The incident at Allure Of Moline came to light when another aide found the resident's call light sitting on her nightstand during the morning shift, completely out of reach.
The resident, identified in inspection records as R1, suffered a stroke that left her unable to move her left arm independently. Her bed was positioned so the nightstand sat on her left side, making it impossible for her to reach across her body to access the call light.
When inspectors interviewed her on September 12, the resident said an aide had come into her room at night and removed her call light. The aide "threw it and said that she was using it too much," according to the resident's account.
The morning shift nursing assistant, identified as V4, discovered the situation around 7:30 AM when she went to help the resident get up for the day. V4 told inspectors that R1 typically called around 7:00 AM to request assistance getting out of bed, but on this particular morning, no call came.
"R1's call light was on her nightstand and not within reach of her," V4 told inspectors. "R1 is unable to turn herself so she would not have been able to place it on the nightstand nor reach it if she needed something."
The resident confirmed to V4 that the night shift nursing assistant had taken the call light away and told her she was using it too much.
V4 acknowledged that R1 does use her call light frequently, typically every one to two hours throughout the night, usually requesting to be repositioned in bed. But facility policy requires staff to ensure call lights remain within reach of residents at all times.
The facility's Director of Nursing, V2, explained that R1 came to the nursing home after suffering a CVA and cannot move her left side, though she retains movement on her right side. The director said R1 is "fairly alert and oriented" and capable of using her call light when it's properly positioned.
"R1 is able to use her call light and it should be pinned to her chest when she is in bed," V2 told inspectors. "R1 would not be able to reach her call light if it was on her nightstand."
Another nursing assistant, V5, confirmed the standard protocol: "If a resident is in bed, the call light should be clipped on or near them."
R1's medical records show she has intact cognition but suffers impairment to one side of her upper and lower extremities, requiring substantial to maximal assistance for bed mobility. Her care plan specifically notes she has a "self-care performance deficit related to CVA with hemiplegia affecting her left side" and includes the intervention to "encourage to use bell to call for assistance."
The facility's own Call Light policy states that "staff will ensure the call light is within reach of resident and secured, as needed."
Administrator V1 said V4 reported the incident to her immediately. When the administrator interviewed R1, the resident repeated the same account of what happened with the night shift aide.
The administrator launched an investigation and ultimately terminated the nursing assistant responsible for removing the call light.
The violation represents a failure to reasonably accommodate the needs and preferences of residents, a basic requirement under federal nursing home regulations. For a stroke patient with limited mobility, access to a call light represents the difference between receiving needed care and lying helpless in bed.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, but noted it affected few residents during their review of accommodation practices at the facility.
The incident highlights the vulnerability of nursing home residents who depend entirely on staff assistance for basic needs. Without access to her call light, R1 had no way to request help with repositioning, toileting, or any other care needs that might arise during the night shift.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Allure of Moline from 2025-09-12 including all violations, facility responses, and corrective action plans.