Allure Of Moline

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on interview and record review the facility failed to prevent abuse for two residents (Resident R5 and Resident R8) of three residents reviewed for abuse in a total sample of forty-two. The Facility's undated Abuse, Neglect and Exploitation policy documents It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. 1.The Facility's Final Investigative Report dated 11/10/25 documents that Resident R6 pushed Resident R8 into a wall. On 11/25/25 at 2:30 PM Resident R8 confirmed that he was pushed by Resident R6 some time ago. Resident R8 stated I ran into the wall. Resident R8 stated I was relatively new to the place and did not realize once (staff) announce it is time for a smoke break that some of them (other residents) will run for the door. (Resident R6) wanted me out of his way pronto. Throughout the survey Resident R6 refused to speak to this surveyor. V5 (Licensed Practical Nurse) stated (Resident R6) only speaks when

he wants to. It is normal for him to not answer questions when he is asked. 2.The Facility's Final Investigative Report dated 11/24/25 documents that Resident R7 struck Resident R5 on the arm. The investigation documents that Resident R5 has a history of mumbling to himself and making noises randomly which then annoyed Resident R7 who struck him on the arm. Throughout the survey Resident R5 did not answer any questions. Resident R5 was noted to be mumbling incoherently and making clicking noises. On 11/25/25 at 2:45 PM Resident R7 confirmed he lightly smacked Resident R5's arm. Those noises are annoying. On 11/26/25 V1 (Administrator) confirmed that the allegation of physical abuse regarding Resident R6 and Resident R8 dated 11/10/25 and the allegation dated 11/24/25 regarding Resident R7 and Resident R5 would be considered substantiated because they did happen.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Allure of Moline

430 South 30th Avenue East Moline, IL 61244

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview and record review the facility failed to securely store medications for two residents (Resident R15 and Resident R21). This failure has the potential to affect all medications being stored in the E Hall cart (Resident R5,Resident R6 and Resident R9 through Resident R42.)The Facility's undated Medication Storage documents It is the policy of

this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light and ventilation, moisture control, segregation and security. On 11/25/25 at 8:45 AM V5 (Licensed Practical Nurse) was in the main dining room with two clear medication cups with pills in them in one hand and a glass of tan brownish liquid. V5 handed the glass of liquid to a resident then stopped and handed medications to Resident R15 and then handed another cup to Resident R21. On 11/25/25 at 9:15 AM V5 (LPN) stated that she forgot to give a resident his protein drink, so she dropped that off and then administered Resident R15 and Resident R21's medications. V5 stated that the medication cups contained all of Resident R15 and Resident R21's scheduled 8:00 AM medications. Resident R15's Medication Administration Record dated November 2025 documents Resident R15's scheduled 8:00 AM medications as Gabapentin 100 mg (milligrams), Aspirin 81 mg, Baclofen 10 mg, Multiple Vitamins with Minerals, Pepcid 20 mg, and Senna Tablet 8.5 mg. Resident R21's Medication Administration Record dated November 2025 documents Resident R21's scheduled 8:00 AM medications as Famotidine 20 mg, Lithium Carbonate 150 mg, Ascorbic Acid 500 mg, Aspirin 325 mg, Potassium Chloride 20 meq (milliequivalents), Vitamin D3 2000 Units, Eye-Vites (multivitamins), mucus relief 400 mg. On 11/25/25 at 10:00 AM V1 (Administrator) stated All medications should be kept in the carts and the nurses should only pass one person's medications at a time to avoid possible medication errors.

Event ID:

Facility ID:

If continuation sheet