Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
Based on observation, interview and record review the facility failed to perform catheter care in a clean
manner for one resident (R62) of three residents reviewed for catheters in a total sample of 38. This failure
resulted in R62 having repeated Urinary Tract Infections.
Findings Include:
The Facility's undated Catheter Care Policy documents the purpose of this procedure is to prevent urinary
catheter-associated complications, including urinary tract infections. General Guidelines: follow aseptic
technique.
The Center for Disease Control website documents Require healthcare personnel to perform hand hygiene
in accordance with Centers for Disease Control and Prevention (CDC) recommendations. Use an
alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately
before touching a patient; Before performing an aseptic task (e.g., placing an indwelling device) or handling
invasive medical devices; Before moving from work on a soiled body site to a clean body site on the same
patient; After touching a patient or the patient ' s immediate environment; After contact with blood, body
fluids or contaminated surfaces and Immediately after glove removal.
On 7/18/23 V8 (R62's spouse/Health Care Power of Attorney) stated (R62) has had eleven UTIs (Urinary
Tract Infections) since he went (to the facility) in October 2022.
On 07/18/23 at 9:35 AM V6 (Certified Nurse Assistant/CNA) and V4 (Assistant Director of
Nurses/ADON/Registered Nurse) performed catheter care. V6 (CNA) pulled down R62's absorbent
undergarment and tucked it between his legs. V6 stated Not too messy, just a little mucous. Without
washing performing any hand hygiene, V6 then retracted R62's foreskin and washed urethral opening. V6
went on to wash and rinsed R62's perineal area then put both soiled washcloths on the clean side of the
towel lying on the bed and wrapped them up in the towel and then dried R62's urethral opening and
perineal area with the side of the towel that hand been on the bed.
On 7/18/23 at 9:45 AM V4 (ADON) stated (V6 CNA) should have changed her gloves and washed her
hands between clean and dirty and she should not have used the towel laying on the bed with the
bunched-up washcloths. V4 also confirmed that R62 has chronic urinary tract infections.
The Facility's Antimicrobial Use Tracking Log dated October 2022 documents R62 had burning and dark
urine on 10/26/23, UTI (Urinary Tract Infection) was marked and R62 received Rocephin 1 Gram daily on
10/26/22,10/27/22,10/28/22 and 10/29/22.
(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 5
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
07/19/2023
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)
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
The Facility's Antimicrobial Use Tracking Log dated November 2022 documents R62 had Negative UA
(Urinalysis) UTI (Urinary Tract Infection) was marked and R62 received Ciprofloxacin 500 mg (milligrams)
on 11/12/22 and 11/14/22, then the culture returned on 11/19/22 to show growth of Staphylococcus Aureus
and R62 received Keflex 500 mg (milligrams) from 11/19/22-12/2/23.
The Facility's Antimicrobial Use Tracking Log dated February 2023 documents R62 had (urinary)odor, pain
(with urination) and altered mental status, UTI was marked, R62 received Keflex 500 mg (milligram) daily
2/11/23,2/12/23 and 2/13/23. The Tracking Log documents the urine culture was received and showed
resistance to Levaquin, so the antibiotic was changed to Levaquin 500 mg every day on 2/14/23-2/20/23.
The Facility's Antimicrobial Use Tracking Log dated April 2023 documents R62 had (urinary) odor, pain
(with urination) UTI (Urinary Tract Infection) was marked. R62 received Amoxicillin 500 mg (milligram)
4/16/23-4/31/23.
The Facility's Antimicrobial Use Tracking Log dated June 2023 documents R62 had burning (at catheter
insertion site) urgency and frequency of urination, UTI (Urinary Tract Infection) was marked. R62 received
Keflex 500 mg (milligram) 6/2/23-6/6/23.
R62's Nurse's Notes document for unknown reasons a urinalysis was obtained on 7/9/23 when those
results were called to V11 (Urologist) and V 11 ordered Augmentin 875 mg (milligrams).
On 7/19/23 at 12:00 PM V10 (Doctor) stated that contamination during catheter care can lead to repeated
urinary tract infections.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146099
If continuation sheet
Page 2 of 5
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
07/19/2023
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to identify an appropriate indication for use of an
antipsychotic medication and failed to identify specific target behaviors in the care plan for one residents
(R178) with Dementia diagnosis of five residents reviewed for unnecessary medications in the sample of
38.
Findings include:
Facility Policy/Psychopharmacological Medication Use (undated) documents:
Residents will receive psychotropic medication when necessary to treat specific conditions for which they
are indicated and effective.
Policy does not include obtaining consent to administer psychotropic medications, indications or
expressions of distress or potential adverse consequences.
On 7/18/23 at 2:45pm V9 (Social Service Director/SSD) acknowledged the facility's Psychotropic policy is
very outdated and does not cover some of the necessary elements of psychotropic medication
management.
1) Current Physician's Orders indicate R178 is [AGE] years old, was admitted on [DATE] with diagnoses
that include Unspecified Dementia without Behavioral Disturbance and Unspecified Mood Disorder.
Physician's Orders indicate R178 receives Seroquel 12.5mg twice daily for Behavioral Disorders associated
with Dementia (initiated on 6/27/23).
Antipsychotic/Neuroleptic Medication Use Consent Form dated 7/1/23 indicates consent was received for
R178 to receive Seroquel To treat behavior problems such as combativeness, explosiveness, or manic
behavior. Used also to treat depression and anxiety, or to control hallucinations or delusions. Used for
management of psychotic disorders.
MAR (Medication Administration Record)/Behavior Monitoring dated 6/2123 indicates R178 is monitored
every shift for crying, yelling, and screaming. MAR indicates R178 had no behaviors documented in 6/2023.
MAR dated 7/2023 indicates R178 had six yelling behaviors and two episodes of anxiety.
MAR indicates R178 has received Seroquel daily since 6/28/23.
On 7/17/23 and 7/18/23 R178 was observed in various areas of the unit, usually self-propelling wheelchair.
R178 often had a distressed, anxious facial expression. R178 displayed word salad when spoken to and did
seem consoled by reassurances.
Current Care Plan indicates R178 has diagnosis of behavioral disorders associated with Dementia for
which R178 receives Seroquel. Care Plan does not indicate target behaviors to be monitored.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146099
If continuation sheet
Page 3 of 5
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
07/19/2023
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
On 7/19/23 at 11:15am V2 (Chief Nursing Director) stated that verbal consent was received on 6/27/23 for
R178's Seroquel, however the form was not signed until 7/1/23. V2 acknowledged there also wasn't any
progress note indicating a verbal consent to initiate Seroquel on 6/28/23. V2 acknowledged that R178
received Seroquel on 6/28, 6/29, and 6/30, 2023 without a (verbal or written) consent in R178's medical
record.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146099
If continuation sheet
Page 4 of 5
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
07/19/2023
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review the facility failed to store food items in accordance with
professional standards for food service safety in the facility refrigerator by not discarding outdated food
items. This failure has the potential to affect all 79 Residents residing in the Facility.
Findings include:
Facility Census and Conditions Report, dated 7/16/23, documents 79 Residents residing in the Facility.
Facility Food Storage Policy and Procedure Manual, dated 3/2023, documents: sufficient storage facilities
will be provided to keep foods safe, wholesome and appetizing; food will be stored by methods designed to
prevent contamination or cross contamination; food should be dated as it is placed on the shelves if
required by state regulation; leftover food must be used within three days or discarded; and all foods should
be covered, labeled and dated and routinely monitored to assure foods (including leftovers) will be
consumed by their safe use by dates or discarded.
On 07/16/23, at 6:35 am, the Facility refrigerator located closest to the food preparation area had the
following items: salsa (dated 7/12/23); sliced beef (dated 7/8/23); sliced ham (dated 7/5/23); wrapped onion
half (dated 7/12/23); gluten free cooked pasta (dated 7/10/23); chopped chicken pieces (dated 7/11/23);
egg salad (dated 7/13/23); dinner rolls (dated 7/10/23); wheat bread (dated 7/7/23); and prepared gelatin
with fruit (dated 7/12/23).
On 7/17/23, at 6:50 am, the Facility refrigerator located closest to the food preparation area had the
following items: onion half in metal container (dated 7/10/23); sliced ham (dated 7/15/23); tomato puree
(dated 7/12/23); and sliced beef (dated 7/8/23).
On 7/16/23, at 6:40 am, V7 (Dietary Aide) stated, The label that is on the food is the date that that the food
was opened or prepared. It should be used within three days. We did a lot of preparation last week for the
weekend meals, so some of this food has been in the refrigerator since then.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146099
If continuation sheet
Page 5 of 5
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the July 19, 2023 survey of FRIENDSHIP MANOR?
This was a inspection survey of FRIENDSHIP MANOR on July 19, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at FRIENDSHIP MANOR on July 19, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, an..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.