Health inspection·February 17, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop a plan of care for two residents (R30 and R49) of 47 residents reviewed for comprehensive care planning in the sample of 47. Residents Affected - Few Findings include: The facility's Comprehensive Assessments and Care Plans, revised 4/5/21 documents: The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan - (C) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (D) Any updated information based on the details of the comprehensive care plan, as necessary. 1. The Medical Diagnoses listed for R30 include: Nontraumatic Intracerebral Hemorrhage in subcortical hemisphere, Malignant Neoplasm, Hemorrhage of anus and rectum, Diabetes type 2, Gastrointestinal Hemorrhage, and Vascular Dementia. The Physician Order Summary for R30, dated 2/17/23, documents Discharge of OT (occupational therapy) to patient going hospice on 1/11/23. This same Order Summary documents senile degeneration of the brain as the hospice diagnosis on 2/14/23. The current Care Plan for R30, as of 2/14/23, does not include a comprehensive care plan was developed for R30. On 2/17/23 at 8:24 am, V4 (Care Plan Coordinator/CPC) confirmed R30 is receiving hospice services. V4 stated R30 went back on Hospice on 1/16/23 and should be on his care plan. V4 stated someone resolved R30's hospice care plan on 2/3/23. V4 does not know why and shouldn't have been. 2. R49's medical record documents an admission date of 1/11/23. R49's current care plan does not document a history of suicidal ideations. R49's POS (Physician Order Sheet) dated 1/13/23 documents Quetiapine Fumarate (Seroquel/Anti-Psychotic) 200 milligrams (mg) Tablet. give one tablet by mouth one time a day for na (Not Applicable) R49's medical record dated 1/20/23 documents Patient reports he takes Seroquel for suicidal ideations. Suicidal ideation, treatment resistant depression precipitated by chronic illness and paralysis from congenital spina bifida. Patient reports has a long history of suicidal ideation and was placed on medication by primary psychiatrist for persistent suicidal thoughts. Patient reports that he remains on antipsychotic medication for major depressive disorder recurrent, and patient declines to change medication prescribed by primary psychiatrist familiar with history of condition, and further believes that any change made in medication may precipitate the return of thoughts of suicide and being better off dead. Patient further reports that medication should not be changed by facility nurse practitioner as patient is short term resident there for skilled care. On 02/15/23 10:52 AM, V2, Director of Nursing verified there is no identified diagnosis for R49 taking Seroquel and stated I don't know why (R49) is taking it. Him and his parents told us the Seroquel was for sleep, but he takes it in the morning. He has Melatonin he takes at night for sleep. I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 2 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete sent an email to our behavioral health service to evaluate him for the Seroquel, but I never heard back of why he's taking it. Oh wait, there's a note in here from (V28, Psychiatric Nurse Practitioner) on 1/20/23 that he's taking Seroquel for a history suicidal ideations and severe depression. Ok, that's why he's taking it. On 02/15/23 12:10 PM V4 (CPC) verified R49's care plan does not include suicidal ideations and stated I was not aware that (R49) had a history of suicidal ideations. I was told he's taking Seroquel for sleep, not suicidal ideations. If I knew he had a history of Suicidal ideations, I would have definitely added it to the care plan, but no one told us. Yeah, I see it here in the psychiatric visit note on 1/20/23 indicating it. This is the first I'm hearing this. Had we known he had a history of suicidal ideations, myself and V5 (Social Services Director) would have talked to him and (V5) would have done an evaluation on him. Event ID: Facility ID: 145680 If continuation sheet Page 3 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0657 Level of Harm - Minimal harm or potential for actual harm Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review the facility failed to revise the dialysis care plan access site for one resident (R25) of three residents reviewed for dialysis in the sample of 47. Residents Affected - Few Finding include: Facility Policy/Comprehensive Assessments and Care Plans dated/revised 4/5/21 documents: The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(C) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (D) Any updated information based on the details of the comprehensive care plan, as necessary. On 2/14/23 1:30pm R25 stated that her dialysis access is in her left upper chest. R25 stated that dialysis takes care of the dressing. Current Care Plan indicates staff are to monitor shunt for bruit and thrill. On 2/16/23 at 9am V2 (Director of Nurses) confirmed that R25 has a dialysis access port in her chest - not a shunt - and R25's care plan should have been updated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 4 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Medical Diagnoses form includes the following diagnoses for R18: Fracture of fifth Lumbar Vertebra, Stage 4 Chronic Kidney Disease, Tubulo-Interstitial Nephritis, Muscle wasting and Atrophy, and Malignant Neoplasm of Head, Face and Neck. Residents Affected - Few The admission MDS (Minimum Data Set) for R18, dated 1/8/23, documents R18 is cognitively intact with no behaviors. This MDS documents R18 requires extensive assist of one staff for personal hygiene. The current Care Plan for R18, documents focus area that R18 has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) ADL needs and participation vary with intervention as Resident currently requires assistance with ADL's. The Care Plan lists focus area that R18 has potential fluid imbalance r/t Heat exposure and poor intake with goal of adequate fluid volume balance AEB (as evidenced by) good skin turgor, pink and moist mucous membranes, and sufficient fluid intake. Interventions include offering fluids, activities, and monitoring fluid consumption and report abnormalities. This same Care Plan documents focus area that R18 has potential for an actual oral health concerns. Has functional limitations and needs assistance to complete oral care tasks. Interventions include: assist with, or provide mouth care as needed to ensure task completion. On 2/14/23 at 10:20 AM, R18 was lying in bed with malnourished appearance and oral cavity was coated with dry thick white substance with same substance dried and caked to her teeth. R18's lips were dry with white substance dried to lips and corners of her mouth. During this time R18 was having difficulty moving lips and tongue due to dryness. R18 stated the staff have helped here a couple of times with cleaning her mouth since she came to the facility. At this time there was a full glass of water noted on bed side table out of resident reach. On 2/15/23 at 11:22 AM, R18 was lying in bed with same dry oral cavity appearance, thick white substance covering teeth, lips, and corners of mouth. R18 stated her mouth is dry a lot of the time and she needs help when drinking and can't reach her water. During this same time there was a bed side table with a full glass of water out of resident reach. On 2/15/23 at 11:22 AM, V24 (Certified Nurse Assistant) confirmed R18 was in need of oral care. Based on observation, interview and record review, the facility failed to ensure residents who required the assistance of staff for Activities of Daily Living/ADLs were provided ADL care to include the removal of unwanted facial hair and oral care for two of three residents (R18 and R74) reviewed for Activities of Daily Living in the sample of 47. Findings include: The facility's Standards and Guidelines: SG ADL Care and Assistance Policy, revised 3/27/21, states, Standard: It will be the standard of this facility to provide the resident with Activities of Daily Living (ADL) care and assistance while attempting to maintain the highest practicable level of function for the resident. Personal Hygiene: How a resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers). 2. Each ADL should be provided at the level of assistance that promotes the highest practicable level of function for the resident, while ensuring the needs and desired goals of the resident are met safely. 3. Staff should be mindful to provide ADL care with dignity, privacy and respect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 5 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0677 to the resident, unless otherwise indicated by the resident. Level of Harm - Minimal harm or potential for actual harm 1. R74's Face sheet documents R74 admitted to the facility on [DATE] with diagnoses to include but not limited to: Cerebral Infarction; Flaccid Hemiplegia affecting left dominant side; Need for Assistance with Personal Care; Nontraumatic Intracerebral hemorrhage; Obesity; Lack of Coordination; Muscle Wasting and Atrophy; and Weakness. Residents Affected - Few R74's current Order Summary Report documents that R74 is NPO (Nothing by Mouth) and receives enteral tube feedings. R74's current Care Plan documents R74 with following: requires assistance with ADLs stating that R74 is dependent on assistance with personal hygiene; has hemiparalysis on the left side of R74's body; and needs assistance to complete oral care tasks. This same Care Plan states, Assist with or provide mouth care as needed to ensure task completion. Review ADL Care Plan interventions for degree of assistance needed. R74's Minimum Data Set (MDS Assessment) dated 12/21/22, documents R74 with severe cognitive impairment and requires extensive assistance of one personal physical assist for personal hygiene. R74's MDS Assessments dated, 12/21/22, 12/29/22 and 2/7/23 documented R74 had no rejection of cares during the seven day look back period. As of 2/15/23, R74's Point of Care Response History for the task bathing/showers states the question, Was the resident's face shaved? For a look back period of 30 days, this question is only answered as yes on 1/19/23. On 02/14/23 at 10:50 AM, R74 was seen lying in bed in R74's room. R74 was alert and able to answer questions well. A large cluster of long, curly white and gray strands of hair, approximately one to one and a half inches long were noted to R74's chin and extended down onto her neck. R74's mouth was dry with a thick white cakey substance noted to the corners of R74's mouth. R74's lips were dry and chapped. A small dried bloody area was noted to the center of R74's bottom lip. At this time, R74 stated, I can't eat or drink, so my mouth gets dry. On 02/15/23 at 11:42 AM, R74 was seen lying in bed in R74's room. R74 was alert, answering questions well. R74 continued to have the large cluster of long, curly white and gray strands of hair, approximately one to one and a half inches long on R74's chin extending down onto her neck. R74's mouth remained dry with the thick white cakey substance on the corners of R74's mouth. R74's lips were dry and chapped. A small dried bloody area was noted to the center of R74's bottom lip. When asking R74 about R74's facial hair and mouth care, R74 stated, Nobody does anything with them (chin and neck hairs). I want them to. I used to tweeze them when I was at home. R74 stated, My lips are dry. I wish I had (lip balm). They just put me in this room and forget about me, that's how I feel. On 02/15/23 at 11:51 AM, V2 (Director of Nursing) entered R74's room. At this time, V2 verified that R74 has long chin and neck hairs that should be removed and R74's mouth was dry with buildup. V2 attempted to locate supplies in R74's room to perform oral care and moisten R74's mouth. No supplies were able to be located in R74's room. V2 stated that R74 requires assistance for ADLs and V2 would notify staff to assist R74. V2 stated that residents should be shaved on their shower days and as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 6 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 2/14/23 at 10:20 AM, R18 was lying in bed on her back and stated I have a sore near my tailbone that is very painful. They just gave me some medicine so hopefully will be better soon. Residents Affected - Few 02/15/23 at 11:15 AM V3 (ADON/Wound Nurse) stated she is not aware of any pressure ulcers to R18's bottom and R18 is not on her list of wounds to assess weekly. On 2/15/22 at 11:22 AM, V24 (Certified Nursing Assistant/CNA) and V3 assisted R18 onto her left side, removed R18's incontinence brief and revealed an open area to R18's coccyx area that did not have any ointment or dressing over it. V3 stated the wound is an open stage II pressure ulcer and measures 1.0 cm (centimeters) by 0.2 cm with depth of 0.2 cm. V3 stated she was unaware of R18's pressure ulcer and the staff should have notified her at the time they found it. V3 stated she would call R18's doctor and get a treatment order. On 2/15/23 at 11:35 AM, V2 (Director of Nurses/DON) stated she spoke with the nurse who took care of R18 yesterday and said the nurse saw the area and notified hospice yesterday but forgot to chart it. On 2/15/23 at 12:02 PM V26 (Hospice Registered Nurse), stated she was at the facility on the morning of 2/14/23 and R18 had complained to her about her bottom being sore and when (V26) asked the nurse about it the nurse said it was only a small shearing area. V26 stated she asked the nurse specifically if the area was a pressure ulcer and the nurse said no. V26 stated no one called her about a pressure ulcer on R18's bottom. On 2/15/23 at 12:45 PM, V25 (Licensed Practical Nurse/LPN), stated she was the nurse for R18 on 2/14/23 and only saw a friction/shearing area to R18's sacrum that measured about 2 cm. V25 stated the area was only red at the time and was not open. V25 stated she did not call R18's family or R18's Physician and probably should have. V25 stated she thought V26 (Hospice RN) would notify the family. The Progress Note for R18, dated 2/14/23 at 1:00 pm, documents During cares patient observed to have skin shearing/red in color, area to coccyx. Area was not open. No drainage or warmth to area. Hospice nurse was at facility at the time, and it was reported. Hospice nurse stated we may use topical cream or zinc to area daily and prn until resolved. Zinc cream was applied to area at this time. The Physician Order Summary, dated 2/15/23, does not include any pressure ulcer treatment orders for R18. Based on observation, interview and record review, the facility failed to notify the physician for an identified sign of infection in a pressure ulcer for one resident (R7). The facility also failed to identify a pressure ulcer and notify the physician for one resident (R18). These failures effected two out of four residents reviewed for pressure ulcer in a sample of 47. This failure caused a delay in treatment resulting in R7 being admitted to the Intensive Care Unit (ICU) for septic shock due to an infection in his stage IV right hip pressure ulcer. Findings include: The facility's Standards and Guidelines: SG Wound Care policy dated 3/27/21, documents 11. Document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 7 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0686 Level of Harm - Actual harm Residents Affected - Few the progression of the wound being treated. Such observations should be items size, staging (if applicable), odors, exudate, tunneling, etiology etc. 12. Contact the physician for additional order changes as appropriated or to notify of skin condition changes or refusals of care. 1. On 02/14/23 at 12:14 PM, V4 (Licensed Practical Nurse/LPN), stated (R7) isn't here, he had an appointment this morning at the wound clinic, but he's not coming back. I was just informed the wound clinic sent him to the emergency room (ER) due to an elevated heart rate, low blood pressure and fever. They think he may have sepsis. R7's wound assessment dated [DATE] documents Left hip pressure ulcer stage IV and Right hip pressure ulcer stage IV. R7's physician order sheet dated 2/6/23 documents Change wound vacuum to left and right ischial ulcers using black foam at 175 millimeters of mercury (mmhg) for left 125 mmhg for right continuous changing three times a week and utilize xeroform, with a bordered gauze changing three times per week to his left lower extremity. (Wound solution, a mixture of sodium hypochlorite (0.4% to 0.5%) and boric acid (4%) diluted in water) soak for five to ten minutes with dressing changes. Cleansing all wounds with normal saline or wound wash of choice with dressing changes. 2/13/23 12:16pm R7's medical record documents Late Entry: Note Text: Wound vacuum to right and left hip changed per orders. Right hip noted to have foul smell and necrotic tissue. Resident to follow up with wound clinic on 2/14/23. Resident denies any pain at this time. Will continue to monitor. V29's (Medical Director) physician visit note dated 2/7/23 document's Of note, (R7) also reportedly had a seizure in the setting of acute infection in October. Of note, upon further review of his chart, it appears that he was admitted locally in October 2022 with sepsis and seizure like activity requiring intubation for airway protection. During that hospitalization, he underwent bilateral ischial wound debridement with left ischial bone biopsy by general surgery. Cultures grew klebsiella pneumoniae, proteus mirabilis, enterococcus faecalis, enterococcus faecium, corynebacterium, bacteroids thetaiotaomicron. Surgical pathology was consistent with necrotic skin and soft tissue with acute inflammation and acute osteomyelitis. On 2/14/23 2:11 PM, V7 (Wound Clinic Registered Nurse/WCRN), I was the one that saw him today. (V28 Nurse Practitioner), assessed his wounds and he had signs of infection in his right hip wound along with a low blood pressure, elevated heart rate and fever, so she had him sent to the ER for possible sepsis. If the facility identified a foul smell with necrotic tissue yesterday during his wound vacuum dressing change, they should have contacted us prior to putting the wound vacuum back on because his symptoms indicated an infection. 2/14/23 at 2:24 PM, V3 (Assistant Director of Nursing/ADON), stated I changed the wound vacuum yesterday and noticed the wound had a foul smell with some necrotic tissue. When I changed it yesterday, I knew he had an appointment today, so I didn't contact the wound clinic or his physician because I knew he was going to the wound clinic today. Yes, the foul smell and necrotic tissue typically indicates an infection. If the resident is being followed by a wound clinic, we normally notify the clinic of any wound changes, but like I said, he was being seen the next day and that's why I didn't. I guess it was just poor communication of why I didn't notify anyone. On 02/15/23 at 9:17 AM V7 (WCRN) stated After our conversation yesterday, I spoke to (V28 NP) about (R7). She agreed that the facility should have called when they noticed the foul smell and necrotic (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 8 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0686 Level of Harm - Actual harm tissue in his right hip wound. It indicates a possible infection and given his history of sepsis; we would have had him sent to the ER for evaluation instead of waiting the next day for his appointment. I looked at his medical record he's currently in the ICU for septic shock. He shouldn't have waited for his appointment here. He should have gotten immediate treatment when they identified the infection. Residents Affected - Few R7's hospital medical record dated 2/14/23 documents R7 was admitted to the intensive care unit for septic shock and pressure injury of contiguous region involving right buttock and hip, stage IV. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 9 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, interview, and record review the facility failed to ensure indwelling urinary catheters were not placed on the floor to prevent contamination for two (R18 and R30) of six residents reviewed for indwelling catheter care in the sample of 47. Findings include: The facility Indwelling Catheters policy and procedure, Revised 3/27/21, documents 10. Staff should ensure proper placement of the catheter tubing as to ensure that it is not kinked, pulling excessively and allows for gravity drainage. The facility Prevention of Catheter Associated Urinary Tract Infections policy and procedure, Revised 11/5/22, documents 9. Keep the collection bag below the level of the bladder. Do not rest the bag on the floor. 1. The Physician Order Summary, dated 2/15/23, documents a physician order on 1/3/23 as insert/maintain indwelling catheter 16FR (French type and size of catheter) Neuromuscular dysfunction. On 2/15/23 at 11:22 AM, R18 was lying in bed with her indwelling urinary catheter bag resting on the floor in a large pool of urine. On 2/15/23 at 11:25 AM V24 (Certified Nursing Assistant/CNA) confirmed R18's indwelling urinary catheter bag was resting on the floor in a pool of urine and stated she is unsure what happened or why there is urine on the floor. V24 CNA stated no catheter bag or tubing should be on the floor. 2. The Physician Order Summary report for R30, dated 2/17/23, documents a physician order for 1/12/23 to Insert/maintain indwelling catheter (16 French) - obstructive uropathy. On 2/14/23 at 10:12 AM R30 was lying in bed with an indwelling urinary catheter in place with the catheter tubing coiled up and resting on the floor. R30 stated he can't pee as the reason for having the catheter. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 10 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain a physician order for care of a resident's Gastrostomy site and failed to provide care to a resident's Gastrostomy site for one of one resident (R74) reviewed for tube feedings in the sample of 47. Findings include: The facility's Standard and Guidelines: SG Enteral Tube Feeding Policy, revised 3/27/21, states, 13. Provide cleaning and dressing changes as ordered to enteral tube feeding sites. R74's Face sheet documents R74 admitted to the facility on [DATE] with diagnoses to include but not limited to: Cerebral Infarction; Gastrostomy Status, Flaccid Hemiplegia affecting left dominant side; Need for Assistance with Personal Care; Nontraumatic Intracerebral hemorrhage; Feeding Difficulties; and Weakness. R74's current Care Plan documents R74 requires a tube feeding due to a stroke. This same Care Plan documents an intervention to provide skin care to R74's feeding tube insertion site daily and as needed. R74's After Visit Summary Report, dated 2/10/23, documents R74 was hospitalized from [DATE] to 2/10/23 for PEG (Percutaneous Endoscopic Gastrostomy) Tube Malfunction. This same report documents care of the feeding tube includes keeping the skin around the tube clean and dry. On 02/14/23 at 11:30 AM, V8 (Licensed Practical Nurse) entered R74's room to administer pain medication via R74's Gastrostomy Tube/G-Tube. R74's feeding tube was noted to have a large amount of gauze with a transparent adhesive dressing bunched up and tangled around R74's G-tube. The edges of the transparent adhesive dressing were rolled up and not secured to R74's skin. V8 struggled manipulating the gauze to administer R74's medication. V8 stated, This needs cut off. At this time, V8 stated it was possible this gauze was R74's original dressing after returning to the facility from the hospital that had fallen off. V8 lifted R74's gown up to expose R74's G-tube insertion site. R74's G-tube insertion site was noted with a large amount of brown-crusty build-up directly around R74's insertion site and on R74's surrounding skin area, measuring approximately one inch in diameter. On 2/14/23 at 11:35 AM, V8 stated that V8 had not performed G-Tube site care for R74 since R74 returned from the hospital on 2/10/23. V8 stated, I haven't had any orders for the (G-Tube site) care to be completed on my shift. V8 stated that V8 has taken care of R74 previously since R74's return from the hospital on 2/10/23 and V8 did not complete G-Tube care on those shifts either. V8 stated that before R74 left the facility (on 2/7/23), V8 recalls R74 having a previous order for G-Tube site care. V8 verified that R74's G-tube site and surrounding skin needed to be cleansed. On 2/14/23 at 11:40 AM, V2 (Director of Nursing) verified that R74's G-Tube site care should have been added as a physician order once R74 returned back to the facility after having R74's tube replaced, and it wasn't. V2 stated that there is an order set for feeding tubes that gets initiated and a specific order for site care is not part of that set. V2 stated the insertion site care has to be added separately. V2 stated, I am going to talk to Corporate about getting that added. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 11 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0693 Level of Harm - Minimal harm or potential for actual harm As of 2/14/23 at 12:00 PM, R74's medical record did not contain a current order for G-Tube site care and did not contain any documentation that G-Tube site care had been completed since R74's return from the hospital on 2/10/23. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 12 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, and record review the facility failed to keep dietary worker certifications up to date. This failure has the potential to affect all 104 residents who consume food in the facility except R74 and R99 who are NPO (Nothing by Mouth). Findings include: The Dietary [NAME] and Aide Job Descriptions, undated, documents a qualification of Must meet all local health regulations. On 2/14/23 at 12:30 PM, V11 (Cook) and V13 (Dietary Aide) were in the kitchen handling food and food items in preparation for the lunch meal. On 2/14/23 at 9:50 AM, V9 (Dietary Manager) stated that V9 has 15 staff members and that their certificates are either expired or not available for most all of the dietary staff. V9 stated V9 has been notifying Corporate for the need to get staff certified with food handler's certificates since Corporate would be the ones who would be paying for it. V9 stated that V9 has not gotten a response. At this time, V10's (Dietary Aide) Food Handler Certificate was posted on the outside of V9's office window. This certificate has an expiration date of 10/24/22. V11's (Cook) Food Service Sanitation Manager Certification was posted on the outside of V9's office window. This Certificate has an expiration date of 11/30/21. The local state agency website https://dph.illinois.gov/topics-services/food-safety/food-handler-training.html states, Food employee or food handler means an individual working with unpackaged food, food equipment or utensils, or food-contact surfaces and documents any food handler in Illinois is required to have food handler training. This same website states, Food Handler Training: Food Handler Training is still required for ALL paid employees who meets the definition of a food handler in both restaurants and non-restaurants within 30 days of hire, unless that food handler has a valid Certified Food Protection Manager (CFPM) certification. The ANSI (American National Standards Institute) food handler training certificates are good for three years and those taking other types of training that work in restaurants and other non-restaurant facilities, such as nursing homes, licensed day care homes and facilities, hospitals, schools and long-term care facilities, are good for three years. The facility's list of dietary personnel with hire dates provided by V9 (Dietary Manager) on 2/14/23 documents the following start dates for dietary personnel: V10 (Dietary Aide) 8/17/21; V11 (Cook) 6/1/21; V12 (Cook) 6/1/21; V13 (Cook) 6/1/21; V14 (Dietary Aide) 6/1/21; V15 (Dietary Aide) 6/1/21; V16 (Dietary Aide) 6/8/22; V17 (Dietary Aide) 6/1/21; V18 (Dietary Aide) 2/1/22; V19 (Dietary Aide) 11/17/22; V20 (Dietary Aide) 5/18/22; V21 (Dietary Aide) 5/23/22; V22 (Dietary Aide) 6/22/22; and V23 (Dietary Aide) 12/14/22. On 2/16/23 at 10:34 AM, V9 stated that V9 was not able to provide any current Food Handler Certificates for the above employees. V9 stated their employee files were checked and no record of the Food Handler Certificates being completed could be located in the facility. V9 stated, I am getting everyone signed up now. V9 verified that all dietary staff members should have current Food Handlers Certificates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 13 of 14 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 145680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Celebrate Sr Living of Moline 7300 34th 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 0801 The Resident Census and Condition of Residents signed and dated by V1 (Administrator) on 2/14/23 documents 104 residents currently reside in the facility. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 14 of 14