Cycle 1
Health 2024-07-24 · Fire 2024-07-24
5 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Rock Island, IL
Friendship Manor
3-star overall rating with 3-star inspections with $31,272 in total fines with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1209 21st Avenue, Rock Island, IL
(309) 786-9667
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
75
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2005-12-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.59
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.85
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
4.88
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,458
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.04% · Performance 21.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.81
Baseline 5.91% · Performance 7.00% · Measure score 2.81 · Achievement 2.81 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
6.10
Baseline 4.14 hours · Performance 4.81 hours · Measure score 6.10 · Achievement 6.10 · Improvement 3.63
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.84% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 11.4% · Lower 95% interval 8.02% |
| Discharge to community | 42.25% |
50.57%
8.3 pts worse
|
No Different than the National Rate · Eligible stays 86 · Observed rate 37.21% · Lower 95% interval 32.61% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 55 · Denominator 55 |
| Falls with major injury | 3.64% |
0.77%
2.9 pts worse
|
Numerator 2 · Denominator 55 |
| Discharge self-care score | 30.23% |
53.69%
23.5 pts worse
|
Numerator 13 · Denominator 43 |
| Discharge mobility score | 25.58% |
50.94%
25.4 pts worse
|
Numerator 11 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 55 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 4.84% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 10.71% |
8.2%
2.5 pts better
|
Numerator 33 · Denominator 308 |
| Staff flu vaccination coverage | 42.64% |
42%
0.6 pts better
|
Numerator 168 · Denominator 394 |
| Discharge function score | 20.93% |
56.45%
35.5 pts worse
|
Numerator 9 · Denominator 43 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 75.86% |
25.2%
50.7 pts better
|
Numerator 22 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.0
About the same
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.3
0.4 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
89.6%
10 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.4% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.8% |
3.3%
3.5 pts worse
|
3.3%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 7.4% · Q3 7.9% · Q4 4.9% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.6% |
50.3%
46.7 pts better
|
11.4%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.0% · Q3 3.3% · Q4 7.1% · 4Q avg 3.6% |
| Percentage of long-stay residents who lose too much weight | 9.0% |
6.5%
2.5 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 14.3% · Q3 4.8% · Q4 2.6% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
18.5%
5.3 pts better
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 10.0% · Q3 9.3% · Q4 17.5% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.1% |
22.8%
18.7 pts better
|
16.7%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.5% · Q3 6.1% · Q4 3.3% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.5% |
17.2%
4.3 pts worse
|
16.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 9.7% · Q3 23.3% · Q4 45.0% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
15.0%
3.2 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 12.2% · Q3 16.7% · Q4 45.9% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.1% |
1.7%
6.4 pts worse
|
1.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 6.0% · Q3 3.2% · Q4 11.9% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
21.3%
2.1 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 32.2% · Q2 31.0% · Q3 10.3% · Q4 0.0% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
5.2%
4.1 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.1% · Q3 1.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
68.8%
30.1 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.3% · Q4 98.8% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.4% |
14.0%
7.4 pts worse
|
12.0%
9.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 18.9% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.8% |
63.0%
18.8 pts better
|
79.7%
2.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
26.2%
9.9 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 15.1% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-19 · Fire 2023-07-19
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-05-09 · Fire 2022-05-09
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-24
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-07-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-13
F · Potential for more than minimal harm
2024-07-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-15
F · Potential for more than minimal harm
2024-07-24
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-07-24
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-07-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-07-24
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-07-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-15
E · Potential for more than minimal harm
2023-07-19
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-07-18
E · Potential for more than minimal harm
2023-07-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-07-19
E · Potential for more than minimal harm
2023-07-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-19
F · Potential for more than minimal harm
2022-05-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-05-24
E · Potential for more than minimal harm
2022-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-05-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-05-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
G · Actual harm
2025-09-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-30
G · Actual harm
2025-04-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-24
G · Actual harm
2024-07-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-25
F · Potential for more than minimal harm
2023-07-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-07-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-09
D · Potential for more than minimal harm
2023-07-19
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-08-16
G · Actual harm
2023-05-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-30
F · Potential for more than minimal harm
2022-05-09
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-05-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-05-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-05-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-05-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-27
D · Potential for more than minimal harm
2022-05-09
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-05-27
Penalties and ownership
What sits behind the stars
$10,358
2025-04-09
Fine
Fine · fine $10,358
Fine
$0
2024-07-24
Payment Denial
Payment Denial · denial start 2024-08-22 · 12 days
12 day denial
$20,914
2023-05-16
Fine
Fine · fine $20,914
Fine
Ownership
Devinney, Patrick
Operational/Managerial Control · Individual
Devinney, Patrick
Corporate Officer · Individual
Leverenz, Mark
Operational/Managerial Control · Individual
Pappas, Theodosis
Operational/Managerial Control · Individual
Pappas, Theodosis
Corporate Officer · Individual
Staley, Thomas
Operational/Managerial Control · Individual
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