Allure of the Quad Cities

Inspectors wroteBased on interview and record review, the facility failed to identify an area of pressure for a resident at risk of developing pressure injuries, failed to do a full assessment of the wound when it was identified, and failed to obtain a treatment order when it was first identified for 1 of 3 residents (R2) reviewed for pressure in the sample of 11. These failures caused the wound to further deteriorate and become necrotic (non-viable, dead skin tissue).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement procedures regarding the reconciliation and management/disposal of controlled substances. This applies to 2 of 3 residents (R3 and R4) reviewed for controlled substances in the sample of 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to store controlled substances behind a double lock allowing activity staff to enter an area with controlled substances. This applies to 2 of 3 residents (R3 and R4) reviewed for controlled substances in the sample of 11.

Inspectors wroteBased on interviews and record review, the facility failed to adequately supervise a known wandering resident (R1) who was evaluated to be at risk for elopement, failed to remain with an eloped resident (R1) once found out in the community, and failed to assure a secured door was locked preventing access to a wandering resident (R1). These failures resulted in R1, a moderately cognitively impaired resident with the diagnosis of unspecified dementia, eloping from the facility through the Maintenance Office exterior exit door, crossing a moderately busy road to a gas station and park approximately one block from the facility. These failures have the potential to affect all three (R2, R3, R4) Elopement Risk residents who reside off the secured floor in the facility. The Immediate Jeopardy began on April 14, 2026, when R1 eloped from the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to document the reason for a transfer to the hospital for 1 of 3 residents (R1) reviewed for hospitalization in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to perform weekly assessments for a pressure injury, failed to have an ordered pressure injury treatment in place, and failed to have preventive interventions in place for 3 of 3 residents (R1, R3, R4) reviewed for pressure injuries in the sample of 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered on time and medications were administered under the supervision of the nurse for 1 of 5 residents (R8) reviewed for medication administration in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer insulin on time, failed to administer the correct insulin dose, and failed to administer a cardiac medication to 2 of 4 residents (R4 and R8) reviewed for medication administration in the sample of 9.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident room was sanitary for 1 of 4 residents (R4) reviewed for environment in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement personalized fall prevention measures for a resident (R4) resulting in (R4) obtaining a laceration that required sutures, and the facility failed to prevent a resident (R1) at risk for elopement from exiting the building unsupervised. These failures apply to 2 of 3 residents reviewed for safety in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from physical abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 getting punched in the face by R3 and sustaining an abrasion and swollen lip.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect cognitively impaired residents (R7, R5, R6) from sexual abuse by another resident (R4) with a known pattern of sexually inappropriate behaviors. R4 was observed with her hand on R7's vaginal area. R4 was observed with her whole hand inside R5's pants in his penile area. R4 was observed with her hand in R6's groin moving towards his penile area in a tapping motion up and down. This failure applies to 4 of 13 residents (R4, R7, R5, R6) reviewed for abuse in the sample of 14 and resulted in immediate jeopardy. The Immediate Jeopardy began on 11/22/25 when R4 put a glove on that she took from the nurses' cart, placed her gloved hand onto R7's vaginal area. V16 (Regional Nurse Consultant) was notified of Immediate Jeopardy on 3/13/26 at 3:32 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement interventions to prevent a resident from developing Stage 4 pressure wounds, failed to assess the wounds in a timely manner, and failed to implement treatment interventions of the wounds for 1 of 3 residents (R1) reviewed for pressure wounds in the sample of 14. These failures resulted in R1 developing wound infections leading to sepsis.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from misappropriation of resident property for two of seven residents (R9, R3) reviewed for Abuse/Misappropriation in the sample of 14.

Inspectors wroteBased on observation, interview and record review the Facility failed to perform hand hygiene and follow Physician treatment orders for one of four Residents (R12) and follow Physician treatment orders, prevent a worsening pressure ulcer and prevent a newly acquired pressure ulcer for one of four Residents (R3) reviewed for pressure ulcers in a sample size of 46. This failure resulted in R3 developing a new in-house pressure ulcer to the left Ischium, a new in-house stage 4 pressure ulcer to right Ischium and increasing in size in stage 4 pressure ulcers to right and left heels.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a fractured right ankle. This past non-compliance occurred from 8/21/25 to 8/29/25.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's medication was available for 1 of 3 residents (R2) reviewed for medication administration in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure blood pressure monitoring was performed after a change in condition for 1 of 3 residents (R1) reviewed for change in condition in the sample of 3.

Inspectors wroteBased on record review and interview the facility failed to ensure one resident (R2) was free from sexual abuse and failed to ensure two residents (R3,R4) were free of physical, resident-to-resident abuse of five residents reviewed for abuse in a total sample of five. 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 prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual Abuse is non-consensual sexual contact of any type with a resident. R1's Medical Record documents that he was admitted on [DATE] with diagnosis to include but not limited to Dementia, Insomnia and repeated falls. [...]

Inspectors wroteBased on observation and interview the facility failed to have documented behaviors to warrant the use of antipsychotic and other psychotropic medications and the facility failed to attempt nonpharmacological interventions prior to using antipsychotic and other psychotropic medications for three residents (R1, R3 and R5) of three residents whose psychotropic medications were reviewed in a total sample of five. The Facility's undated Use of Psychotropic Medication(s) documents It is the intent of this policy to ensure that residents only receive psychotropic medication when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of abuse for one resident (R1) of five residents reviewed for abuse in a total sample of five. 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 prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Sexual Abuse is non-consensual sexual contact of any type with a resident. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to provide resident's medical records when requested for 1 of 4 residents (R1) reviewed for medical records in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to notify a physician of a high blood sugar for 1 of 4 residents (R2) reviewed for notification in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate shift-to-shift controlled medication counts for all residents that had controlled medications stored on the Station C/Front Hall medication cart in the month of April 2025. This failure has the potential to affect 27 residents (R2, R6-R41).

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent the theft of controlled medications for one resident (R2) of three residents reviewed for misappropriation of property in the sample of 15.

Inspectors wroteBased on interview and record review the facility failed to obtain a urine specimen according to physician orders for one resident (R1) of three residents reviewed for implementing physician orders in the sample of 15.

Inspectors wroteBased on interview and record review the facility failed to utilize two staff members when transferring residents with a mechanical lift for two (R1 and R2) of four residents reviewed for mechanical lift transfers in the sample of eight.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ordered pain medication timely, for one of three residents (R2) reviewed for pain control, in a sample of three. This failure resulted in R2 experiencing intermittent excruciating pain from 12/12/24 until 12/16/24.

Inspectors wroteBased on record review and interview the facility failed to ensure quality assurance meetings were held quarterly and that the facility medical director attended quality assurance meetings. This failure has the potential to affect all 94 residents residing in the facility. Findings Include: A facility policy, entitled Quality Assurance and Performance Improvement (QAPI), undated, document, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides; and 1. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) committee and a written QAPI plan. 2 The QAA committee shall be interdisciplinary and shall: a, Consist at a minimum of: i. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents electronic medical records and care plans matched the Physician's Order for Life-Sustaining Treatment (POLST) for Cardio-Pulmonary Resuscitation (CPR) code status for three of five residents (R25, R69, R74) reviewed for Advanced Directives in a total sample of 39 residents.

Inspectors wroteBased on interview and record review the facility failed to revise an antipsychotic medication care plan and a dialysis care plan for two residents (R12, R23) of 19 residents reviewed for care plans in the sample of 39.

Inspectors wroteBased on record review and interview the facility failed to ensure physician orders for dialysis were written and communication sheets were completed for two of two residents reviewed for dialysis (R23, R87) in a sample of 39.

Inspectors wroteBased on interview and record review the facility failed to administer a medication to prevent EPS (Extrapyramidal Symptoms) in conjunction with an antipsychotic medication according to physician orders for one resident (R12) of five residents reviewed for psychotropic medications in the sample of 39.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure enhanced barrier precautions were followed for one resident (R78) of two residents reviewed for infection control in a total sample of 39.

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (R1) was free of mistreatment of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to initiate and implement Enhanced Barrier Precautions for 24 residents (R1, R2, R3, R6, R8 - R27) reviewed for Infection Control practices of 26 residents reviewed. This failure has the potential to affect all 95 residents who reside in the facility.

Inspectors wroteBased on record review and interview the facility failed to prevent misappropriation of property for one resident (R1) of 3 residents reviewed for misappropriation of property in the sample of 8. Findings Include: Controlled Substance Administration and Accountability, dated 2023, documents the following. It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place to prevent loss, diversion, or accidental exposure. The Facility Reported Incident, with Date of Occurrence dated: 1/19/2024, Incident Category: Resident Misappropriation of Property/Theft. Incident Description: Missing medications noted for R1. Per Pharmacy: Hydrocodone 5/325MG (Narcotic pain reliever) with a quantity of (89) tablets delivered on 1/5/2024. [...]

Inspectors wroteBased on record review and interview the facility failed to prevent an occurrence of staff-to-resident verbal abuse from occurring for one of three residents (R1), reviewed for abuse in the sample of 6. Findings Include: The undated facility policy, Abuse, Neglect and Exploitation 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 prohibit and 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 altercations. It also includes verbal abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy of immediately reporting potential abuse, protecting a resident from further potential abuse, and investigating an allegation of potential abuse for one of three residents (R1) reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to failed to ensure one allegation of abuse was immediately reported to the Administrator for one of three residents (R1) reviewed for abuse, in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered pain medications were available at time of admission for a resident experiencing pain for one of one resident (R145) reviewed for pain in the sample of 48. R145 was admitted to the facility on [DATE] with a fractured sacrum, and remained in constant, severe pain for nearly 40 hours before the first dose of her pain medication was administered on 12/03/23.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident council with responses, actions, and rationales taken regarding their concerns. This has the potential to affect all 96 residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide a sufficient number of staff to provide assistance to dependent residents. This failure has the potential to affect all 96 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at a palatable temperature. This has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize signs and symptoms of illness of facility staff and residents as a possible contagious illness (RSV, COVID-19, Influenza), failed to perform the required COVID-19 testing on staff and residents actively demonstrating signs and symptoms of a possible infectious respiratory illness, failed to test for other infectious respiratory illnesses (RSV and influenza) when a COVID-19 test was negative, failed to implement isolation precautions with symptomatic residents, and failed to ensure a surgical mask covered the staffs' mouth and nose while serving food. These failures had the potential to affect all 96 residents residing within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to designate an onsite staff member as Infection Preventionist. This has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a smoke detector was not covered causing it to be inoperable and not providing smoke protection. This failure has the potential to affect all 96 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity by serving their meal fluids in disposable cups. This has the potential to affect all 29 residents (R2, R4, R5, R7, R11, R13, R17, R19, R22, R28, R30, R32, R33, R40, R42, R45, R54, R56, R60, R63, R65, R66, R68, R69, R71, R77, R80, R87, R295) residing on the Arcadia unit in the sample of 48.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide range of motion exercises for one of one resident (R25) with a known history of limited range of motion, in a sample of 48.

Inspectors wroteBased on observation, interview and record review, the facility failed to check placement of a gastrostomy feeding tube prior to the administration of fluids and medications; and failed to flush a gastrostomy feeding tube with the prescribed water flushes between medications for one of one resident (R70), reviewed for feeding tubes, in a sample of 48.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain medication was available upon admission for a resident with reports of pain for one of one resident (R145) reviewed for pain in the sample of 48.

Inspectors wroteBased on interview and record review, the facility failed to document a rational for the continued use of an antibiotic for one of one resident (R25) reviewed for unnecessary medications in a sample of 48. Findings Include: The (undated) facility policy, Antibiotic Stewardship Program directs staff, The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. All prescriptions for antibiotics shall specify the dose, duration and indication for use. R25's Physician Order Sheet, dated 12/5/2023 includes the following medication: Cefdinir Capsule 300 MG Give 1 capsule by mouth one time a day for maintenance. No stop date is included for the antibiotic usage. On 12/4/23 at 3:09 P.M., V2/Director of Nurses stated, (R25) is on continuous antibiotics due to recurrent knee wound infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure antibiotics were prescribed appropriately for one of one resident (R25) reviewed for antibiotic use in the sample of 48.

Inspectors wroteBased on observation, interview and record review the facility failed to identify specific target behaviors; and monitor and track behaviors for three residents (R2, R55, R69) of four residents reviewed for psychotropic medications in the sample of 21 residents.