Inspection·April 9, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few 01/13/2025 indicated severe cognitive impairment with score of 03/15. Section GG for functional abilities indicated R1 requires partial to moderate assistance to walk 10 to 150 feet. Section I for active diagnosis indicated non-traumatic brain dysfunction. R1's Wandering Risk Scale dated 01/23/2025 indicated resident is a high risk for wandering. R1's screening assessment for aggressive and/or harmful behavior dated 03/13/2025 documented minimal risk for aggression. On 04/08/2025 at 9:28 AM, R1 was observed sitting in a recliner chair in the day area on the memory unit. R1 was alert to self and was not interviewable. R2's face sheet documented last admission date of 10/31/2022 and a past medical history not limited to alcohol abuse with alcohol-induced anxiety disorder, major depressive disorder, unspecified personality and behavioral disorder due to known physiological condition, unspecified mood [affective] disorder, anxiety disorder and adult failure to thrive. R2's care plan with date initiated of 07/21/2023 reads in part: demonstrates behavior symptoms concerning inappropriate personal boundaries due to cognitive impairment secondary to alcohol persisting dementia or a related dementia; demonstrates behavioral distress as manifested by verbally abusive behavior when agitated, use of profanity/racial slurs, demeaning statements, verbal threats and yelling at others, physically abusive behavior when agitated towards staff, attempting to push, shove, scratch, hit, slap, kick, grab, choke or otherwise harm staff (date initiated 09/19/2024); has current self-harmful ideation (thoughts) and/or behavior (date initiated 09/19/2022); displays conflictual, difficult behavior with other persons related to mental/severe mental illness, dementia of the Alzheimer's type, difficult time adjusting to life in long-term care facility, history of substance abuse, poor ineffective coping skills initiated on 03/13/2025 with interventions not limited to: physical stop sign to resident's door way and intervene when any inappropriate behavior is observed; stop sign on door to deter others from entering .to prevent unwanted interaction due to agitation or confusion, initiated on 03/14/2025. R2's Brief Interview for Mental Status (BIMS) under Section C for cognitive patterns dated 12/31/2024 indicated severe cognitive impairment with score of 00/15. R2's psychiatric note dated 03/06/2025 (4 days prior to the incident with R1) indicated the resident was seen per staff request; increased agitation and aggression with plan to obtain urinalysis to rule out medical cause for behavior change and start sertraline [an antidepressant] and decrease mirtazapine [an antidepressant] due to ineffectiveness. R2's Medication Administration (Behavior Monitoring) note dated 3/10/2025 at 6:50 PM documented by V9 (Registered Nurse) reads in part, around [2:30 PM], resident pushed another male resident onto the ground because the resident accidentally wandering into his room. R2's screening assessment for aggressive and/or harmful behavior with effective date of 03/13/2025 documented a moderate problem with history or recent episode of aggressive/agitated behavior that includes aggression towards others. R2's trauma screening with effective date of 03/13/2025 documented history or presence of dysfunctional behavior and of mistreating others and showed significant trauma-related symptomology. R2's psychiatric note dated 03/13/2025 (3 days after to the incident with R1) indicated resident was seen per staff request for aggression towards peers after another confused resident walked into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145269 If continuation sheet Page 2 of 7 Printed: 05/15/2026 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 145269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hope Creek Nursing & Rehab 4343 Kennedy Drive 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 0600 Level of Harm - Actual harm Residents Affected - Few [R2's] room and [R2] pushed the resident to the floor. Note continued to document a plan to start donepezil (used to treat Alzheimer's disease/dementia) 5mg (milligram) by mouth at night for cognition and continue to taper mirtazapine due to ineffectiveness.dementia is worsening and unstable this visit. R2's active orders as of 04/08/2025 showed orders for behavior monitoring including verbal aggression with staff, agitation and aggression; alprazolam (an antianxiety medication) 0.25mg by mouth three times a day related to anxiety (03/27/2025); divalproex sodium tablet (a mood stabilizer) delayed release 250mg by mouth two times a day related to unspecified personality and behavioral disorder and mood [affective] disorder; donepezil hydrochloride 5mg by mouth at bedtime for dementia (03/14/2025); memantine hydrochloride 10mg by mouth daily related to unspecified personality and behavioral disorder; mirtazapine 30mg by mouth at bedtime related to major depressive disorder (03/14/2025); and sertraline hydrochloride 25mg by mouth daily related to major depressive disorder (03/11/2025). On 04/08/2025 at 9:24 AM, observed a white banner across R2's doorway that had a red stop sign in the middle of banner. R2 was in his room lying on the bed. When asked about the incident with R1, R2 said he came into my room, and I pushed him out. R2 did not recall whether this resident fell to the floor then repeated his previous statement, he came into my room, and I pushed him out. R2 did not answer any more questions asked by surveyor. On 04/08/2025 at 9:29 AM, V4 (Certified Nursing Assistant) said regarding the incident with R1 and R2, R1 went into R2's room and R2 pushed him out. V4 added that R1 had a bump on his head, then proceeded to show surveyor the area by patting the top and back of her head. V4 then said R1 either sits in the recliner chair in day area or wanders around the unit and gets anxious at times. V4 also said that R2 mainly stays in his room and doesn't let staff do a lot for him; he mainly goes out for smoke breaks and meals. On 04/08/2025 at 9:34 AM, V5 (Registered Nurse) said she was not working on the day of incident involving R1 and R2. V5 then said that R1 wanders throughout the day and R2 stays in his room. V5 added that R2 had no prior aggression, just likes to be alone. On 04/08/2025 at 11:13 AM, V1 (Administrator) said regarding incident with R1 and R2, that R1 was observed on floor outside of R2's room and there was suspicion that R2 pushed him because R1 wandered into the room. V1 added that the primary witness, V8 (Physical Therapy Assistant) saw R1 on the floor but didn't see R2 physically push him. V1 added that when he was informed about the incident, there were no apparent injuries found. V1 (Administrator) then said that R2 has no history of aggression with residents, but there have been prior staff concerns then referred surveyor to R2's progress note dated 03/03/2025 that indicated R2 had his hand on a nurse due to behaviors related to smoking. V1 added that V5 was the nurse involved. Informed V1 that during previous interview with V5 (Registered Nurse), she indicated that R2 had no prior aggression. V1 said he was unsure as to why V5 would make that statement because R2 was seen by psych that week due to this incident. V1 (Administrator) then said that R1 wanders, and his cognition is very low; staff try to supervise him and redirect as needed. Review of R2's progress note created by V5 (Registered Nurse) on 03/03/2025 at 11:23 AM documented that resident drew his fist back at nurses, cussing at [certified nursing assistant], staff told resident that he was not going out to smoke due to his behaviors On 04/08/2025 at 11:41 AM, V8 (Physical Therapy Assistant) said she was walking with another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145269 If continuation sheet Page 3 of 7 Printed: 05/15/2026 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 145269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hope Creek Nursing & Rehab 4343 Kennedy Drive 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 0600 Level of Harm - Actual harm Residents Affected - Few resident in the hallway near R2's room after 2:00 PM and had stopped at that resident's doorway which was across the hall and passed R2's room. V8 added that she saw what appeared to be, R1 being shoved from R2's doorway and into the hallway with force, then R2's door slammed shut. V8 (Physical Therapy Assistant) said R1 landed pretty hard and hit the back of his head on the ground. V8 said she did not see R2's hands physically push R1 out of the room. V8 (Physical Therapy Assistant) called for help because no one else was in the hallway at that time. V8 then said she opened R2's door and said to him, don't you put hands on anyone. R2 was in bed and did not respond. V8 then closed his door and at this time, an aide and a nurse were coming down the hallway. On 04/08/2025 at 1:07 PM, V2 (Director of Nursing) said she was not aware that R1 sustained any injuries after the incident with R2, and indicated there is no documentation that any injury was being monitoring. V2 then said she assumed nurses would assess resident's during neuro checks and if they found any injury, then they would document those findings. On 04/08/2025 from 1:22 to 1:31 PM, V9 (Registered Nurse) said that she documented an abrasion and swelling to the top of R1's scalp at the time of incident but now thinks they both were present prior to the incident with R2. V9 added that R1 had fallen in the past but couldn't recall any falls that occurred near the time of incident with R2. V9 (Registered Nurse) then said R2 is kind of [NAME] and can get agitated. She added that upon assessment, R2 was lying in his bed and was very agitated so she could only perform a quick body assessment on resident. On 04/08/2025 at 2:39 PM, V7 (Certified Nursing Assistant) said she was working on the memory unit on the day of R1 and R2's incident which had occurred around 3:00 PM. V7 said she was sitting in the dining/day area, and R1 was walking in the hallway like he always does when she heard a noise that sounded like someone fell. V7 (Certified Nursing Assistant) said she went down the hallway and saw R1 on the floor near R2's room and a therapy staff member (V8) were standing in front of another resident's room door who told V7 that R2 had pushed R1. V7 (Certified Nursing Assistant) then said that R1 had a bump to the back of his head with a small amount of blood present, that was not actively bleeding. V7 (Certified Nursing Assistant) added that after she was told what happened, she opened R2's door and he was standing in the middle of the room and didn't say anything but looked mad. V7 said she closed door then asked V8 to stay with R1 while she went to look for the nurse. V7 said when she returned to R1, a nurse was already there. V7 (Certified Nursing Assistant) then said that R2 can be aggressive to staff at times, shakes his fist at people, and doesn't like anyone coming into his room because he doesn't want to be bothered. V7 added that sometimes she is scared of R5. On 04/08/2025 at 2:53 PM, V10 (Agency Nurse) said she worked on the memory unit on the night shift after R1 and R2's incident and didn't recall being told about any head trauma. V10 said we did neuros [neurological assessments] on him; he didn't have any bruising. V10 then said she don't really recall the incident and ended the phone call. On 04/09/2025 at 1:50 PM, V1 (Administrator) said he did not identify or substantiate the incident with R1 & R2 as abuse because both residents have dementia and impaired cognition so there was no willful intent, and there was no concrete evidence or identification that R2 had pushed R1 out of his room. 2. Final incident report with incident date of 01/25/2025 at 8:47 PM documented that R4 and R5 were roommates on the memory care unit and were both in their room for the evening. Staff noted residents in the hallway and R5 had a hold of R4's hair then took a hold of R4's wrists. Staff intervened and R5 immediately released R4, residents were separated. R5 was placed on 1:1 supervision until (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145269 If continuation sheet Page 4 of 7 Printed: 05/15/2026 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 145269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hope Creek Nursing & Rehab 4343 Kennedy Drive 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 0600 transferred to the hospital for evaluation. Injuries non-apparent for both residents. New room assignment. Level of Harm - Actual harm R4's incident report dated 01/25/2025 initiated by V12 (Agency Nurse) documented that staff heard yelling and upon assessing situation, R4 told staff that her roommate (R5) pulled her hair; R5 was yelling at R4 and staff. Residents Affected - Few R4's face sheet documented admission date of 12/19/2024 and a past medical history not limited to dementia, hypertension, atrial fibrillation and right femur fracture. Care plan with date initiated of 12/30/2024 documented impaired cognitive function or impaired thought processes related to dementia. R4's clinical census showed a room change from building 1-2 to 4-2 on 01/29/2025. R4's Brief Interview for Mental Status (BIMS) under Section C for cognitive patterns dated 03/24/2025 indicated severe cognitive impairment with score of 02/15. R4's screening assessment for aggressive and/or harmful behavior dated 01/28/2025 documented minimal risk for aggression. R4's trauma screening with effective date of 01/28/2025 documented exposure to and an increased vulnerability to trauma. On 04/09/2025 at 11:53 AM, V13 (Certified Nursing Assistant) said R4 is easy to work with and she has not seen any aggressive behaviors from R4. On 04/09/2025 at 11:55 AM, R4 said regarding the incident with R5, I didn't do anything to her, she just came behind me and pulled my hair. R5 was visibly distraught during interview and said she was angry and scared of her then indicated that she wanted to press charges but knows that R5 has mental problems. R5's incident report dated 01/25/2025 initiated by V12 (Agency Nurse) documented that staff heard yelling and upon assessing situation, R5 told staff that her roommate (R4) hit her. Report indicated that R5 was confused and agitated/anxious. R5's face sheet documented admission date of 09/26/2022 and a past medical history not limited to depression, dementia, history of covid and edema. R5's care plan with date initiated of 11/04/2022 documented in part, demonstrates behavioral distress manifested by verbal behaviors when agitated and physical altercation with another resident; has displayed conflictual, difficult behavior with other persons manifested by getting defensive when other peers come into her room uninvited and my express the need to physically or verbally defend herself (initiated 11/16/2023); impaired cognitive function .becomes easily confused, overwhelmed, and disoriented (initiated 05/31/2024); problem with depressed mood that is evidenced by and not limited to fluctuations in mood, behavior, and affect .(initiated 05/31/2024). R5's progress noted dated 01/25/2025 at 11:13 PM documented by V12 (Agency Nurse) indicated that yelling was heard, and upon V12's assessment, she saw aides separating R5 and her roommate (R4). R4 said that R5 pulled her hair. R5 was yelling at R4 and staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145269 If continuation sheet Page 5 of 7 Printed: 05/15/2026 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 145269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hope Creek Nursing & Rehab 4343 Kennedy Drive 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 0600 Level of Harm - Actual harm Residents Affected - Few R5's psychiatry note dated 01/28/2025 reads in part, history of Alzheimer's dementia with behavioral disturbance. Visited acute on this day after an altercation with another resident. She (R5) was reportedly the aggressor and attacked her new roommate [R4]. Note also documented a plan to start divalproex sodium 125mg capsule by mouth two times daily for BPSD (behavioral and psychological symptoms of dementia. R5's screening assessment for aggressive and/or harmful behavior dated 01/28/2025 documented history or recent episode of aggressive/agitated behavior, history of abuse/neglect either as recipient or perpetrator including abusive and/or inappropriate sexual behavior. R5's trauma screening with effective date of 01/28/2025 documented history or presence of dysfunctional behavior (e.g., provoking, aggressive . abrasive/inappropriate behavior) but is documented as a minimal risk for aggression. R5's Brief Interview for Mental Status (BIMS) under Section C for cognitive patterns dated 04/01/2025 indicated severe cognitive impairment with score of 03/15. R5's active orders as of 04/09/2025 showed orders for behavior monitoring including agitation with peers, wandering, restlessness; divalproex sodium 125mg capsule by mouth two times daily for BPSD (01/31/2025); donepezil 10mg by mouth the evening for dementia; memantine hydrochloride 10mg by mouth two times a day for dementia. On 04/09/2025 at 11:50 AM, R5 was observed in her room, alert to self and was not interviewable. On 04/09/2025 at 12:06 PM, V11 (Certified Nursing Assistant) said R4 and R5 were roommates on the memory unit and indicated that R5 is normally confused. On day of incident, V11 said she was in the day area on the unit after supper when she heard someone yelling out for help. When she went down the hallway, V11 (Certified Nursing Assistant) said she saw R5 standing behind R4 in the hallway and R5 had a hold of R4's hair. V11 added that when she approached the residents and tried to redirect R5, she let go of R4's hair but then grabbed her by the wrists. V11 continued to redirect R5 in a calm manner, then R5 finally let go of R4's hair and they were separated. R4 was redirected to the day area. R5 was redirected back to her room; V11 stayed with R5 until she left facility via ambulance. V11 (Certified Nursing Assistant) added that during her 1:1 with R5, she seemed angry and was saying that R4 needed to go to jail. On 04/09/2025 at 1:38 PM, V12 (Agency Nurse) said the incident between R4 and R5 occurred after dinner. V12 said she was in the nurse's office on the unit charting when she heard some commotion and headed down the hall and could hear the aides saying, let her go. V12 (Agency Nurse) added that when she approached R4 and R5, they were standing in the hallway outside the doorway of their room and R4 was accusing R5 of attacking her. V12 said R4 was visibly upset and was assessed for any injuries with none found. She added that R5 was sent out because she was the aggressor and R4 was moved to another room on the unit, then was eventually moved to another unit because R4's son didn't feel comfortable with R4 staying on the unit. On 04/09/2025 at 1:50 PM, V1 (Administrator) said he did not identify or substantiate the incident with R4 & R5 as abuse because both residents have dementia and impaired cognition so there was no willful intent. V1 added that R5 grabbed R4's hair, but it was not stated that R5 pulled R4's hair and R5 had grabbed R4's wrists but did not push her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145269 If continuation sheet Page 6 of 7 Printed: 05/15/2026 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 145269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hope Creek Nursing & Rehab 4343 Kennedy Drive 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 0600 Level of Harm - Actual harm Residents Affected - Few Abuse Prevention Program policy last revised 01/2019 reads in part: it is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. Screen-Train-Report-Identify-Investigate-Protect-Prevent. Abuse and Crime Reporting policy last revised 01/2019 reads in part: this facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends or other individuals. This policy will define how the investigation of abuse allegations and mistreatment, or crimes will be conducted and outline the process of reporting, investigating and arriving at a conclusion or disposition of the allegation. All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment, neglect, or exploitation including injuries of an unknown origin . For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain and is not limited to: physical abuse-hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145269 If continuation sheet Page 7 of 7