Inspection·February 27, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on record review and interview the facility failed to ensure a resident was free from sexual abuse by a staff member for 1 of 3 residents (R33) reviewed for abuse in a sample of 33. Residents Affected - Few Findings include: A policy titled Abuse and Neglect Prevention last revised 10/14/24 defines abuse as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. It includes abuse, sexual abuse, physical abuse, and mental abuse including facilitated or enabled through the use of technology. The policy continues, 3. Willful, as defined at 483.4 and as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm and 6. Mistreatment means inappropriate treatment r exploitation of a resident. This abuse policy documents, No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. A facility reported incident report dated (undated) documents R33 has a Brief Interview for Mental Status/ BIMS of 15 indicating he is cognitively intact. This report documents that on 02/21/25 at approximately 12:30 PM R33 showed a staff member a picture of a woman's naked vagina and some messages. R33 stated V8/Registered Nurse (RN) sent him the photo and messages. The messages were sent under the name Hot (V8's first name) and were from V8's phone number. The message read, Tell me the first thing that comes to mind when you see this. Mine was holocaust victim. An interview with R33 dated 02/21/25 and signed by V2/Director of Nursing documents R33 showed V2, V1/Administrator and V3/Human Resources a nude photo which R33 stated V8 had sent to him via text message. The message was from Hot/ (V8's first name) and was from V8's personal cell phone number. R33 stated that he and V8 do sometimes exchange messages, but he didn't expect or appreciate this message. R33 stated that he wasn't really too upset, but that it was inappropriate and shouldn't have happened. An interview dated 02/24/25 and signed by V2 titled (V8) abuse investigation documents V1 and V3 interviewed V8 and asked if V8 had sent an explicit photo to R33. V8 initially denied this and then admitted she had sent the photo to R33. V8 stated she knew it was inappropriate to send the photo, but she doesn't have many friends outside of work, so just thought she'd send it to R33. On 02/25/25 at 11:07 AM R33 stated V8 had sent him inappropriate text messages and pictures trying to entice him. R33 stated the messages upset him and were inappropriate so he reported this occurrence to staff and to V1. An undated final report, provided to surveyors on 02/26/25 documents, The facility has concluded its investigation and does believe (V8) is guilty of sending an explicit photo to (R33). V8 was terminated on 02/24/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145387 If continuation sheet Page 2 of 9 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 145387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony's Nsg & Rehab Ctr 767 30th Street Rock Island, IL 61201 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review the facility failed to prevent one of five residents (R46) from sustaining a smoking/vape-related burn and failed to complete quarterly Smoking Assessment Evaluations for four of 18 Residents (R33, R46, R51 and R79) reviewed for smoking in the sample of 33. Findings include: Facility Resident and Employee Smoking Policy dated 10/14/24 documents: It is the policy of the facility to provide a safe environment for Residents, staff and visitors by providing guidelines for the use of smoking materials; and the Smoking Evaluation tool will be done upon admission, quarterly and with change of condition; and the information will be available to staff members and will be updated with any changes in the Resident's capabilities and needs. Procedure for Residents: Smoking is only permitted under the supervision of a staff member in the facilities designated smoking areas based upon a smoking evaluation. the Smoking Evaluation tool will be done upon admission, quarterly and with change of condition; and the information will be available to staff members and will be updated with any changes in the Resident's capabilities and needs. The Facility Resident Smoking List, dated 2/24/25, documents R33, R46, R51 and R79 as smokers. Progress Note dated 2/10/25 at 11:31am indicates V11. NP (Nurse Practitioner) reported to V2, DON (Director of Nursing) that R46 showed V11 an area on his right forearm and stated he burned it while he was out smoking. Note indicates V2 assessed R46 and observed a 3cm (centimeter) X 1.6cm red and yellow area to R46's right forearm. At that time R46 told V2 he might have got the wound from his vape pen. Note indicates R46's wound Does appear size and shape of a vape pen. Note indicates V2 spoke with R46 regarding his non-compliance with only smoking at supervised times. Note indicates R46 stated he will go outside whenever he wants to. Note indicates an alarm was applied to R46's wheelchair to alert staff whenever R46 attempts to leave the unit/enter the elevator. Skin Check Note dated 2/10/25 at 12pm indicates R46 has a new skin issue right anterior arm - Type: Partial Thickness Burn. On 2/26/25 at 2:25pm R46 pulled his right sleeve up and an oval thickened scabbed wound was noted middle anterior arm. Peri wound had no signs/symptoms of infection. At that time R46 acknowledged vaping at times when he was unsupervised. On 2/27/25 at 10:20am V11, NP stated that the affected area on R46's right arm did initially look like it may have had blistering but blisters were not present when she first saw the wound. V11 stated R46 told her the burn was from a vape pen. R46's current Care Plan indicates R46 has an actual skin impairment of right forearm related to a burn from vape/cigarettes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145387 If continuation sheet Page 3 of 9 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 145387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony's Nsg & Rehab Ctr 767 30th Street Rock Island, IL 61201 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 0689 Level of Harm - Minimal harm or potential for actual harm Care Plan indicates R46 is not compliant with Smoking Policy as he is supposed to be supervised but leaves his unit unattended. Care Plan indicates R46 is non-compliant with Smoking Policy as evidenced by going outside to smoke at undesignated times. Care Plan indicates R46 requires Supervision during smoking. Residents Affected - Some R51's Medical Record documented R51's most recent Smoking Assessment (dated 6/18/24). R33's 06/04/24 Smoking assessment documents Resident is cognitively intact, able to light his own cigarettes and put his cigarettes out safely. Resident is able to self propel himself outside. He is safe to smoke without supervision. There is not a quarterly assessment completed for R33. A sheet of residents who smoke dated 02/24/25 documents R79 smokes independently. Review of R79's assessments does not have a smoking assessment. On 02/26/25 at 10:05 AM V1/Administrator stated there is no quarterly smoking assessment for R33 and no smoking assessment completed for R79. On 2/27/25 at 10:05 am, V1 (Administrator) stated, We do not have any quarterly Smoking Assessments for R33, R46, R51 or R79. It looks like we are only doing the Assessments annually. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145387 If continuation sheet Page 4 of 9 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 145387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony's Nsg & Rehab Ctr 767 30th Street Rock Island, IL 61201 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on observation, interview and record review the facility failed to provide an appropriate indication for use of an antipsychotic medication and failed to provide supporting behaviors for the use of an antipsychotic medication for one resident (R21) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 33. Findings include: Facility Policy/Psychotropic Medications dated 10/14/24 documents: The facility must ensure that residents who: Have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Antipsychotics will be used only for Behavioral Symptoms that are: A danger to the resident or to others OR cause the resident inconsolable or persistent distress, a significant decline in function, and/or substantial difficulty receiving needed care, AND Not due to a medical condition or problem AND Persistent or likely to reoccur without continued treatment AND Not sufficiently relieved by non-pharmacological interventions AND Not due to environmental stressors that can be addressed to improve the psychotic symptoms or maintain safety AND Not due to psychological stressors that can be expected to improve or resolve as the situation is addressed AND Conditions/diagnoses listed in the (Mental Illness Directory) or subsequent editions: Schizophrenia Schizoaffective disorder Delusional disorder Mood disorders Schizophreniform disorder Psychosis NOS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145387 If continuation sheet Page 5 of 9 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 145387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony's Nsg & Rehab Ctr 767 30th Street Rock Island, IL 61201 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 0758 Atypical psychosis Level of Harm - Minimal harm or potential for actual harm Brief psychotic disorder Dementing illnesses with associated behavioral symptoms Residents Affected - Few Medical illnesses or delirium with manic or psychotic symptoms R21's January 2025 Physician Order Report Summary indicates Quetiapine/Seroquel (antipsychotic) 100mg (milligrams) twice daily was ordered on 6/25/24 and indicates on 1/27/25 that order was changed to Seroquel 100mg three times daily on 1/27/25. R21's February 2025 Physician Order Report Summary indicates R21 continued on Seroquel 100mg three times per day until 2/27/25 for Mild Vascular Dementia with Behavioral Disturbance. R21's Current Care Plan indicates R21 has the potential to be verbally aggressive, yelling out exaggerated claims example: ripping his hair out when putting on his shirt. Care Plan indicates R21 has Ineffective coping skills and Mental/Emotional illness; Poor impulse control; Rolls self out of bed when not getting enough attention. (Last revised 9/14/22). Care Plan also indicates R21 has a behavior problem of yelling out constantly for help and wants someone to be in his room at all times; attention seeking; loud and disruptive. (Last Revised 09/14/2022) On 2/25/25 and 2/26/25 at random times throughout both days R21 was observed in his room, frequently calling out for help. On 2/27/25 at 3:15pm V2, DON (Director of Nursing) stated R21's behavior is mostly a constant yelling out. V2 stated they are going to try and reduce R21's Seroquel/Quetiapine and acknowledged it hasn't really reduced R21's yelling out behavior and also acknowledged the dosage is higher than usual. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145387 If continuation sheet Page 6 of 9 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 145387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony's Nsg & Rehab Ctr 767 30th Street Rock Island, IL 61201 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to prevent a significant medication error for one resident (R21) who receives an antipsychotic medication of five residents reviewed for unnecessary medications in the sample of 33. Residents Affected - Few Findings include: Facility Policy/Medication Administration dated 10/14/24 documents: The facility will provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all medications, to meet the needs of each resident. On 2/25/25 and 2/26/25 at random times throughout both days R21 was observed in his room, frequently calling out for help. On 2/27/25 at 3:15pm V2, DON (Director of Nursing) stated R21's behavior is mostly a constant yelling out. Hospice Physician Order dated 1/22/25 indicates to Start Seroquel (antipsychotic) 50mg (milligrams) by mouth three times per day. Nurse Note dated 1/27/25 at 11:22am indicates Hospice nurse in facility for routine visit and received new orders for R21 to increase the following medications from twice daily to three times daily: Lorazepam (antianxiety) 1mg, Seroquel 50mg, Tramadol (pain) 50mg, and Trazodone (antidepressant) 100mg. Orders updated. R21's January 2025 Physician Order Report Summary indicates Quetiapine/Seroquel (antipsychotic) 100mg twice daily was ordered on 6/25/24 and indicates on 1/27/25 that order was changed to Seroquel 100mg three times daily on 1/27/25. R21's Medication Administration Record (MAR) dated January 2025 indicates R21 received Seroquel 100mg three times per day from 1/27/25 until 2/27/25 when the error was discovered. The MAR indicates R21 received twice the dosage ordered (300mg per day instead of 150mg per day) from 1/27/25 through 2/27/25. Medication Error Report - Date and Time of Error 1/27/25 at 1200 for R21 indicates: Medication ordered: Seroquel (antipsychotic) 50mg (milligrams) three times per day Medication given: Nurse (V8) entered Seroquel 100mg three times per day into R21 Physician orders Report indicates No Adverse Effects noted At this time On 2/26/25 at 3:25pm V2, DON stated It looks like this is a medication error. The nurse who transcribed the order in error has already been terminated for other reasons. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145387 If continuation sheet Page 7 of 9 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 145387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony's Nsg & Rehab Ctr 767 30th Street Rock Island, IL 61201 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff follow infection control practices during wound care, in that, V4/Licensed Practical Nurse failed to change gloves during pressure ulcer wound care for R25. This failure has the potential to effect one resident [R25] of two residents reviewed for Pressure ulcer wound care, in a total sample of 33. Residents Affected - Few Findings include: The [NAME], A., [NAME], P., [NAME], W., & [NAME], N. (2024). Clinical Nursing Skills & Techniques (11th ed., pp. 1115-1116). Elsevier Health Sciences, document: 11. Apply clean gloves and remove soiled dressings; remove gauze one layer at a time; 12. Examine dressings for quality of drainage (color, consistency), presence or absence of odor, and quantity of drainage (note if dressings were saturated, slightly moist, or had no drainage). Discard dressings in waterproof biohazard bag. Remove and discard gloves; 13. Perform hand hygiene and apply clean gloves; 17. Apply dressings per order. Place time, date, and initials on new dressing; and 19. Discard biohazard bag and soiled supplies per agency policy. Remove and dispose of gloves. Perform hand hygiene. R25's Electronic Medical Record/EMR Physician Order, dated 2/24/25, document, Cleanse right buttock with NS [normal saline], apply barrier cream and border gauze daily and prn [as needed] until healed. On 2/25/2025, at 10:15 a.m., V4 performed hand hygiene, applied gloves, and without changing gloves, V4 removed R25's wound dressing from R25's right buttock wound; grabbed a clean 4 x 4 gauze; cleansed R25's wound; grabbed a dry 4 x4 gauze and dried R25's wound; grabbed container of barrier cream and placed small amount of V4's glove; applied barrier cream to wound area; and grabbed new foam dressing and applied to R25's right buttock wound. On 2/25/25 at 10:30 a.m., V4 confirmed not changing gloves after removing R25's soiled right buttock wound dressing. On 2/27/25, at 8:25 a.m., V2/Director of Nursing confirmed the expectation that V4 should have changed gloves/performed hand hygiene after removing R25's soiled right buttock wound dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145387 If continuation sheet Page 8 of 9 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 145387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony's Nsg & Rehab Ctr 767 30th Street Rock Island, IL 61201 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 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Based on record review and interview the facility failed to document staff were provided education regarding the benefits and potential risks associated with the Covid-19 vaccination. This failure has the potential to affect all 82 residents in the facility. Findings include: A Policy titled Employee Vaccination last revised 10/14/24 documents the purpose of this policy is, To reduce the risk of infectious disease transmission among employees, residents, and visitors by providing access to recommended immunizations. Procedure 4. Education and Awareness documents, Educational materials regarding the benefits, risks and availability of vaccines will be provided to all employees. Employees will be informed about recommended vaccination schedules and any updates from the Centers for Disease Control and Prevention (CDC) or Illinois Department of Public Health (IDPH). Review of employee Covid-19 Consent forms for staff who received a Covid-19 vaccination this year documents three staff received the Covid-19 vaccination (V4, V12, V13). There is no documentation these three or any staff received education regarding the benefits and potential risks associated with the Covid-19 vaccination. On 02/26/25 at 11:34 AM V9/Assistant Director of Nursing and Infection Preventionist confirmed she cannot provide documentation that staff were provided with education regarding the potential risks and benefits of receiving the Covid-19 vaccination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145387 If continuation sheet Page 9 of 9