Health inspection·April 9, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident was safely positioned in bed for 1 of 3 residents (R2) reviewed for safety in the sample of 5. This failure resulted in R2 falling from her bed and sustaining a laceration requiring staples. The findings include: R2's physician visit form documents she was admitted to the facility on [DATE] with multiple diagnoses including vascular dementia, and history of falling. R2's quarterly resident assessment and care screening of 2/17/25 documents her to have severe cognitive impairment. Her mobility assessment shows she requires substantial/maximal assistance with rolling right to left. Meaning the helper provides more than half of the effort to perform the task. The 2/17/25 care plan for hospice services notes R2 requires extensive to dependent assistance with 1 staff for all cares and uses a mechanical lift for transfers. The facility incident report of 3/26/25 documents R2 had a fall at 4:50 AM in her bedroom by the bedside. The description of the incident was staff preparing resident to get up and resident rolled out of the bed and fell on the floor with head injury and bleeding. Sent to the ER (emergency room) for further evaluation. On 4/9/25 at 10:22 AM, V13 (Certified Nursing Assistant/CNA) said on the morning of 3/26/25, she was getting R2 ready to get out of bed. When she does care for any resident, she has the bed in the high position, so it is easier on her back, and she had R2's bed in the high position, probably to her waist or higher. V13 said during cares, R2 can either be stiff and difficult to move, or she is wiggly. V13 said on that morning, after she had R2 dressed, she rolled her towards the wall, and placed the mechanical lift sling under her and needed to pull it through. V13 said she moved R2's bed out from the wall, and standing between the wall and the bed, she rolled R2 towards the other side, and R2 began moving her legs and fell off the side of the bed. She said the bed had no side rails, so R2 just fell to the floor, landing on the concrete floor on her back. V13 said there was nothing she could do to stop it because she was on the opposite side of the bed. V13 said there was immediately blood present, and she notified the nurse. The ED (emergency department) report for 3/26/25 documents the reason for the visit was a laceration to the scalp. The physical exam shows a 1 cm (centimeter) laceration to the occipital (back of the head) area. The laceration repair included the placement of 4 staples. (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 04/09/2025 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)