Health inspection·May 8, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 05/06/25 at 02:20 PM, V2 (Director of Nursing) stated she could not provide documentation indicating a written notice of transfer or the facility's bed hold policy was provided upon R65's 12/15/24 transfer to the hospital. 3. R79's Nursing Progress Notes, dated 4/14/2025, documents at 10:19 AM, R79 was transferred to the local emergency room after suffering a fall. R79's current electronic medical record does not document a bed hold notice or notice of hospital transfer was provided to R79 or her representative at the time of transfer to the hospital. On 5/6/25 at 2:20 PM, V2 (Director of Nursing) stated she could not provide documentation a written notice of transfer or the facility's bed hold notice was provided upon R79's 4/14/25 transfer to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 2 of 8 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 05/08/2025 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 0760 Ensure that residents are free from significant medication errors. 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, facility staff failed to recognize the potential adverse effects of abruptly stopping a medication without tapering for one of five residents (R73), reviewed for unnecessary medications, in a sample of 49. Residents Affected - Few FINDINGS INCLUDE: The facility policy, Standards and Guidelines: Medication Errors, dated (revised 3/27/2021), documents, It will be the standard of this facility that the staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. The staff and practitioner shall strive to minimize adverse consequences by: Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration and monitoring of the medication. The 2024 American Association of Psychiatric Pharmacists Medication Fact Sheet for Escitalopram documents, Do not stop taking Escitalopram, even when you feel better. With input from you, your health care provider will assess how long you will need to take the medicine. Missing doses of Escitalopram may increase your risk for relapse in your symptoms. Stopping Escitalopram abruptly may result in one or more of the following withdrawal symptoms: irritability, nausea, feeling dizzy, vomiting, nightmares, headache, and/or paresthesia (prickling, tingling sensation on the skin). R73's facility admission Record documents R73 was admitted to the facility on [DATE], with the following diagnoses: Peripheral Vascular Disease, Abdominal Aortic Aneurysm, Paroxysmal Atrial Fibrillation, Chronic Combined Systolic and Diastolic Heart Failure, Major Depressive Disorder, Anxiety Disorder, Hypertensive Urgency, Essential Hypertension, and Chronic Kidney Disease. R73's Follow Up Psychiatric Assessment, dated 4/17/2025, documents, (R73) has a history of Major Depressive Disorder and Anxiety seen for follow up evaluation. Current Psychiatric Medications: Escitalopram, Buspirone and Lorazepam. Assessment: (R73) is calm, cooperative and sitting on her bed during the evaluation. (R73) denies depression and anxiety. Staff reports no change in mood but states resident is anxious without (medications). Treatment Plan: Continue Buspirone twice daily for anxiety, Lorazepam for anxiety and Escitalopram for depression. R73's April 22, 2025 Medication Administration Record includes the following physician orders: Escitalopram Oxalate (Selective Serotonin Reuptake Inhibitor) 5 MG (Milligrams) daily for Agitation and Anxiety related to Major Depressive Disorder; Lorazepam (Benzodiazepine) 0.5 MG at bedtime related to Anxiety Disorder; Nifedipine Extended Release (Calcium Channel Blocker) 90 MG daily for Hypertension and Metoprolol Succinate Extended Release (Beta Blocker) 25 MG twice daily for Hypertension. R73's After Visit Summary, dated 4/23/25, from the local Renal Clinic documents, Today's medication changes: Stop taking Amiodarone 200 MG, Escitalopram, Lorazepam, Metoprolol, Nifedipine and Potassium Chloride. On 5/05/25 at 10:16 A.M., R73 was sitting at side of the bed, attempting to pull up her pants. R73 was crying and visibly distressed. When asked what was wrong, R73 stated, Everything. Everything is all wrong. R73 was unwilling to say anything else when prompted. V6/Licensed Practical Nurse (LPN) was at R73's bedside, and stated some of R73's medications were changed recently, and R73 just hasn't (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 3 of 8 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 05/08/2025 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 0760 been herself. Level of Harm - Minimal harm or potential for actual harm R73's Nursing Progress Notes, dated 5/5/2025 at 12:36 PM, documents, Renal (Clinic) d/c (discontinued) (R73's) Lexapro (Escitalopram) and lorazepam on 04/23/25. Since then (R73) has been tearful and upset. Called Renal (Clinic) to find out why these meds (medications) were discontinued on (05/02/2025) with no call back. Called Renal (Clinic) back today. Nurse states that she will talk with the doctor and call facility back with response. Facility number clarified. Residents Affected - Few R73's Nursing Progress Notes, dated 5/5/2025 at 2:11 PM, documents, Renal (Clinic) called back stating that d/c (R73's) meds was a mistake. Psych (Psychiatric) doctor gave order to reinstate both Lexapro (Escitalopram) and lorazepam. POA (Power Of Attorney) notified. Will continue to monitor mood. On 5/06/25 at 1:41 PM, V7/Certified Nursing Assistant (CNA) stated she often works with R73. V7 stated R73 has a history since admission of being tearful and distraught due to her family moving R73 to the facility and selling her home and belongings. V7 stated R73 has been more tearful and distraught in the past week or so. On 5/06/25 at 2:10 PM, V10/Licensed Practical Nurse (LPN) stated she was the nurse that was present when R73 returned from the doctor's appointment with orders to discontinue Amiodarone (Class 3 Antiarrhythmic); Escitalopram (Selective Serotonin Reuptake Inhibitor); Lorazepam (Benzodiazepine); Metoprolol (Beta Blocker); Nifedipine (Calcium Channel Blocker); and Potassium Chloride (Supplement). V10/LPN states she didn't question the order, nor did she notify R73's medical doctor prior to discontinuing the medications. On 5/06/25 at 2:20 PM,V11/R73's Physician stated, I was not aware that (R73's) medications had been stopped. No one notified me. I would not have agreed to stopping those medications without tapering them. That is very dangerous and could cause serious side effects. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 4 of 8 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 05/08/2025 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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately explain the admission arbitration agreements to residents, or their representatives, in a form or manner that allows them to understand for 12 of 12 residents (R25, R27, R49, R62, R83, R85, R87, R90, R242, R243, R245, R246) reviewed for Arbitration in the sample of 49. Residents Affected - Some Findings Include: The facility's Resident or Resident Representative Arbitration Agreement (undated), documents Whereas it is the intent of the parties that this agreement govern the resolution of any disputes, claims, and any other matters arising out of, or relating to the admissions agreement to fashion a fair and efficient process for resolving any such dispute, claim, or matter. Now, therefore, in consideration of the mutual covenants, terms, and conditions set forth herein, and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows: The arbitrator, and not any federal, state, or local court or agency, shall have exclusive authority to resolve the dispute, claim, or matter relating to the admissions agreement, including the determination of the scope or applicability of this agreement to arbitrate. Waiver of Trial by Jury. The parties understand and fully agree that by entering into this agreement to arbitrate, they are giving up their right to file a lawsuit in court against the other, have a trial by jury, and file an appeal following the issuance of the arbitrator's award, except as applicable law provides for judicial review of arbitration proceedings. The facility's Resident List report, dated 5/5/25, and provided by V1 (Administrator), documents the facility has a total of 12 out of 90 residents who signed a binding arbitration agreement upon admission. This report documents R25, R27, R49, R62, R83, R85, R87, R90, R242, R243, R245, and R246 have signed the agreement. The facility's Electronic Resident Census report documents R25, R27, R49, R62, R83, R85, R87, R90, R242, R243, R245, and R246 were all admitted to the facility after February 2025. R242's Arbitration agreement, dated 3/19/25, documents R242 signed the binding arbitration agreement on 3/19/25, with an effective date of R242's admission on [DATE]. On 5/7/25 at 9:50 AM, R242 confirmed he has not lived at the facility for long, and stated he isn't sure if he signed his paperwork on admission. R242 stated he does not remember anything about arbitration or signing something related to legal concerns. R242 stated, I don't recall giving up my rights to sue (the facility) or ever agreeing to that. On 5/7/25 at 9:23 AM, V12 (Admissions Coordinator) confirmed she is the one who goes over arbitration agreements with residents and families during admission. V12 stated, I tell them arbitration is where a situation is handled in house before taking it to the next level. I don't explain that they are giving up the right to sue. I tell them they can take it to that next level, but that we just try to settle it in house first. I did not realize the language in the arbitration agreement states they are giving up the right to seek their own council and sue. V12 stated she has been doing the job of admissions and explaining arbitration since February 2025. V12 stated the prior admissions employee no longer works in the facility, and V12 is unaware of how it was explained to residents who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 5 of 8 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 05/08/2025 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 0847 admitted prior to her taking over, three months ago. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 6 of 8 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 05/08/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review, the facility failed to implement Enhanced Barrier Precautions prior to administering cares for two of six residents (R13 and R65) reviewed for Transmission Based Precautions in the sample of 49. Residents Affected - Few Findings include: The facility's Enhanced Barrier Precautions Policy (dated 04/05/24) documents the following: (Facility) will implement Enhanced Barrier Precautions (EBP) to protect residents, staff and visitors by reducing the transmission of MDROs (multi-drug resistant organisms). EBP will be used for residents with specific risk factors, as outlined by the Centers for Disease Control and Prevention, (State Agency), and relevant local health authorities. These precautions will be applied consistently across the facility as part of routine care. This same policy documents, Procedures: Identification of residents for Enhanced Barrier Precautions; EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with the following: Wounds or indwelling medical devices, regardless of MDRO colonization status; Infection or colonization with an MDRO. This policy also documents: Gowns and gloves will be used by all healthcare personnel when performing high-contact resident care activities. These precautions must be used when providing care related to: Dressing, bathing and hygiene assistance; Wound care, handling bandages and dressings; Caring for devices such as urinary catheters or central lines; Moving or transferring residents in/out of bed; Cleaning rooms or touching frequently touched surfaces (bed rails, Intravenous poles, etc.). Staff should don PPE (personal protective equipment) before resident contact and discard PPE upon leaving the resident's care area, followed by hand hygiene. 1. R13's current Physician's Orders document the following order: Enhanced Barrier Precautions. Diagnosis: Wound. On 05/05/25 at 11:05 AM, a sign indicating Enhance Barrier Precautions currently in place was posted on R13's door, and a bin containing personal protective equipment was sitting in the hallway near the entrance to R13's room. R13 was sitting in a wheelchair next to her bed and was wearing an orthopedic shoe on her right foot. R13 stated, I've had a couple of my toes amputated, and then explained that she currently receives a daily dressing change to an open area on her right foot between her first toe and second toe. On 05/07/25 at 09:45 AM, R13 was sitting in a wheelchair in her room near her bed. R13 was wearing an orthopedic boot on her right foot. V9 (Licensed Practical Nurse/Wound Nurse) entered R13's room to perform wound care and a dressing change to R13's right foot wound. V9 applied gloves, removed R13's orthopedic boot and sock, and a dressing was in place on R13's right foot. V9 removed R13's current dressing, and an open, oval-shaped wound measuring approximately 2.5 centimeters by 1 centimeter was present between R13's right first toe and second toe. V9 cleansed R13's wound with saline, applied betadine to the open area, covered the wound with a betadine-soaked gauze and secured it with a thin gauze wrap and tape. Once cares were completed, V9 reapplied R13's sock and orthopedic shoe. V9 did not wear a gown while performing R13's cares. On 05/07/25 at 09:55 AM, V9 confirmed R13 is currently in Enhanced Barrier Precautions, and verified she did not wear a gown while performing R13's wound care. 2. R65's current Physician's Orders document the following order: Enhanced Barrier Precautions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 7 of 8 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 05/08/2025 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 0880 Diagnosis: Indwelling Catheter. Level of Harm - Minimal harm or potential for actual harm On 05/05/25 at 11:15 AM, a sign indicating Enhanced Barrier Precautions currently in place was posted on R65's door and a bin containing personal protective equipment was sitting in the hallway near the entrance to R65's room. R65 was lying in bed with his eyes closed at this time. An indwelling urinary catheter drainage bag was secured to the lower aspect of R65's bed. R65 stated he has had an indwelling urinary catheter in place, for a while. Residents Affected - Few On 05/07/25 at 09:30 AM, R65 was lying in bed with the head of his bed elevated to approximately 45 degrees. R65 was wearing a gown and was covered with a sheet from the waist down. An indwelling urinary drainage bag was attached to the lower aspect of R65's bed, and the drainage bag's tubing was draining yellow urine with sediment present. V8 (Certified Nursing Assistant) entered R65's room at this time to provide indwelling urinary catheter care. V8 applied gloves, approached R65, and uncovered him. R65's indwelling urinary catheter was in place and was secured to his right leg with a securement device. V8 cleansed R65's indwelling urinary catheter with adult incontinence wipes. Once cares were completed, V8 assisted R65 to reposition in bed, and then covered him with a sheet. V8 did not wear a gown while performing R65's indwelling catheter care. On 05/07/25 at 09:40 AM, V8 confirmed R65 is currently in Enhanced Barrier Precautions for his indwelling urinary catheter, and stated she should have worn a gown while performing his indwelling urinary catheter care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145680 If continuation sheet Page 8 of 8