facility failed to notify a physician and initiate treatment for a resident's skin fold wound, as required by their policy. The resident had a reddened area under her chin, which was noticed by a CNA but not reported to a nurse. Although Nystatin powder was applied, there was no specific treatment order for the neck area, only for the abdomen and under the breasts. An LPN was informed about the issue but did not apply treatment due to the lack of a specific order. The resident's care plan did not address the fungal skin issues.
A facility failed to maintain and process pharmacist drug regimen review recommendations for a resident. The resident's Medication Regimen Review (MRR) for two months indicated that any noted irregularities and/or recommendations should be seen in the report, but the medical record lacked documentation. The DON acknowledged the inability to locate the MRRs, indicating a lapse in maintaining required documentation.
The facility failed to provide a resident and their POA with a written notice of transfer to the emergency room after the resident experienced violent tremors. Additionally, the facility did not notify the Ombudsman of resident transfers to the hospital since 2021, potentially affecting all 31 residents.
A resident with diabetes was hospitalized for hypoglycemia after the facility failed to notify the physician of the resident's inadequate diet and continued administration of diabetic medications. The resident, who was sick and consuming only a liquid diet, was not eating solid meals for several days. Despite this, nursing staff continued to administer the resident's prescribed diabetic medications without informing the physician, leading to the resident's hospitalization.
A facility failed to honor a resident's right to choose to eat meals in bed, citing an undocumented choking hazard, while another resident was allowed to eat in bed without restrictions. The inconsistency in treatment violated the facility's policy and the resident's rights.
A resident with multiple health conditions, including Diabetes Mellitus type 2 and Morbid Obesity, was not provided with a nourishing, well-balanced diet as required. During a period of illness, the resident received a clear liquid diet for about a week while remaining in bed, contrary to the facility's policy that limits such a diet to 48 hours without a physician's order. This resulted in the resident not receiving adequate nutrition.
Failure to Provide Proper Notice and Planning for Facility-Initiated Discharges
Penalty
Summary
The facility failed to ensure that facility-initiated discharges were conducted in accordance with regulatory requirements for 13 of 14 residents reviewed. Specifically, the facility did not obtain physician orders for discharge, did not follow current discharge care plans, and failed to provide written 30-day notices of discharge to residents or their responsible parties. There was also a lack of documentation regarding discharge planning, resident-specific needs and services, and sufficient preparation or orientation to ensure safe and orderly transfers or discharges. These failures were identified through interviews and record reviews, which revealed that residents and their families were often unaware of the discharge until shortly before it occurred, and did not receive the required written notifications or explanations for the discharge. Multiple residents with complex medical histories, including diagnoses such as dementia, hemiplegia, diabetes, depression, and chronic obstructive pulmonary disease, were affected by these deficiencies. In several cases, residents expressed confusion, distress, and a lack of choice regarding their discharge, with some stating they were told to leave due to facility restructuring or remodeling. Family members and responsible parties also reported receiving little to no notice, inadequate communication, and no written documentation regarding the reason for discharge or available services. In some instances, residents were transferred to facilities far from their families, and there were reports of missing personal items and difficulties in obtaining medical records or medications after transfer. The facility's records did not consistently document whether the residents' needs could be met at the facility, the services available or unavailable, or the rationale for the discharge. There was also no evidence of discharge meetings or that residents or their representatives had requested the transfers. The lack of proper discharge planning and communication resulted in psychosocial harm, as residents experienced anxiety, sadness, anger, and disruption of their established living situations. The facility's actions did not align with regulatory requirements for safe and orderly discharges, as evidenced by the absence of required documentation and resident/family involvement.
Failure to Provide Required Written Notice and Documentation for Resident Discharges
Penalty
Summary
The facility failed to provide required written notifications and documentation related to resident transfers and discharges for 12 out of 14 residents reviewed for facility-initiated discharges. Specifically, the facility did not notify residents or their representatives in writing at least 30 days prior to transfer or discharge, did not record the reasons for the transfer or discharge in the residents' medical records, did not provide statements of appeal rights, and did not send copies of the notices to the Office of the State Long-Term Care Ombudsman. These failures were confirmed through record review and interviews with residents, their families, and facility staff, all of whom reported not receiving any written notice or documentation regarding the discharges. Multiple residents and their representatives described being informed of the need to leave the facility with little to no notice, often by phone call, and without being given a choice or adequate explanation. Some residents were told the facility was being remodeled or restructured, while others were told it was being converted to a mental health facility. In several cases, residents and families reported significant distress, confusion, and lack of involvement in discharge planning. There was no evidence in the medical records of discharge meetings, physician discharge orders, or documentation of the residents' needs or the reasons for discharge. The facility's own policies require written notice, documentation of reasons, and provision of appeal rights, none of which were followed. Interviews with facility leadership and staff confirmed that no thirty-day written notices, statements of appeal rights, or proper discharge documentation were provided. The Director of Nursing, Administrator, and Corporate Social Service Director all acknowledged that discharges were initiated by corporate direction to convert the facility's purpose, and that families and residents were only contacted by phone. The Medical Director was not informed or involved in the discharge process. The Ombudsman was also not notified, and expressed concern about the lack of proper discharge procedures and the impact on residents and families.
Failure to Supervise and Assess Resident Leads to Elopement
Penalty
Summary
The facility failed to provide adequate supervision and assessment for a resident with a known mental health history and previous elopement incidents. The resident, who had diagnoses including major depressive disorder, anxiety, schizoaffective disorder, and bipolar disorder, eloped from the facility at night during freezing temperatures without staff knowledge. The resident was later found wandering over half a mile from the facility, near a busy highway, in a confused and agitated state with urine-saturated pants. The facility did not conduct a new elopement risk assessment or develop a comprehensive care plan addressing the resident's exit-seeking behaviors after the incident. Despite the resident's history of wandering and refusal of medications, there was no documentation of interventions to prevent future elopements. The facility also failed to notify the physician of the resident's elopement, and there was no investigation into the incident as an elopement attempt. The facility's policy required an elopement risk assessment to be completed with any increase in exit-seeking or wandering behaviors, but this was not done for the resident. Additionally, the facility did not implement increased supervision or safety checks following the elopement incidents, and there was no documentation of such measures being taken. The lack of appropriate assessment and intervention led to the resident's repeated elopement and placed them in immediate jeopardy.
Removal Plan
- Facility ensured all residents are safe and not at risk and psychosocial needs are being met. The facility evaluated all residents' community survival assessments.
- New Elopement Assessments were completed on all residents to ensure appropriate services are in place.
- Directives have been posted at timeclock and nurses' station with the procedure to follow when any signs of elopement occur. Signs were posted at time clock and nurses' station.
- All staff educated on elopement policy, mental disorders, change of condition reporting, door alarm policy, and community survival/pass.
- Residents that have severe MI (mental illness), history re-evaluated for appropriate interventions.
- All residents assessed to ensure resident based intervention care plan services are in place. Initiated and completed related to severe MI (mental illness), and elopement.
- All resident charts were audited for elopement, community survival, and community pass by the IDT (Interdisciplinary) team.
- QAPI meeting held to ensure compliance.
- It was initiated to review and discuss daily in morning meeting regarding residents identified by the facility as requiring services for mental illness. The facility will notify psychiatry and medical physician for guidance for 1:1, 15-minute checks or hospitalization. Notifications will be made immediately by nursing or social services. This is ongoing.
- The facility door code was changed. All visitors and family will be assisted with exiting the facility.
- Agency staff were educated on all policies via their agency portal before starting their shift. They are required to read and acknowledge. They will be in serviced again once in the building. Agency staff were educated.
Insufficient Night Shift Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by the staffing plan and daily assignment postings. The facility's assessment tool indicated that eight nurse aides were needed in a 24-hour period, with a direct care staff ratio of three for days and evenings, and two for nights. However, on multiple occasions, the night shift was staffed with only one CNA and one nurse for the entire eight-hour shift, despite an average census of over 30 residents. This staffing shortage was not addressed, and no accommodations were made to cover the absence of a second CNA during the night shift. A resident, who requires the use of a mechanical lift and assistance from two people for personal care, reported having to wait a long time for care due to the insufficient staffing on the night shift. The Director of Nursing confirmed the staffing challenges, stating that while efforts were made to fill open shifts and hire additional staff, there were instances where only one CNA was available for the night shift. The facility's reliance on their own agency staffing service, which often had no available staff, further exacerbated the issue, as corporate policies limited the use of external agency staff for CNAs.
Infection Preventionist Role Omitted from Facility Assessment
Penalty
Summary
The facility failed to include the Infection Preventionist position or duties in its Facility Assessment, which is necessary to determine the resources required for competent resident care during regular operations and emergencies. The facility's application for Medicare and Medicaid documented 31 residents, and the assessment indicated that services provided included infection prevention and control. However, the assessment did not list the Infection Preventionist position or duties under Nursing Services or any other area. The Infection Preventionist's job description, dated 3/3/23, outlines responsibilities for reducing infectious disease transmission among residents, staff, visitors, and the community. On 9/19/24, the Administrator acknowledged that the Infection Preventionist is a key nursing position that should be included in the Facility Assessment.
Failure to Maintain QAPI Program Documentation
Penalty
Summary
The facility failed to develop, implement, and maintain documentation for its Quality Assurance and Performance Improvement (QAPI) program, which has the potential to affect all 31 residents currently residing in the facility. The facility's application for Medicare and Medicaid, dated September 16, 2024, confirmed the presence of 31 residents. The QAPI plan, last updated on April 1, 2024, outlined the program's purpose to achieve and sustain a culture of excellence through a fact-based, team-driven decision-making model. However, the facility was unable to present a QAPI plan to the State Survey Agency that was no older than one year and failed to provide any current documentation or evidence of an ongoing QAPI program. During an interview on September 18, 2024, the administrator, who had been in the position for only a week, verified that the last QAPI program was implemented in February 2023 and acknowledged not currently working on any QAPI plan.
Failure to Implement QAPI Plans
Penalty
Summary
The facility failed to develop and implement plans of action to improve residents' quality of care and quality of life as part of its Quality Assurance Performance Improvement (QAPI) program. This deficiency has the potential to affect all 31 residents currently residing in the facility. The facility's QAPI plan, updated in April 2024, outlines the purpose of achieving and sustaining a culture of excellence through a proactive approach to continual improvement. However, the facility was unable to provide evidence of a QAPI plan or Performance Improvement Project (PIP) conducted in the last year. During an interview, the administrator confirmed that the last QAPI/PIP program was implemented in February 2023, and no current projects were underway. The administrator, who had been in the position for only a week, acknowledged the need for improvement but had not yet developed a plan.
Failure to Implement Infection Control and Water Management Programs
Penalty
Summary
The facility failed to implement an ongoing infection prevention and control program (IPCP), which included a lack of surveillance and management of waterborne pathogens. The facility did not have a designated Infection Preventionist (IP) since September 2023, and the Director of Nursing (DON) lacked the necessary IP certification or training. There was no evidence of surveillance monitoring or tracking for staff or resident illnesses, nor was there any antibiotic or infection tracking for several months in 2024. The DON confirmed that no formal infection control in-services or monitoring of infection control practices had been conducted since the last IP left. Additionally, the facility's water management plan was not being followed. The Maintenance Director, who was responsible for carrying out checks and maintaining records, was unaware of the water management program and had not received any training. The Legionella Management Procedure required a team to control the risk from Legionella bacteria, but the Maintenance Director did not know about the procedure or the responsibilities involved. This lack of training and awareness contributed to the facility's failure to manage and minimize the risk of waterborne pathogens effectively.
Failure to Implement Antibiotic Monitoring System
Penalty
Summary
The facility failed to develop and implement an ongoing system to monitor antibiotic use, which is a critical component of their infection control program. This deficiency was identified through interviews and record reviews, revealing that the facility lacked leadership support and accountability in their antibiotic stewardship efforts. Specifically, the facility did not have a designated Infection Preventionist (IP) since the previous IP left, and the current Director of Nursing (DON) did not possess the necessary IP certification or training. Additionally, the regional IP nurse did not oversee the facility, leaving it without proper infection control leadership. The facility's policies on infection assessment and antibiotic stewardship, which emphasize the importance of monitoring antibiotic use and aligning it with guidelines, were not followed. Pharmacy reports from April to July 2024 showed multiple residents receiving antibiotics, yet there was no evidence of antibiotic tracking or infection surveillance during this period. This lack of monitoring and oversight has the potential to affect all 31 residents in the facility, as there was no system in place to ensure safe and appropriate antibiotic use.
Lack of Certified Infection Preventionist in Facility
Penalty
Summary
The facility failed to employ a Certified Infection Preventionist, which has the potential to affect all 31 residents. The job description for the Infection Preventionist requires completion of specialty training in Infection Prevention and Control through accredited continuing education such as CDC or APIC. The facility's application for Medicare and Medicaid confirms 31 residents reside there. On multiple occasions, the Administrator confirmed that there is no designated Infection Preventionist at the facility. The previous Infection Preventionist left on 9/27/23, and the Director of Nursing (DON) who took over the role until April 2024 did not have certification. The current DON, hired on 8/1/24, is also not certified. Training modules for the previous DON were provided, but no certification of a completed Infection Prevention program was found.
Failure to Document and Track Resident Vaccinations
Penalty
Summary
The facility failed to ensure proper documentation of the administration or refusal of Influenza and Pneumococcal vaccinations for three residents out of five reviewed in a sample of 21. Specifically, there was no documentation for one resident regarding whether they were offered or refused the Influenza vaccine in 2023. Another resident's consent form indicated they had already received the Influenza vaccine, but no date was provided, and there was no documentation regarding the Pneumonia vaccine. A third resident's records did not include any information about vaccinations being offered or administered. Additionally, the facility did not have a system in place for surveillance monitoring and tracking of immunizations for residents. The newly appointed Administrator and the Director of Nursing were unaware of who was responsible for the vaccination program, as the previous Infection Preventionist, who had been monitoring vaccinations, left the facility in September 2023. No line list or tracking of immunizations was found, and the Medication Administration Records did not contain vaccination information for any residents.
Inadequate Infection Control Program and Surveillance
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, which is crucial for identifying and managing communicable diseases and infections. The deficiency was identified through interviews and record reviews, revealing that the facility did not have a surveillance system in place to identify possible communicable diseases or infections. Additionally, there was a lack of training on when and how to use Transmission-Based Precautions and proper infection control practices during resident care activities. This oversight has the potential to impact all 31 residents residing in the facility. The facility's records showed gaps in infection tracking and surveillance, with no documentation for several months in 2024. Furthermore, there was only one formal infection control in-service related to hand hygiene conducted in March 2024. The Director of Nursing (DON) confirmed that no formal infection control in-services or monitoring of infection control practices had been conducted since the departure of the Infection Preventionist in September 2023. During a recent COVID outbreak, the facility did not conduct any formal in-services to review infection control practices or Transmission-Based Precautions, further highlighting the deficiency in their infection control program.
Failure to Provide Bed Hold Policy Upon Hospital Transfer
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to a resident or their representative upon discharge to a hospital. The facility's policy, dated 8/1/2017, requires that the resident, family, or legal representative be given the Notice of Bed Hold Policy at the time of discharge or therapeutic leave, or within 24 hours thereafter. However, for one resident who was transferred to a local hospital for end-of-life care, there was no documentation in the medical record to confirm that the bed hold policy was provided. The Director of Nurses confirmed that neither the resident nor their representative received the policy prior to leaving the facility.
Failure to Conduct New PASRR Screenings
Penalty
Summary
The facility failed to obtain a new Level I PASRR (Pre-Admission Screening and Resident Review) for two residents, R13 and R25, who were reviewed for pre-admission screenings. According to the facility's policy, if a resident stays longer than 30 days, a new Level I screening must be conducted, and any resident with or potentially having a mental illness or intellectual disability should be referred to the appropriate state authority. R25 was admitted on 10/28/2020, with a screening valid for only 90 days, yet no new screening was documented in the medical record. Similarly, R13 was admitted on 9/9/2019, with a screening also valid for 90 days, but lacked documentation of a new screening. During an interview, the Social Service Director (SSD) expressed unawareness of who was responsible for the PASRR screening process, indicating a lack of clarity in roles and responsibilities regarding this requirement.
Failure to Notify Physician and Initiate Treatment for Skin Fold Wound
Penalty
Summary
The facility failed to notify the physician and initiate treatment for a skin fold wound for one resident, identified as R20, who was reviewed for skin impairments. The facility's policy on skin condition monitoring requires that upon notification of a skin lesion or abnormality, the nurse must assess, document, and notify the physician to obtain a treatment order. However, this procedure was not followed for R20, who had a large fat pad under her chin causing a deep skin fold with an inflamed reddened area. Although R20 mentioned that a CNA noticed the red area, she did not inform the nurse, and no treatment order was obtained for the neck area. The progress note indicated that Nystatin powder was applied to R20's neck area, but there was no specific treatment order for this area, only for the abdomen and under the breasts. An LPN stated that she was informed about the red neck area during a morning report and that the area was cleaned during a shower. However, she did not feel comfortable applying treatment without a specific order. The resident's current care plan did not address the neck, abdomen, or breast fungal skin issues, indicating a lack of proper documentation and follow-through on the facility's policy for skin condition monitoring.
Failure to Maintain Drug Regimen Review Documentation
Penalty
Summary
The facility failed to maintain and process pharmacist drug regimen review recommendations for a resident among those reviewed for drug regimen review. Specifically, the resident's Medication Regimen Review (MRR) for July and September 2024 indicated that any noted irregularities and/or recommendations should be seen in the report. However, the resident's medical record lacked documentation of these MRRs, and the facility was unable to provide them prior to the survey exit. During an interview, the Director of Nursing (DON) acknowledged the inability to locate the MRRs for the specified months, despite the facility's practice of keeping them in the residents' medical records. This indicates a lapse in the facility's process of maintaining and processing drug regimen review documentation as required.
Failure to Provide Written Transfer Notice and Notify Ombudsman
Penalty
Summary
The facility failed to provide a resident and the resident's representative with a written notice of transfer to the emergency room. On 9/6/2024, a resident was experiencing violent tremors, and hospice staff requested a hold on medications, suspecting overmedication. The resident's Power of Attorney (POA) was notified and requested the resident be sent to the emergency room for evaluation. However, the resident's chart lacked documentation showing that the resident and the POA were notified in writing of the transfer. The Director of Nurses confirmed the absence of written notification. Additionally, the facility failed to notify the facility Ombudsman of resident transfers to the hospital on a monthly basis. The last notification to the Ombudsman was in 2021, as stated by the facility's Administrator. This oversight has the potential to affect all 31 residents residing in the facility.
Failure to Notify Physician of Resident's Inadequate Diet and Medication Administration
Penalty
Summary
The facility failed to notify the physician of a diabetic resident who was receiving a nutritionally inadequate clear liquid diet or not eating at all for five days, while continuing to administer the resident's prescribed oral and injectable diabetic medications. This oversight led to the resident being hospitalized for hypoglycemia and altered mental status. The resident, who had a history of diabetes mellitus type 2, morbid obesity, and other health conditions, was admitted to the hospital after being found confused and hypoglycemic with a blood sugar level of 42. The resident's care plan indicated that they typically consumed more than 75% of meals and were able to feed themselves with assistance. However, during the period in question, the resident was sick with a cold, requested to eat in bed, and was provided with a 'sick tray' consisting only of fluids. Despite the resident's refusal to eat solid meals, the nursing staff continued to administer the full regimen of diabetic medications without notifying the physician of the resident's dietary intake issues. The physician confirmed that they were not informed of the resident's missed meals or liquid diet, which could have prompted a change in the treatment plan to prevent hospitalization.
Violation of Resident Rights in Meal Service
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not allowing a resident, R1, to exercise the choice to eat meals in bed. R1, who is cognitively intact and able to feed himself with tray setup assistance, expressed a preference to eat breakfast in bed and occasionally supper. However, a registered nurse, V5, imposed a rule that if R1 did not get up for supper, he would only receive a 'sick tray' consisting of broth and tea, citing R1 as a choking hazard without documented evidence. This restriction was not applied to another resident, R2, who was allowed to eat all meals in bed without issue. R1's care plan indicated that he should be encouraged to eat in the dining room but allowed to eat in bed with supervision if he refused. Despite this, R1 was denied his regular meal in bed, unlike R2, who consistently received a regular diet in his room. R2, also cognitively intact, had a history of remaining in bed for all activities and was not subjected to the same restrictions as R1. The inconsistency in treatment between R1 and R2 highlights a failure to uphold resident rights and facility policy. The facility's policy stated that residents choosing not to attend the dining room should be served appropriate meals in their rooms, with the same menu choices as the dining room. However, staff interviews revealed a practice of providing only liquid diets to residents who chose to eat in their rooms, except for R2. The administrator in training acknowledged the lack of documentation supporting R1 as a choking hazard and recognized the potential violation of R1's rights due to the unequal treatment compared to R2.
Failure to Provide Adequate Nutrition to Resident
Penalty
Summary
The facility failed to provide a resident with a nourishing, well-balanced diet, as required by their dietary needs. The resident, who was admitted with multiple diagnoses including Diabetes Mellitus type 2, Morbid Obesity, and other health conditions, was placed on a Carbohydrate Controlled Diet (CCD). However, during a period of illness, the resident was given a 'sick tray' consisting of a clear liquid diet while remaining in bed, as they refused to get up for meals. This practice continued for about a week, despite the facility's policy that a clear liquid diet should not be used for more than 48 hours without a physician's order. Interviews with facility staff revealed that the resident had been sick with a head cold and was not eating much, preferring to eat in bed. The facility's policy allows for a clear liquid diet to be used as a nursing measure for less than 48 hours without a physician's order in cases of acute illness. However, the resident continued to receive this inadequate diet beyond the stipulated time frame, which did not meet their nutritional needs, as there was no physician's order to extend the diet beyond 48 hours.
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Illustrative
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.
Illustrative
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Illustrative
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Nursing homes near Silvis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Silvis Center For Nursing Rehab & Care | 0.4 mi | ★★★★★ | 6 | 0 |
| Allure Of Moline | 1.9 mi | ★★★★★ | 5 | 1 |
| Celebrate Sr Living Of Moline | 2 mi | ★★★★★ | 1 | 0 |
| Hope Creek Nursing & Rehab | 2.3 mi | ★★★★★ | 6 | 0 |
| The Vistas At Bettendorf | 4.6 mi | ★★★★★ | 14 | 0 |
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