Celebrate Sr Living of Moline: Wrong Resident Given Meds - IL
The nurse, identified in the report as V3, administered nine medications belonging to a resident identified as R2 to a different resident, R1, during the 8 p.m. medication pass. The drugs included Norco 7.5/325 mg, an opioid and acetaminophen combination prescribed for pain. They also included Multaq 400 mg, a medication used to treat abnormal heart rhythms, and Metoprolol 50 mg, a beta-blocker that lowers heart rate and blood pressure. Rounding out the regimen were Gabapentin 300 mg, GuaiFENesin ER 600 mg, Magnesium oxide 420 mg, Melatonin 6 mg, Pravastatin 20 mg, and Trazodone 200 mg.
None of those medications had been prescribed for R1.
When inspectors spoke with V3 on the morning of October 16, the nurse did not dispute what had happened. "I misidentified the gentleman and confused him with someone else," V3 told investigators.
The Director of Nursing, identified as V2, confirmed the mix-up during a separate interview that same morning. She told inspectors that the standard expectation during medication administration is that staff use two resident identifiers before giving any drugs, a basic verification step designed specifically to prevent this kind of error. She confirmed that step did not happen.
The medications were prescribed to R2 for reasons the inspection report does not detail. What the report makes clear is that R1 received a substantial combination of drugs, including a controlled opioid and a cardiac medication, that his own physician had not ordered for him. Norco, the opioid in the mix, carries risks of respiratory depression and sedation. Multaq is prescribed for a specific heart condition and is not appropriate for patients who don't have that condition. Metoprolol can cause a significant drop in blood pressure and heart rate in someone whose body is not accustomed to it.
The inspection was triggered by a complaint and took place on October 16, 2025. CMS assigned the violation a harm level of minimal harm or potential for actual harm, and noted that few residents were affected.
That designation reflects what inspectors determined about the outcome, not about what could have gone differently. R1 received nine medications belonging to another man. The nurse confirmed it. The director of nursing confirmed it. The two-identifier check that exists to catch exactly this kind of mistake before a pill is swallowed was skipped entirely.
V3's explanation was brief: one man was mistaken for another.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Celebrate Sr Living of Moline from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
CELEBRATE SR LIVING OF MOLINE in MOLINE, IL was cited for violations during a health inspection on October 16, 2025.
The drugs included Norco 7.5/325 mg, an opioid and acetaminophen combination prescribed for pain.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.