Allure of the Quad Cities: Improper Transfer Broke Resident's Ankle - IL
The resident was on hospice. After the transfer, hospice ordered a portable X-ray on August 22. The imaging was done the same day. The results, showing fractures of the right lateral and medial malleoli with mild displacement, weren't shared until August 24.
Two days to learn the ankle was broken in two spots.
The facility immobilized and elevated the ankle and administered medications per orders. The CNA who performed the transfer was no longer working as a certified nursing assistant at the facility by the time inspectors arrived on September 19.
CMS rated the violation at actual harm.
The facility's own safe handling policy, cited in its plan of correction, states that mechanical lifting equipment or other approved transfer aids are to be used based on resident needs, and that manual lifting is prohibited except in medical emergencies. Staff are expected to maintain compliance. The CNA did not.
What the plan of correction doesn't say is how long the resident went without anyone recognizing she might be injured, or what symptoms, if any, staff observed between the transfer and the moment hospice ordered imaging. The inspection narrative is silent on that. So is the plan.
The administrator conducted an in-service with nursing staff on August 28, six days after the X-ray and four days after the fracture was confirmed. The session covered the facility's policy and procedure for safe resident handling and transfer. Whether any staff who attended had witnessed the improper transfer, or had cared for the resident in the days before the X-ray was ordered, is not stated.
The facility's plan going forward involves a quality assurance study, overseen by the director of nursing or a designee, checking whether residents who need transfer assistance are being moved safely and according to their care plans. The audit runs five days a week for two weeks, then twice weekly for two months, then weekly for one month. Results go to the quarterly QAPI committee.
That's the system. A hospice resident with a fractured ankle is where it starts.
The facility identified all residents requiring transfer assistance as potentially affected by the lapse. No other residents were identified as having been harmed at the time of the inspection.
Allure of the Quad Cities sits at 833 Sixteenth Avenue in Moline. The complaint inspection that produced this finding was completed September 19, 2025. The deficiency carries CMS tag F0689, governing safe transfers and resident handling, and was cited at the level of actual harm.
The CNA is gone. The resident's ankle was immobilized. And somewhere in the gap between the transfer and the X-ray order, between the X-ray and the results, a woman on hospice waited with two broken bones in her ankle before anyone put a name to what had happened to her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Allure of the Quad Cities from 2025-09-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 27, 2026 · Our methodology
Allure Of The Quad Cities in MOLINE, IL was cited for violations during a health inspection on September 19, 2025.
After the transfer, hospice ordered a portable X-ray on August 22.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.