Avenues at Quad Cities

In the surveyor’s words

From the most serious findings on record at Avenues at Quad Cities, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 4, 2025

  Based on interview, observation and record review, the facility failed to provide supervision to a wandering resident with a known mental health history and previous elopement, conduct an assessment and investigation to determine risk of elopement, develop a care plan addressing elopement risk, and ensure the physician was notified of a resident elopement for one of three residents (R1) reviewed for elopement in the sample of three. These failures resulted in R1, a resident with a known history of multiple psychiatric issues, eloping from the facility at night during freezing temperatures, without staff knowledge, and was later found wandering over a half of a mile from the facility, near a busy highway, with urine saturated pants, confusion, and agitation. […]

• Actual harm, patternF627May 7, 2025

  Based on interview and record review the Facility failed to obtain Facility Initiated Discharge Physician Orders, follow current Discharge Care Plans, provide written 30 Day Notice of Discharges to resident's/resident's responsible party, document discharge planning and resident specific needs/services, and document sufficient preparation/orientation to residents to ensure safe/orderly transfers/discharges from the facility for 13 of 14 residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for Facility Initiated Discharges in a sample of 14. […]

• Actual harm, patternF628May 7, 2025

  Based on record review and interview the Facility failed to notify Resident/Resident's Representatives of transfers/discharges and the reasons for the move in writing at least 30 days prior to transfer discharge, send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, record the reasons for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights for 12 of 14 Residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for Facility Initiated Discharges in a sample of 18. […]

• Actual harm, isolatedF580Jul 7, 2024

  Based on interview and record review, the facility failed to notify the physician of a diabetic resident receiving a nutritionally- inadequate clear liquid diet tray for most meals or not eating at all during the span of five days, while continuing to receive the ordered oral and injectable diabetic medications. This failure resulted in R1 being hospitalized for Hypoglycemia and Altered Mental status. FINDINGS INCLUDE: R1's facility Profile Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Diabetes Mellitus, type 2; Morbid Obesity; Vitamin D Deficiency; Anemia; Depression; Mood Disorder, Gastric Esophageal Reflux Disorder and Morbid Obesity. […]

• Actual harm, isolatedF689Jun 9, 2022

  Based on observation, interview and record review, the facility failed to assess and implement resident specific fall prevention interventions and evaluate current interventions following falls for one (R1) of three residents reviewed for falls. This failure resulted in R1 experiencing multiple falls with one fall resulting in a laceration to R1's head requiring evaluation at the local hospital for sutures. Findings include: Facility Fall Prevention Policy, revised 11/10/2018, documents: To provide safety and to minimize injuries related to falls, decrease falls and still honor each resident's wishes/desires for maximum independence and mobility; All staff must observe residents for safety. […]