Allure Of The Quad Cities

F 0689 Level of Harm - Actual harm Residents Affected - Few

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

residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote

a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. 3. Mechanical lifting equipment or other approved transferring aids will be used based on the residents needs to prevent manual lifting except in medical emergencies. 13.

Staff members are expected to maintain compliance with safe handling/transfer practices. Prior to the survey date of 9/19/25, the facility had taken the following actions to correct the noncompliance:1.

Corrective action for residents identified in the deficiency. A. The CNA that transferred the resident improperly is no longer a certified nurse's assistant at the facility. B. Hospice ordered a portable x-ray on 8/22/25, it was done the same day. The results were shared on 8/24/25 and showed a fracture of the right lateral and medial malleoli with mild displacement. Her ankle was immobilized and elevated per orders and medications given per orders. 2. Identifying other residents with potential for being affected and corrective action. Any resident that needs transfer assistance have the potential to be affected, but no others were identified at the time. 3. Systemic changes to reasonably assure deficiency does not recur. A. In-service was conducted by the administrator with nursing staff on 8/28/25 which included the facilities policy and procedure for safe resident handling/transfer. 4. The DON or designee will conduct QA (Quality Assurance) study to determine 1) does the resident need assistance with transferring, and 2) was the resident transferred safely and per the care plan. The QA study will be completed 5 days a week for 2 weeks, twice weekly for 2 months and weekly for 1 month. Audit results will be forwarded to the facility quarterly QAPI committee for review.

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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

09/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Allure of the Quad Cities

833 Sixteenth Avenue Moline, IL 61265

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview and record review the facility failed to ensure a resident's medication was available for 1 of 3 residents (Resident R2) reviewed for medication administration in the sample of 3.The findings include:Resident R2 September Treatment Administration Record (TAR) shows he was admitted to the facility on [DATE REDACTED] with multiple diagnoses including type 2 diabetes mellitus without complications, non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, and cellulitis.The TAR shows an order for triamcinolone Acetonide external cream 0.1%, apply to RLE (right lower extremity) open area topically every day shift for wound care.On 9/19/25 at 11:00 AM, V9 Registered Nurse was asked to provide the triamcinolone cream applied to Resident R2's legs. She began searching the medication cart, and the treatment cart and said there was none in stock. She said she applied the antifungal cream instead. She could not recall when she had used the triamcinolone. V9 said it should be in the medication cart and applied every day to his right leg for cellulitis. V9 looked in the pharmacy orders and said the last time the cream was ordered was May 2025. She said the triamcinolone cream was being used to prevent infection and the derma fungal cream she was using was not the same thing. On 9/19/25 at 11:10 AM, V9 presented a tube of cream labeled Derma Fungal, Miconazole Nitrate 2%, and was used to treat athletes' foot, jock itch and ring worm.

On 9/19/25 at 11:23 AM, V3 Director of Nursing (DON) said the triamcinolone cream comes from the pharmacy and is a steroid cream. The nurses should be re-ordering though the computer. She said the anti-fungal cream would not be effective for Resident R2's wound care. The nurses should not have been documenting the cream as applied if it was not available. The antifungal cream is not an appropriate substitution for triamcinolone cream. They should have contacted pharmacy and if they could not get it, they should have let us know. and not just use something random.The order summary for R2s triamcinolone cream shows the last re-order date was 6/17/25.The facility's undated policy for medication administration policy documents: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 10. Ensure that the six rights of medication administration are followed: b. Right drug. 11.

Review medication administration record (MAR) to identify medication to be administered. 12. Compare medication source with MAR to verify resident name, medication name, form, dose, rout, and time.

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