Health inspection·January 30, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review the facility failed to follow their policy and use two staff members to perform a mechanical lift transfer for one of three Residents (R1) reviewed for Falls in a sample of six.Findings include:The Facility Lifting Machine, Using a Mechanical Lift Policy, revised 7/2017, documents: to establish general principles of safe lifting using a mechanical lifting device; at least two people are needed to safely move a Resident with a mechanical lift; and before the Resident is lifted, double check the security of the sling attachment; check the stability of the straps.The Facility Safe Lifting and Movement of Residents Policy, revised 9/17/25, documents: to protect the safety and well-being of staff and Residents to promote quality care, this Facility uses appropriate techniques and devices to lift and move Residents; Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of Residents; staff responsible for direct Resident care will be trained in the use of mechanical lifting devices; mechanical lifting devices (total lifts) shall be used for heavy lifting, including lifting and moving Residents when necessary; and mechanical lifting devices require two-to-one staff assistance.The Certified Nurse's Aide Job Description, undated, documents: to assist with lifting, moving and transporting Residents into and out of beds, chairs and lifts; and to follow established safety precautions in the performance of all duties.The Facility Fall Incident Report, dated 11/2025, documents R1 sustained a witnessed fall on 11/27/25 at 5:00 pm and sustained an abrasion to the ear.R1's Minimum Data Set/MDS, Section C (Cognitive Patterns), dated 9/11/25, documents severe cognitive impairment (rarely/never understood) and dependent on staff for Activity of Daily Living/ADL assistance with transfers.R1's current Care Plan documents: that R1 is receiving Hospice End of Life services for a diagnosis including Alzheimer's; alert with confusion and mumbled speech; and extensive two-person assistance with mechanical lift transfer.R1's Fall Risk Assessment, dated 9/11/25, documents R1 is at a high risk for falls and requires a two-person assist with ambulation.The Facility's Final Incident Report, dated 12/1/25, documents R1 sustained a fall from a mechanical lift on 11/27/25. The Incident Report documents that on 11/27/25 at 5:00 pm, V7 (R1's Private Caregiver) and V5 (Certified Nursing Assistant/CNA) placed R1 into a mechanical lift for transfer from R1's bed to R1's recliner. During the transfer, R1 slipped out of the bottom of sling and fell onto R1's buttocks onto the floor. Due to R1's Alzheimer's and inability to verbalize pain, R1 was sent to the local hospital for evaluation. The hospital Comminuted Tomograph/CT (spine and head/brain) and Pelvic X-ray were negative for fractures/injury. R1 sustained a Left Ear superficial abrasion. R1's local Hospital Emergency Notes, dated 11/27/25, document negative results Comminuted Tomography/CT (spine and head/brain) and Pelvic X-ray for fractures/injury.V5 (Certified Nursing Assistant/CNA) Employee Human Resource Records/File, documents: hire date of 4/8/25; completion of mechanical lift training on 4/14/25 and 11/20/25; and a Performance Correction Notice (dated 12/1/25) for improperly placing a mechanical lift sling.On 1/29/26 at 11:00 am, V7 (R1's Private Caregiver) was (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 01/30/2026 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)