Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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 record review and interview the facility failed to complete an Identified Offender care plan for one
resident (R85) of five residents reviewed for Identified Offender Status in a total sample of thirty-three.
Residents Affected - Few
Findings Include:
The Facility's Baseline Care Plan Policy dated 12/06/2022 documents The facility will develop and
implement a baseline care plan for each resident that includes the instructions needed to provide effective
and person-centered care of the resident that meet professional standards of quality of care.
The Facility's Identified Offender Procedure/Protocol document Complete an Identified Offender/Behavior
Risk Assessment, if one has not already been completed and complete an IO (Identified Offender) Care
Plan as soon as possible (within 36 hours is suggested.) Make sure to communicate any high-risk
convictions and concerns to Administration/Director of Nursing to address safety issues and risk
management.
R85's Criminal History Report documents the following convictions: 08/09/2018 Criminal Trespass to
Residence, 12/17/2018 Criminal Trespass to Residence, 2/10/2020 Criminal Trespass to Residence,
1/21/2014 Aggravated DUI (Driving under the Influences), 2/27/13 DUI/Alcohol, 5/22/2013 DUI
Alcohol/Drugs, 10/16/24 DUI Alcohol/Drugs, 7/14/2015 Aggravated DUI, 11/7/2012 Knowingly Damage
Property, 11/7/2012 Resist Peace Officer, 9/8/12 Knowingly Damage Property, 9/10/2012 Knowingly
Damage Property, 11/7/2012 Criminal Damage to Property, 1/23/2012 2 counts of Resist Peace Officer,
11/21/2011 Resist Peace Officer, 1/23/2012 Resist Peace Officer, 10/30/2011 Resist Peace Officer,
1/23/2012 Resist Peace Officer, 9/21/2011 Retail Theft/Merchandise less than $150, 8/11/21 Retail Theft,
9/21/11 Retail Theft, 12/29/10 Criminal Trespass to land and Domestic Battery/Physical Contact,
11/27/2010 Criminal Trespass to Building, 11/29/2010 Criminal Trespass to Land and 12/27/2010 Criminal
Trespass to Land.
R85's Criminal History Analysis Security Recommendation Report completed by the State Police on
10/23/23 documents The resident requires closer supervision and more frequent observation than standard
or routine for most residents in an open facility. Regular monitoring should be attentive to behavioral
changes that may signal a need for closer observation or sustained visual monitoring on a time-limited
basis. His compliance with psychiatric/medical treatment and abstinence from alcohol/drug use should be
closely monitored. In view of his alcohol/drug abuse history and extensive criminal history, a moderate risk
supervision status is recommended.
R85's current Care Plan dated 01/12/24 shows an admission date of 9/28/23 and does not include any
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
145680
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
03/15/2024
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
information about R85's identified offender status, or how frequently R85 should be monitored.
Level of Harm - Minimal harm
or potential for actual harm
On 3/13/24 at 1:50 PM V1 (Administrator) confirmed that there was no mention of R85's criminal history in
his care plan and there should be.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145680
If continuation sheet
Page 2 of 10
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
03/15/2024
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Facility failures resulted in two deficient practices.
Residents Affected - Few
A. Based on observation, interview and record review the Facility failed to comprehensively assess a facial
wound for one resident (R75) of three residents reviewed for wounds in the sample of 33.
B. Based on observation, interview and record review the Facility failed to complete scheduled daily
Diabetic Foot Ulcer treatments per Physician orders for one resident (R34) of five residents reviewed for
Skin Issues in the sample of 33.
Findings include:
A. The Facility's Skin and Wound Policy dated 3/27/21 documents: Document the progression of the wound
being treated. Such observations should include items size, staging (if applicable), odors, exudate,
tunneling, etiology, etc. The presence of skin impairment should be denoted on the person-centered plan of
care. Residents with pressure injuries or other wounds requiring measurements should also have weekly
documentation in the clinical record reflecting the condition of the wounds and any changes that take place.
R75's Hospital History and Physical Report dated 10/15/22 indicates R75 has a lesion around right orbital
area suggestive of skin cancer.
R75's admission Nursing Note dated 10/20/22 indicates R75 has Right has blackened area around orbit of
eye. Skin missing above eye. States it's been like this for 22 years; got infected and scratches area.
R75's Nurse Note dated 2/29/24 at 1:44pm indicates R75 is on antibiotics for infection to right eye; yellow
pus noted to be coming from area surrounding eye. The note indicates R75 has a history of skin impairment
to this eye and surrounding tissue.
On 3/12/24 at 2:39pm R75 was seen in his room resting on the bed. At that time R75 was noted to have a
scaly, red, scabbed area over entire right eye, extending over bridge of nose and surrounding areas. At that
time R75 stated he is only able to see about 75% from his right eye.
On 3/12/24 at 2:45pm V2 (Director of Nursing/DON) stated that R75 has never been officially diagnosed but
has probable cancer of the eye and surrounding tissue. V2 stated R75's eye started weeping pus-like
drainage and was recently put on antibiotics.
R75's Current Physician Order Summary Report/Diagnoses includes Ischemic Optic Neuropathy. Diagnosis
list does not include cancer of R75's right eye or skin cancer of surrounding tissues. Order Report also
indicates staff are to apply [NAME] Petrolatum to area around eye wound topically every eight hours as
needed for skin care.
R75's Care Plan indicates R75 has impaired visual function related to visually impaired due to blindness in
right eye secondary to possible ocular cancer. Care Plan also indicates has a skin impairment right forearm
skin tear but does not include facial wound across R75's right eye.
On 3/14/24 at 9:00am V2 (DON) stated Our weekly wound assessments, only ask if there's a new
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145680
If continuation sheet
Page 3 of 10
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
03/15/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
problem - if stays the same - no further assessment. V2 stated that staff only document if there are
changes.
Current non-pressure wound logs do not include monitoring of R75's right eye/face wound.
No further descriptions/assessments of R75's right eye/orbital area were found or presented after
admission skin assessment of 10/20/22.
B. Facility Standard and Guideline Wound Care Policy, revised 3/27/21, documents: it will be the standard of
the this Facility to provide assessment and identification of residents at risk of developing pressure injuries,
other wounds and the treatment of skin impairment; wound care procedures and treatments should be
performed according to Physician orders; wound care treatment should maintain proper technique, as
indicated by the type of wound and Physician orders; document in the clinical record when treatments are
performed; and contact the Physician for additional order changes as is appropriate or to notify of skin
condition changes.
Facility Standards and Guidelines Physician/Non-Physician Practitioner Order Policy, revised 10/24/22,
documents it will be the practice of this Facility to honor Physician/Licensed Independent Practitioner orders
in the following ways (Telephone Orders, Orders received by Non Physician Practitioner /Nurse
Practitioner/Physician Assistant, Faxed Orders and Electronic Orders).
The Facility Skin Log, dated 3/6/24, documents Diabetic Foot Ulcers to R34's Left First Toe and Left
Second Toe and an Arterial wound to R34's Right Heel.
R34's Physician Order Sheet/POS, dated 3/13/24, documents R34's diagnoses including Peripheral
Vascular Disease, Hyperlipidemia, Palliative Care, Diabetes Mellitus due to underlying condition with Foot
Ulcer, Severe Protein-Calorie Malnutrition, Diabetes Mellitus due to underlying condition with Diabetic
Chronic Kidney Disease, Hypertension, Dysphagia, Chronic Systolic Heart Failure, Anxiety Disorder,
Anemia, Diabetes Mellitus due to underlying condition with Diabetic Polyneuropathy, Vitamin D Deficiency,
Local Infection of Skin and Subcutaneous Tissue, Muscle Wasting and Atrophy and Lymphedema.
V7's (Wound Doctor) Progress Notes, dated 3/6/24, document: Diabetic Wounds to R34's Left First Toe (2.2
centimeters/cm by 1.2 cm by 0.4 cm and 100 percent black necrotic tissue/eschar); Arterial Wound of the
Right Heel (Full Thickness, no measurements) and treatment of a topical medication (Betadine) and cover
with dry dressing (Telfa and Gauze Kerlix); and Diabetic Wound of the Left Second Toe (Full Thickness) and
treatment of a topical treatment (Betadine and Calcium Alginate) and cover with a dry Dressing (Gauze
Island with Border or Band-Aid).
R34's Physician Order Sheet, dated 3/13/24, documents the following orders: apply topical treatment
(Betadine) to Left Heel Wound and Left Pinky Toe every day shift; apply topical treatment (Betadine) to
wounds on Right Ankle, Right Foot, Right Medial Foot and Right Calf, cover with dry dressing (Telfa and
wrap in Kerlix) every day shift; and apply topical treatment (Betadine) to Right Great Toe, Right Second Toe
and Right Third Toe every day shift. R34's Physician Orders did not document a treatment to R34's Left
Second Toe or Right Heel.
On 3/13/24 at 10:46 am, V4 (Licensed Practical Nurse/Restorative Nurse) was performing wound care to
R34. R34's Left Pinky Toe, Left Third Toe and Left Fourth Toe had on an undated, dry gauze dressing. V4
attempted to remove approximately three gauze dressings (measuring four inches by four inches)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145680
If continuation sheet
Page 4 of 10
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
03/15/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
from R34's Toes and V4 was unable to, due to the gauze dressing being adhered to R34's Toes. V4 then
saturated, with Normal Saline, the gauze dressing and attempted to remove the gauze, and was
unsuccessful. V4 made two additional unsuccessful attempts, with the Normal Saline to remove the gauze
dressing. On the fourth attempt, V4 pulled the gauze dressing from all five of R34's Toes, pulling and
removing some of R34's skin, exposing the open areas. R34's Right Heel dressing was dated 3/11/24.
Residents Affected - Few
On 3/13/24 at 12:16 pm, V8 (Licensed Practical Nurse/LPN) stated, I worked on 3/12/24 and even though I
signed the treatments off on the TAR (Treatment Administration Record), I could not find the Betadine, so I
did not do (R34's) treatment that day.
On 3/13/24 at 10:51 am, V4 (Licensed Practical Nurse/Restorative Nurse) stated, That gauze dressing
should not be on (R34's) Left Toes. The treatment should be Betadine and open to air. Whoever did this
treatment should have not covered these areas with gauze because it is sticking to (R34's) toes and pulling
his skin off. Also, (R34's) Right Foot and Heel dressing looks like it did not get changed on 3/12/24,
because the dressing is still dated 3/11/24, and that should be changed every day.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145680
If continuation sheet
Page 5 of 10
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
03/15/2024
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 - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure hand hygiene after glove
use was conducted during wound care for one resident (R51) and failed to follow a Physician ordered
pressure ulcer treatment for one resident (R34) of five residents reviewed for pressure ulcers in a sample of
33.
Residents Affected - Few
Findings include:
1. The facility's Wound Care policy, revised 3/27/21, documents 7. Wound care treatment should maintain
proper technique, as is indicated by the type of wound and physician orders.
The facility's Personal Protective Equipment (PPE) Use policy, revised 3/30/21, documents Standard: It will
be the standard of this facility that staff appropriately utilize personal protective equipment (PPE) for the
prevention of transmission of potentially infectious organisms. Guidelines: 1. Apply clean non-sterile gloves
when touching blood, body fluids, secretions, excretions, contaminated items, mucous membranes, and
non-intact skin. [NAME] clean gloves between tasks and procedures on the same resident after contact
with blood, body fluids, secretions, excretions. remove gloves promptly after use, before touching
non-contaminated items and environmental surfaces. Wash and or sanitize hands after the removal of
gloves.
On 3/13/24 at 10:12am, R51 sat in a reclining chair with bilateral heel protectors on. V4 (Licensed Practical
Nurse/LPN/ Restorative Nurse) prepared supplies for R51's wound treatment. V4 washed her hands then
donned gloves. V4 removed R51's dressing and Calcium alginate then removed her gloves. Without
washing or sanitizing hands V4 donned new gloves. V4 noted that R51's small pea sized open area to
R51's left lateral heel had a small amount of drainage. V4 cleansed R51's wound with normal saline soaked
gauze. V4 removed her gloves then without washing or sanitizing her hands V4 donned new gloves. V4
dried R51's wound area with dry gauze then applied Calcium alginate with silver and bordered foam
dressing. With the same soiled gloves, V4 put R5's gripper socks and bilateral heel protectors back on.
R51's Wound Evaluation & Management Summary, dated 3/6/24, documents R51 has a Stage 4 Pressure
Wound of the left, lateral heel.
On 3/13/24, at 1:15pm, V4 stated that V4 normally washes her hands after glove changes if going from
dirty to clean. V4 stated I should have washed my hands after I took the dressing off and saw the drainage
and after each glove change.
2. Facility Standard and Guideline Wound Care Policy, revised 3/27/21, documents: it will be the standard of
the this Facility to provide assessment and identification of residents at risk of developing pressure injuries,
other wounds and the treatment of skin impairment; wound care procedures and treatments should be
performed according to Physician orders; document in the clinical record when treatments are performed;
and contact the Physician for additional order changes as is appropriate or to notify of skin condition
changes.
Facility Standards and Guidelines Physician/Non-Physician Practitioner Order Policy, revised 10/24/22,
documents it will be the practice of this Facility to honor Physician/Licensed Independent Practitioner orders
in the following ways (Telephone Orders, Orders received by Non-Physician Practitioner /Nurse
Practitioner/Physician Assistant, Faxed Orders and Electronic Orders).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145680
If continuation sheet
Page 6 of 10
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
03/15/2024
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 - Minimal harm
or potential for actual harm
Residents Affected - Few
The Facility Pressure Ulcer Log/Monthly Wound Log, dated 3/24, documents R34's Pressure Ulcers to
R34's Right Ankle (Stage Four/Stage IV), Right Medial Foot (Suspected Deep Tissues Injury/SDTI), Right
Lateral Food (Unstageable), Right Calf (Unstageable) and Left Lateral Foot (Deep Tissue Injury).
R34's Physician Order Sheet/POS, dated 3/13/24, documents R34's diagnoses including Peripheral
Vascular Disease, Hyperlipidemia, Palliative Care, Diabetes Mellitus due to underlying condition with Foot
Ulcer, Severe Protein-Calorie Malnutrition, Diabetes Mellitus due to underlying condition with Diabetic
Chronic Kidney Disease, Hypertension, Dysphagia, Chronic Systolic Heart Failure, Anxiety Disorder,
Anemia, Diabetes Mellitus due to underlying condition with Diabetic Polyneuropathy, Vitamin D Deficiency,
Local Infection of Skin and Subcutaneous Tissue, Muscle Wasting and Atrophy and Lymphedema.
V7's (Wound Doctor) Progress Notes, dated 3/6/24, document: R34's Pressure Ulcers: Stage Four/Stage IV
Pressure Wound of the Right Ankle (Full Thickness, 3.5 centimeters/cm by 3.2 cm by 0.2 cm, black necrotic
tissue/eschar); Unstageable Pressure Ulcer due to Necrosis of the Right Lateral Foot (Full Thickness, 17.0
cm by 8.0 cm by 0.4 cm, black necrotic tissue/eschar); Unstageable Pressure Ulcer/Deep Tissue Injury/DTI
of the Right Medial Foot (Undetermined Thickness, 0.8 cm by 0.8 cm by not measurable, intact with
purple/maroon discoloration); and Unstageable Pressure Ulcer of the Right Calf (12.8 cm by 4.5 cm by 0.2
cm, forty percent/40% eschar). V7's Progress Notes document a daily dressing change to all of R34's
Pressure Ulcers (Betadine, nonstick gauze pad, and gauze wrap).
R34's Physician Order Sheet, dated 3/13/24, documents the following orders: apply topical treatment
(Betadine) to wounds on Right Ankle, Right Foot, Right Medial Foot and Right Calf, cover with dry dressing
(nonstick gauze pad and wrap in gauze) every day shift.
On 3/13/24 at 10:46 am, V4 (Licensed Practical Nurse/Restorative Nurse) was performing wound care to
R34. R34's Right Foot and Right Lower Extremity had an intact dressing (gauze wrap and nonstick gauze
pad) that was dated 3/11/24 with the signature/initials of V3 (Assistant Director of Nursing/ADON). The dry
dressing had a moderate amount of dry red exudate/blood/drainage.
On 3/13/24 at 10:51 am, V4 (Licensed Practical Nurse/Restorative Nurse) stated, (R34's) Right Foot and
Heel dressing looks like it did not get changed on 3/12/24, because the dressing is still dated 3/11/24.
On 3/13/24 at 12:16 pm, V8 (Licensed Practical Nurse/LPN) stated, I worked on 3/12/24 and took care of
(R34), and I could not find the Betadine, so I did not do (R34's) treatment that day, but I did sign the
treatments off anyway, as completed on the TAR (Treatment Administration Record).
On 3/13/24 at 12:25 pm, V3 (Assistant Director of Nursing/ADON) stated, I did (R34's) treatments on
3/11/24. It looks like (R34's) treatments have not been completed since 3/11/24, and I am not sure why
gauze was put on (R34's) Left Toes. V3 verified that V8 (LPN) signed R34's completed treatments out on
the TAR, even though the treatments were not completed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145680
If continuation sheet
Page 7 of 10
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
03/15/2024
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 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Actual harm
Based on observation, interview and record review the facility failed to comprehensively assess pain and
effectively manage pain for one resident (R67) of three residents be reviewed for pain. This failure has
resulted in ineffective pain management and ongoing expression of moderate to severe pain by R67.
Residents Affected - Few
Findings include:
The Facility's Pain Management Policy dated 3/26/21 documents: It will be the standard of this facility to
screen residents and attempt to provide effective pain and comfort management.
Residents may additionally be screened for pain quarterly, annually, upon change of condition or upon
resident report of new pain or newly observed non-verbal signs and symptoms of potential pain. On-going
monitoring of residents receiving interventions should be completed in the clinical record, as indicated.
Implement/update a person-centered care plan of care related to pain management as is appropriate.
R67's Hospital Discharge Note dated 12/31/23 indicates R67 reported generalized and buttock pain score
10/10 (scale 0 = no pain; 1 to 3 = mild pain; 4 to 7 = moderate pain; and 8 or above is severe pain) five
times prior to receiving Acetaminophen 650mg (milligrams) and reported generalized and buttock pain of
6/10 three times and 10/10 twice prior to receiving Tramadol (analgesic). Follow up pain relief/response to
administration of Tramadol was documented as 1 to 4/10 indicating effectiveness of medication.
R67's admission Nursing Note Pain Screen dated 12/31/23 at 3:19pm indicates R67 indicated she was
experiencing generalized pain 7/10. Note indicates R67's pain is relieved by medication management and
repositioning.
R67's Physician Note dated 1/2/24 indicates R67 was previously bedridden at home due to Arthritis. Note
indicates R67 has arthritic changes in her hands, knees, and feet. Note indicates R67 reports severe pain
with turning when wound care is done and reports the pain is in her legs. Note indicates R67 reports pain is
10/10 all over in all joints.
R67's Physician Note dated 2/7/24 indicates R67 has a Stage 4 sacral pressure wound, full thickness.
R67's Physician Note dated 2/16/24 indicates R67 states that she continues to have pain with any kind of
transitioning or rotation in bed and that R67's mood is fine when she is otherwise lying still related to her
arthritis. Note indicates (R67) has pretty significant pains and discomfort of the large coccyx wound.
On 3/13/24 at 9:35am R67 was turned onto her side to receive sacral wound care. R67 was distressed with
facial grimacing, stiffening, guarding, and reporting pain throughout her lower body. While on her side
during wound care R67 continued to intermittently complain of pain. R67 cried out and whimpered when V4
(Wound Nurse) removed the wound vac sponge from inside R67's sacral wound, cleaned inside R67's
sacral wound and inserted a new wound vac sponge into R67's sacral wound. V4 attempted to console R67
during the wound treatment to which R67 replied No, you don't know. It's horrible. At that time V4 reminded
R67 that she had received a Norco (opioid) earlier in the morning (7:40am) to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145680
If continuation sheet
Page 8 of 10
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
03/15/2024
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 0697
help with the pain. R67 replied that the pain was still there.
Level of Harm - Actual harm
On 3/13/24 at 1:40pm R67 stated I have chronic arthritis everywhere, particularly my knees and feet. My
knees are throbbing right now. I'm up all night sometimes, I can't sleep because I'm uncomfortable. Then I
sleep on/off during the day because I'm tired from not sleeping at night. The worse pain is in my coccyx,
then knees and feet. Even the slightest movement is severe pain. I used to ask for the Norco in the evening,
but I became really constipated. It was like having a baby - really painful also causing pressure and pain in
my coccyx. While R67 described her pain she became tearful and expressed how she tries not to complain.
R67 stated her pain was 9 or 10 out of 10 during wound treatments stating, It feels like they are pulling my
skin off. R67 stated the Norco she received at 7:40am (prior to wound care) did not really help much and
barely takes the edge off.
Residents Affected - Few
R67's current Physician Order Summary Report indicates R67 has orders for:
Hydrocodone-Acetaminophen 5-325mg (milligrams), Give one tablet every day shift for pain - to be given
one half hour prior to wound treatment. Hydrocodone-Acetaminophen 5-325mg every six hours as needed
for moderate pain. Acetaminophen 650mg every six hours as needed for general discomfort.
R67's MAR (Medication Administration Record) dated 2/1/24 to 2/29/24 and 3/1/24 to 3/13/24 indicates
R67 received Hydrocodone-Acetaminophen 5-325mg for pain prior to wound care. MARs indicate R67
reported pain level 8/10 seven times, 9/10 twelve times and 10/10 seven times prior to administration of
Hydrocodone prior to the wound care.
R67's MAR dated 2/1/24 to 2/29/24 indicates R67 received as needed Hydrocodone-Acetaminophen
5-325mg on 2/1, 2/3, 2/4, 2/5, 2/6 and 2/7/24 in the evenings for reports of pain 6 - 8/10.
R67's MARs indicate R67 only received as needed Acetaminophen 650mg on 2/9/24 for pain level of 4/10
and on 3/4/24 for pain level of 9/10.
R67's MARs also indicate R67 is monitored for pain every shift and scored zero (no pain) every shift on
every day from 2/1/24 to 3/13/24 even though R67 had expressed pain and received pain medication on the
above dates listed.
Weekly Wound Progress Notes dated 2/15/24, 2/22/24 and 2/29/24 indicates R67 reported pain of 10/10
during sacral wound care on all the above dates. Notes dated 2/22/24 and 2/29/24 indicate R67 had the
following non-verbal indicators of pain: Negative vocalizations (i.e., moaning, groaning, crying, calling out)
Facial expressions (i.e., grimacing, frown, sad) Body language (i.e., tensed, distressed, pacing, fists
clenched, striking out, knees pulled up, guarding) consolability [sic] (i.e., distracted, unable to console).
R67's Weekly Wound Progress Note dated 3/6/24 indicates R67 reported pain level of 5/10 during wound
care and exhibited negative vocalizations.
On 3/14/24 at 1:00pm V2 (Director of Nursing/DON) stated she could not explain why R67's every shift pain
score was zero yet R67 reported pain level of 10/10 during wound care and pain score prior to wound
treatment was usually 6-10. V2 also stated there was no further assessment of R67's pain after reporting
pain 10/10 during wound care.
R67's NP (Nurse Practitioner) note dated 3/13/24 indicates R67 has osteomyelitis of coccyx and Stage 4
sacral wound. Note indicates R67 is seen in her room as she has reported uncontrollable pain.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145680
If continuation sheet
Page 9 of 10
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
03/15/2024
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 0697
Level of Harm - Actual harm
Residents Affected - Few
Note indicates she has been offered additional Norco but has refused due to fear of constipation.
Discussed a long-acting Tylenol for pain and R67 is agreeable to a trial of standard release Tylenol
scheduled every 8 hours. Note indicates an additional Hydrocodone (narcotic) with Acetaminophen in the
evening for severe pain if she needs and if she allows it to be given. Note indicates additional options for
constipation were also discussed. Note indicates R67 has a history of refusing narcotic pain medications.
R67's Care Plan (date initiated 12/31/23) documents Potential/Actual pain related to Arthritis.
Interventions include Monitor and Report signs and symptoms of pain, worsening of pain; notify physician if
resident does not state/demonstrate relief or reduction of pain with current pain management regimen.
This same care plan does not include history of R67 refusing pain medications, locations/characteristics of
pain or non-pharmacologic interventions to assist in alleviating pain.
On 3/14/24 at 1:30pm V2 (DON) stated R67 has had a history of refusing pain medications. V2 was unable
to provide a comprehensive assessment of R67's pain (after admission assessment) and/or
documentation/assessments of R67's refusal of pain medications offered.
On 3/14/24 at 1:30pm V9 (Nurse Practitioner) stated she was unaware R67 had been taking (as needed)
Norco every evening and abruptly stopped (on 2/8/24) due to becoming constipated. V9 stated that as of
yesterday R67 has orders for scheduled Tylenol and an additional Hydrocodone as well as review of bowel
medications to address R67's constipation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145680
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FAQ · About this visit
Common questions about this visit
What happened during the March 15, 2024 survey of CELEBRATE SR LIVING OF MOLINE?
This was a inspection survey of CELEBRATE SR LIVING OF MOLINE on March 15, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CELEBRATE SR LIVING OF MOLINE on March 15, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.