Health inspection·May 9, 2022

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. Based on interview and record review, the facility failed to ensure three allegations of abuse were immediately reported to the Administrator for three of five residents (R12, R17 and R39) reviewed for abuse in the sample of 39. Findings include: The facility's Abuse Investigation and Reporting policy (revised 7/2017) documents the following: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. This policy also documents, Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; The resident's representative (sponsor) of record; Adult protective services (where state law provides jurisdiction in long-term care); Law enforcement officials; The resident's attending Physician; and The facility Medical Director. The facility's Incident Report (dated 04/27/22) documents that on 04/27/22, V12 and V13 (Certified Nursing Assistants) were involved in a verbal altercation at the facility, and then on 04/28/22, V12 reported the following allegations of abuse occurred on or around 04/17/22 or 04/18/22: V12 witnessed V13 (Certified Nursing Assistant) shake R12 in her wheelchair while R12 was approaching doors in the facility in an attempt to exit seek. V12 also witnessed V13 mockingly laugh about it a short while later; V12 observed V13 throwing R17's legs into his bed while V13 was assisting R17 into bed; and V12 overheard V13 using aggressive speech towards R39. This report also documents that V11 (Certified Nursing Assistant) witnessed V13 shake R12's wheelchair and then observed V13 laughing about it. This same report documents after review of timecards, it was determined by the potential witnesses mentioned, the incident would have occurred on 04/18/22. On 05/04/22 at 02:10 PM, V11 (Certified Nursing Assistant) stated a few weeks ago, she observed R12 yell out after V13 (Certified Nursing Assistant) grabbed and shook R12's wheelchair while moving R12 away from a facility door when R12 was exit seeking . V11 stated she did not report this incident to anyone. V11 stated, (V1 Administrator) is the Abuse Coordinator. I should have reported it to him (V1). On 05/05/22 at 10:25 AM, V12 (Certified Nursing Assistant) stated she did not report any of the actions she witnessed V13 display towards R12, R17 and R39 on 04/18/22 to facility management until (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 9 Event ID: 146099 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 146099 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Manor 1209 21st Avenue 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)