Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Friendship Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, Alzheimer’s disease on hospice, and high fall risk, dependent on staff for ADL transfers, was transferred from bed to a recliner using a mechanical lift by one CNA and an untrained private caregiver instead of two trained staff as required by facility policy. The private caregiver attached the top sling loops and the CNA attached the bottom loops, but the sling was not correctly positioned between the resident’s legs, causing the resident to slip out of the sling and fall to the floor, resulting in a superficial ear abrasion; hospital CT and pelvic X-ray were negative for fractures or other injury.
A resident with severe cognitive impairment, muscle weakness, and a history of falls was not safely transferred using a mechanical lift device when a CNA failed to use a gait belt and did not properly position the lift. The resident fell during the transfer, resulting in a displaced femur fracture. Staff interviews and documentation confirmed that facility policy required the use of a gait belt and proper transfer technique, which were not followed in this incident.
A resident with severe cognitive impairment and a history of falls was left unsupervised on an elevated bed without side rails or a properly placed fall mat during morning care. While a CNA was preparing a mechanical lift sling, the resident rolled off the open side of the bed and fell onto the concrete floor, resulting in a scalp laceration that required staples.
The facility failed to provide adequate supervision and adhere to its fall prevention program for three residents, resulting in significant injuries. A resident with severe cognitive impairment fell from a wheelchair, leading to nasal fractures, while another resident with a history of falls suffered hip fractures due to lack of individualized interventions and supervision. Additionally, a cognitively intact resident fell during assistance, resulting in a tibial fracture, due to a lapse in supervision.
The facility did not implement Enhanced Barrier Precautions (EBPs) to prevent the spread of MDROs, despite having a policy in place. Staff were observed performing care activities without the required PPE, and the infection control preventionist admitted to not implementing EBPs due to a lack of awareness. This oversight potentially affects all 73 residents, as several have conditions requiring such precautions.
Improper Mechanical Lift Transfer Performed With Untrained Caregiver
Penalty
Summary
The deficiency involves the facility’s failure to follow its own mechanical lift and safe lifting policies requiring at least two trained staff members to perform mechanical lift transfers and to ensure proper sling placement and security. Facility policies state that mechanical lifting devices require two staff, that staff responsible for direct resident care will be trained in the use of mechanical lifting devices, and that sling attachments and strap stability must be double-checked before lifting. The CNA job description also requires following established safety precautions when lifting and moving residents. Despite these requirements, a CNA and a private caregiver, who was not a facility employee and had no mechanical lift training, jointly performed a mechanical lift transfer for a resident who was severely cognitively impaired, dependent for ADLs including transfers, on hospice for Alzheimer’s disease, and assessed as high risk for falls with a need for two-person assistance. On the date of the incident, the CNA and the untrained private caregiver placed the resident into a mechanical lift to transfer from bed to recliner. The private caregiver attached the top loops of the sling to the lift, and the CNA attached the bottom loops. During the transfer, as they were nearly finished and preparing to place the resident into the recliner, the resident slipped out of the bottom of the sling and fell onto the buttocks on the floor. It was later recognized that the sling had not been properly placed between the resident’s legs, which allowed the resident to slip out. The resident, who had Alzheimer’s disease and was unable to verbalize pain, was sent to the hospital, where CT scans of the spine and head/brain and a pelvic X-ray were negative for fractures or injury; the resident sustained a superficial abrasion to the left ear. The CNA’s personnel file documented prior mechanical lift training and a subsequent performance correction notice for improperly placing a mechanical lift sling.
Failure to Ensure Safe Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of falls, severe cognitive impairment, muscle weakness, and unsteadiness was not safely transferred using a mechanical lift device. The resident, who required substantial to maximal assistance for transfers and had a care plan indicating a high risk for falls, was being assisted by a CNA who did not use a gait belt during the transfer process. The CNA positioned the lift too close to the bed, making it difficult to lower the seat paddles, and subsequently moved the lift without the paddles in place. During this process, the resident let go of the bar and fell to the floor, resulting in a displaced fracture of the right femur. Interviews with staff revealed that the use of a gait belt was required during such transfers, and that the CNA was aware of this requirement but failed to implement it. The CNA also acknowledged that the resident had complained of arm pain prior to the transfer and that she should have considered using a different transfer method or sought additional assistance. Other staff members confirmed that a gait belt should always be used, especially for residents who are unpredictable or have a history of falls, and that two staff members may be needed for such transfers. Documentation and policy review showed that the facility's procedure for using the lift device included locking the casters, ensuring the resident's feet were on the platform, and using a gait belt to assist the resident in standing before lowering the seat paddles. The resident's care plan and assessment indicated a need for extensive assistance and highlighted her fall risk, but these precautions were not followed during the incident, directly leading to the resident's fall and injury.
Resident Fall Due to Inadequate Supervision and Bed Positioning
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of falls was not safely positioned in bed during morning care. The resident required substantial to maximal assistance for mobility and was dependent on staff for all care, including the use of a mechanical lift for transfers. On the morning of the incident, a CNA raised the resident's bed to a high position for body mechanics and was providing care alone. While attempting to place a mechanical lift sling under the resident, the CNA moved to the opposite side of the bed, leaving the resident facing the open side without supervision or protective barriers such as side rails or a fall mat in place. During this time, the resident moved her legs and rolled off the bed, falling onto the concrete floor and sustaining a scalp laceration that required staples. The incident report and staff interviews confirmed that the bed was elevated, the resident was left unsupervised on the open side, and the fall mat was not properly positioned. The facility's own fall risk management policy identifies incorrect bed height and cognitive impairment as risk factors for falls, both of which were present at the time of the incident.
Inadequate Supervision and Fall Prevention
Penalty
Summary
The facility failed to adhere to its fall prevention program and provide adequate supervision for three residents, resulting in significant injuries. Resident R15, who has severe cognitive impairment and requires substantial assistance, experienced an unwitnessed fall from her wheelchair in the hallway, leading to nasal fractures. Despite being identified as high risk for falls, R15 was left unsupervised, contrary to the facility's Falling Star Program guidelines, which mandate that high-risk residents should not be left unattended. Resident R60, with a history of falls and severe cognitive impairment, suffered multiple falls, including two that resulted in hip fractures. The care plan for R60 did not reflect individualized interventions based on her fall history, and she was often left unsupervised, despite being identified as high risk for falls. The facility's failure to implement effective interventions and provide adequate supervision contributed to R60's repeated falls and injuries. Resident R18, who is cognitively intact but requires assistance with mobility, fell while being assisted by a CNA. The CNA momentarily turned away, leading to R18 sliding off the bed and sustaining a tibial fracture. This incident highlights a lapse in supervision and adherence to the care plan, which required one-to-one assistance for R18. The facility's failure to ensure continuous supervision during assistance contributed to the fall and subsequent injury.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBPs) to prevent the spread of multi-drug resistant organisms (MDROs) among its residents. The facility's policy, dated August 2022, requires the use of gowns and gloves during high-contact resident care activities, such as dressing, bathing, and wound care, especially for residents with wounds or indwelling medical devices. However, during a facility tour, no residents were observed to be in isolation or have signs indicating EBPs. Additionally, staff members were observed performing care activities without the required personal protective equipment (PPE), such as gowns, during procedures like suprapubic catheter care and wound care. The facility's infection control preventionist confirmed that no residents had been placed under EBPs, despite several residents having conditions that warranted such precautions, including indwelling urinary catheters and pressure ulcer wounds. The infection control preventionist admitted to not implementing EBPs because of a lack of awareness of its mandatory nature. This oversight potentially affects all 73 residents in the facility, as documented in the facility's Roster Census Status.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rock Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arcadia Care Rock Island | 0.8 mi | ★★★★★ | 5 | 1 |
| St Anthony's Nsg & Rehab Ctr | 1.5 mi | ★★★★★ | 6 | 0 |
| Allure Of The Quad Cities | 2.8 mi | ★★★★★ | 11 | 1 |
| Good Samaritan - Davenport | 3.4 mi | ★★★★★ | 11 | 0 |
| Harmony Davenport | 3.4 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.