Health inspection·May 16, 2023

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on observation, interview and record review, the facility failed to protect a resident from mental and emotional abuse for one of three residents (R1) reviewed for abuse in the sample of three. This failure resulted in (R1) verbalizing feeling demeaned, degraded, and angry. Findings include: The facility's Abuse, Neglect and Exploitation Prevention policy, dated 2/24/23, documents Our residents have the right to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment and involuntary seclusion. Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etcetera, to assist in preventing resident abuse. The facility's Identifying Types of Abuse policy (undated), documents As part of the abuse prevention strategy, volunteers, employees and contractors hired by this facility are expected to be able to identify the different types of abuse that may occur against residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This same policy documents Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. R1's (State agency) Incident Report, dated 4/21/23, documents On 4/21/23 at 9:39 PM, (R1) reported that aide (V4 Certified Nursing Assistant/CNA) had placed a gait belt around her neck. R1's Current Minimum Data Set assessment, dated 4/25/23, documents R1's cognition is intact and that R1 requires the extensive assistance of one staff member for toileting. R1's Current Care plan, dated 4/27/23, documents I (R1) have risk factors that may impact my activity participation they are Anxiety, Depression and Shortness of Breath. This same care plan documents R1 receives scheduled medication for Anxiety, Depression and Panic attacks. On 5/15/23 at 11:30 AM, R1 was sitting in a recliner in her room. R1 stated I do remember the incident that occurred with a CNA (V4) a couple weeks ago. I had to use the restroom and the CNA (V4) came in and started to help me up, but then said she can't do that cause her back will get hurt. I asked her if there was anyone to help and she said she was the only one here. (V4) then took the gait belt from my closet door and put it over my head, around my neck. It was caught on my glasses, and I was trying to adjust my glasses and I said, What are you doing?. She was just laughing and wrapped it around my neck a couple times then pulled slightly like you would a dog, but as she was doing that, (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: 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 05/16/2023 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)