Inspection·January 28, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and Record review, the facility failed to report an allegation of misappropriation of jewelry to the state agency or local law enforcement for one of three residents (R1) reviewed for misappropriation in the sample of four. Findings include: The facility's Abuse policy (undated), documents It is the policy of (the facility) to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation resident property from abuse, neglect, misappropriation of resident property, and exploitation. Any nursing home employee or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home Administrator/Designee. The nursing home Administrator/Designee will report abuse/neglect and/or allegations thereof to (the state agency) per state requirements. This same policy documents The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later that 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator/designee of the facility and to other officials including (the state agency) and adult protective services. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. R1's nursing progress note, dated 1/1/2025 at 9:38 AM and completed by V7 (Licensed Practical Nurse), documents (R1's family member, V5) reported that (R1's) ring is missing. Room searched by staff. (V2, Director of Nursing) notified and (V1, Administrator In Training, AIT) notified. On 1/27/25 at 4:40 PM, V5 (R1's Family) confirmed that R1 resided in the facility from [DATE]-[DATE]. V5 stated I visited every day while (R1) was in the facility. The last day she was there I noticed her ring was not on her finger. This ring was never found. That was the day she went to the hospital. I went in to see her and her ring was missing. It was my grandmother's ring and not replaceable. V5 confirmed she reported the missing item to the nurse working that day but hasn't heard anything since. On 1/28/25 at 12:34 PM, V7 (Licensed Practical Nurse) confirmed working the day that R1 was sent to the hospital. V7 stated Before the ambulance came (V5) came down to the nurses station and was very (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 2 Event ID: 145387 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145387 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE St Anthony's Nsg & Rehab Ctr 767 30th Street Rock Island, IL 61201 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)