Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Encore Village during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple medical conditions did not have a properly implemented or documented power of attorney (POA) in their medical record. Facility staff and family members were unclear about who was authorized to make decisions, and the facility's policy requiring advance directive implementation within 30 days of admission was not followed.
A resident did not receive a scheduled dose of tramadol because the facility ran out of the medication and did not obtain it from the medication tower, despite facility policy allowing this. Documentation confirmed the missed dose and lack of available medication until a new supply was delivered.
A resident's credit card was stolen from their room in a facility, leading to unauthorized charges. The resident, who was alert and oriented, had their card in a wallet attached to their phone. The theft was discovered by the resident's POA, who noticed a charge for a gaming system. The facility staff cooperated with the police investigation, which suggested the involvement of someone connected to the facility.
A resident's credit card was stolen and used without authorization, but the LTC facility failed to report the incident to the state agency within the required 24-hour timeframe. The resident's daughter discovered the theft and reported it to the police, but the facility delayed reporting until contacted by the police in December. The previous administrator was informed but did not act, leading to a significant delay in addressing the issue.
A facility failed to thoroughly investigate a resident's stolen credit card, despite police involvement and the resident's POA reporting the incident. The investigation was inadequately documented, with conflicting staff accounts and missing interviews. The resident, who was cognitively intact, had multiple medical conditions. The facility's prevention program required a complete investigation, which was not conducted.
The facility failed to monitor weight and nutrition for three residents, resulting in significant weight loss. A resident on tube feeding was not weighed weekly, leading to an 11.4% weight loss. Another resident lost 7.67% of their weight without nutritional assessment, and a third resident experienced a 6.6% weight loss due to delayed meal delivery and lack of weight monitoring upon readmission.
A resident with a history of venous thrombosis, embolism, and other conditions was found sitting in a wheelchair without proper leg support, leading to discomfort and reddish-purple legs. The Therapy Director confirmed that proper positioning requires feet to be supported, but only two left-sided footrests were available, indicating a deficiency in accommodating the resident's needs.
A resident's advanced directives were not discussed or implemented upon admission, leading to a discrepancy between the POLST form indicating DNR and a full code order in the Physician's Order Sheet. The facility's policy requires that DNR/POLST orders remain in effect unless a signed request to change them is provided, which was not followed.
Two residents requiring assistance with ADLs did not receive scheduled showers due to staff shortages and reliance on agency staff. Documentation showed significant gaps in recorded showers, contrary to the facility's policy for providing hygiene support.
The facility failed to use a gait belt during a resident transfer and did not update a care plan after a fall. A CNA removed a gait belt during a transfer, contrary to policy, and a resident with severe cognitive impairment experienced two falls without timely intervention. The resident's transfer assessment was only adjusted after the second fall, which resulted in injuries.
A resident with multiple health conditions, including dependence on supplemental oxygen, was not provided with the appropriate high flow nasal cannula for oxygen administration. Despite a physician's order for 7 liters of oxygen, the resident was observed using a regular flow cannula, which was confirmed by a respiratory therapist to be inadequate for the prescribed oxygen level. The facility's policy lacked guidance on when to use a high flow nasal cannula.
A resident with multiple health conditions was found with a cup of crushed medications left on her bedside table, indicating a failure in proper medication administration. The DON confirmed that medications should not be left unattended and that the resident was not assessed for self-administration, except for a nasal spray.
A resident with Parkinson's disease did not receive her Carbidopa-Levodopa medication on time, with a delay of approximately three hours. The facility's policy requires timely administration, but the medication was given late due to the resident being in the dining room during the scheduled time.
A resident was found with medications unsecured on a bedside table, contrary to the facility's policy requiring locked storage. The resident's electronic medical record lacked an assessment allowing for self-administration and bedside storage, as confirmed by the DON and LPNs.
Facility staff failed to follow infection control protocols during care for two residents. A CNA did not change gloves or wash hands after providing incontinence care to a resident, contrary to the facility's hand hygiene policy. Additionally, a wound nurse did not wear a gown while treating a resident under Enhanced Barrier Precautions, violating the facility's EBP policy.
Two residents requiring assistance with ADLs did not receive timely incontinence care. One resident was found with a saturated brief and urine-soaked clothing and bedding, while another was left in a wet brief that leaked onto her wheelchair pad. Both residents reported not receiving care as per their needs, contrary to the facility's policy of providing toileting and incontinence care every two hours and as needed.
A resident with Alzheimer's, dementia, and diabetes experienced significant weight loss due to the facility's failure to assist with eating and provide prescribed nutritional supplements. Despite a care plan that included house shakes and meal assistance, staff did not provide the necessary support, leading to continued weight decline.
A resident with a history of dementia and behavioral disturbances was hospitalized due to excessive drowsiness caused by psychotropic medications. Despite orders to hold medications if lethargy occurred, facility staff failed to do so and did not notify the physician. The resident's daughter raised concerns about her mother's condition, leading to her being sent to the hospital. Documentation showed inconsistencies in following medication orders and communication with the physician.
A resident's pain medication, Norco, was misappropriated by an LPN who initially lied about discontinuing the medication due to dizziness. The LPN later admitted to taking the medication home due to personal financial and health struggles. This incident violated the facility's policy on protecting residents from misappropriation of property.
Failure to Implement and Document Advance Directive/POA for Resident
Penalty
Summary
The facility failed to follow its advance directive and life-sustaining treatment policy by not ensuring that a power of attorney (POA) was properly implemented for a resident with moderate cognitive impairment and multiple medical conditions, including heart failure, atrial fibrillation, urinary retention, UTI, history of falls, and benign prostatic hyperplasia. Interviews revealed confusion among staff and family members regarding who was designated as the resident's POA. The nurse practitioner reported that the resident's daughter was making decisions, but the daughter questioned why the facility was not contacting the individual who actually held the POA. The social service staff was unsure who the POA was and indicated they would need to ask the administrator. The resident's son-in-law stated he was the POA but was not informed about the resident's condition or decline until after the resident passed away, and noted that the facility always contacted another family member instead. The administrator confirmed that the facility did not have any POA paperwork on file for the resident and that staff had mistakenly documented the son-in-law as the POA. The facility's policy required the social service director or designee to assess, care plan, and implement advance directives within 30 days of admission, but the resident's medical record did not contain documentation designating a POA in writing. This lack of proper documentation and implementation of the advance directive policy resulted in the facility not honoring the resident's right to have a designated representative make decisions on their behalf.
Missed Scheduled Pain Medication Dose Due to Medication Unavailability
Penalty
Summary
A cognitively intact resident did not receive a scheduled dose of tramadol, a pain medication, due to the facility running out of the medication. The resident was scheduled to receive tramadol four times daily and as needed, but the Medication Administration Record (MAR) showed that the 12:00 PM dose on 6/11/24 was not administered. Progress notes indicated that the medication was unavailable at the time and would be delivered later that day, but there was no documentation that the medication was retrieved from the medication tower, which was available for such situations. The Controlled Substance Proof of Use sheets confirmed that after the previous evening dose, there was no tramadol remaining on hand until a new supply arrived later the next day. The Director of Nursing confirmed that medications should be reordered before supplies run out and that the medication tower could be used to obtain medications in the interim. Facility policy also stated that staff may obtain medications from the medication tower while waiting for pharmacy delivery, but this was not done in this instance.
Resident's Credit Card Stolen in Facility
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property when a credit card was stolen from a resident's room. The incident involved a long-term resident who was alert and oriented but occasionally forgetful. The theft was discovered when the resident's Power of Attorney (POA), who is also the resident's daughter, noticed an unauthorized charge on the credit card statement for a gaming system. The charge was made at a store, and the POA contacted the facility management and the police. The police investigation suggested that the person who used the credit card might have been connected to someone working at the facility. The facility's staff, including the unit manager and the Assistant Director of Nursing, were informed of the incident and cooperated with the police investigation. The unit manager confirmed that the individual in the photo provided by the police did not work at the facility. The resident's credit card was kept in a wallet attached to her phone, which was in her room. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention emphasizes the residents' right to be free from such incidents, but the theft still occurred, indicating a lapse in the facility's protective measures.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state surveying agency within the required timeframe. A resident's credit card was stolen from their room, and charges were made on the card on October 1, 2024. The resident's daughter, who is also the Power of Attorney, discovered the unauthorized charges and reported the theft to the police. However, the facility did not report the incident to the state agency until December 17, 2024, well beyond the 24-hour reporting requirement. The social worker had informed the previous administrator about the missing credit card in October, but the administrator did not follow up, leading to a delay in the investigation. The resident involved, identified as R2, had a BIMS score indicating no cognitive impairment and had multiple medical diagnoses, including congestive heart failure and type 2 diabetes mellitus. The facility's policy requires immediate reporting of such incidents, but this was not adhered to, as the initial incident report was only filed after the police contacted the facility in December. The executive director and other staff acknowledged the reporting failure, noting that the previous administrator was overwhelmed and did not act on the information provided by the social worker.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of resident property involving a resident's stolen credit card. The incident was initially reported when the unit manager received an email from the police regarding a case involving the resident's stolen credit card. The police provided an image of an individual suspected of using the card. The facility's initial incident report indicated that an investigation was initiated and ongoing, but the final incident report lacked evidence of a thorough investigation. The investigation process was inadequately documented, with conflicting accounts from staff members about who conducted the investigation and what steps were taken. The Assistant Director of Nursing (ADON) and the Registered Nurse/Unit Manager were involved in the investigation, but neither conducted interviews with staff or the resident. The Executive Director acknowledged that the investigation should have been completed to protect residents' rights, but the necessary interviews and documentation were missing. The resident involved was a long-term resident with multiple medical conditions, including congestive heart failure and diabetes, but was cognitively intact with a BIMS score indicating no cognitive impairment. The resident's Power of Attorney (POA) discovered the unauthorized charge on the credit card statement and reported it to the facility and the police. Despite the ongoing police investigation, the facility did not have a complete internal investigation documented, as required by their Abuse, Neglect, Exploitation, and Misappropriation Prevention Program.
Failure to Monitor Weight and Nutrition
Penalty
Summary
The facility failed to ensure proper weight monitoring and nutritional assessment for three residents, leading to significant weight loss. A newly admitted resident on tube feeding was not weighed weekly as required, resulting in a weight loss of 16.8 pounds (11.4%) in 18 days. The Registered Dietitian (RD) acknowledged that weekly weights were not documented and that this oversight delayed the identification of weight loss, preventing timely intervention. Another resident experienced a significant weight loss of 12.6 pounds (7.67%) over one month without any nutritional assessments or interventions. The RD was not informed of the resident's reweigh results promptly, which delayed the recognition of the weight loss. The RD only became aware of the issue when it was highlighted by the surveyor, indicating a lapse in communication and monitoring. A third resident lost 10.2 pounds (6.6%) in 13 days. The resident was not weighed upon readmission, and there was a delay in meal delivery, which contributed to the resident's malnourished state. The RD was unaware of the resident's request for earlier meal delivery before therapy sessions, which could have addressed the resident's hunger and potentially mitigated the weight loss.
Failure to Support Resident's Legs in Wheelchair
Penalty
Summary
The facility failed to ensure that a resident's legs were properly supported while sitting in her wheelchair, which is a deficiency in accommodating the needs of the resident. The resident, who has a history of venous thrombosis, embolism, back pain, scoliosis, osteoporosis, a history of a fracture, and left foot pain, was observed sitting in her wheelchair with her feet hanging approximately six inches from the floor and without any leg rests. Her legs appeared reddish purple in color. The resident expressed discomfort when her legs were hanging and mentioned that she felt more comfortable when her feet were supported on the bar of a tray table. The Therapy Director confirmed that proper wheelchair positioning requires feet to be either flat on the ground or supported by footrests to prevent swelling or pressure on the back of the legs. However, only two left-sided footrests were found in the resident's room, indicating a lack of proper support for the resident's legs.
Failure to Implement Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were discussed and implemented upon admission. The resident, identified as R282, was admitted to the facility with a POLST form indicating a preference for Do Not Resuscitate (DNR). However, the resident's Physician's Order Sheet later showed an order for full code status, which contradicted the POLST form. There was no documentation in the resident's Electronic Medical Record (EMR) that social services had discussed the advanced directives with the resident or their power of attorney prior to the discrepancy being noted. The Director of Nursing (V2) stated that advanced directives are typically discussed by a nurse upon admission and that residents are considered full code until a valid POLST form is received. V2 acknowledged that the facility staff should follow the directives on a valid POLST form unless the resident expresses other wishes, which should be documented and verified with the physician. Despite this protocol, the facility did not implement the resident's POLST directives or follow up with the resident the day after admission, as per their policy. The facility's policy indicates that DNR/POLST orders remain in effect until a signed request to end them is provided, which was not adhered to in this case.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents requiring assistance with activities of daily living (ADLs) received showers or baths as scheduled. This deficiency was observed in two residents, R58 and R39, who were part of a sample of 26 residents reviewed. R58, a cognitively intact resident with multiple health conditions including Parkinson's disease and congestive heart failure, reported not receiving her scheduled showers twice a week due to staff shortages and reliance on agency staff. Documentation revealed that R58's last recorded shower was 17 days prior to the survey, with no showers documented for 30 days in the electronic health record (EHR). Similarly, R39, who requires assistance with bathing, reported not receiving her scheduled showers twice a week. The shower binder and EHR confirmed that R39's last documented shower was 10 days before the survey, with no showers or refusals recorded in the interim. The facility's policy mandates appropriate care and services for residents unable to perform ADLs independently, including hygiene support, which was not adhered to in these cases.
Failure to Use Gait Belt and Update Care Plan After Falls
Penalty
Summary
The facility failed to ensure the proper use of a gait belt during a resident transfer and did not update a resident's care plan following a fall. In the first incident, a Certified Nursing Assistant (CNA) transferred a resident, R39, to the toilet using a gait belt but removed it while providing care. The CNA did not reapply the gait belt before instructing R39 to stand, despite the resident expressing difficulty in holding onto the support bar. The facility's policy recommends the use of a gait belt for one-person transfers, except in specific situations, which was not adhered to in this case. In the second incident, another resident, R110, who has severe cognitive impairment and is at high risk for falls, experienced two falls during transfers. On 9/27/24, R110's knee buckled during a transfer, and the resident was lowered to the floor. No fall intervention was implemented after this incident. On 10/4/24, R110 was again lowered to the floor during a transfer, resulting in injuries. It was only after the second fall that the resident's transfer assessment was adjusted to require two staff members or a sit-to-stand assist. The lack of timely intervention after the first fall contributed to the subsequent incident.
Inappropriate Oxygen Administration for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen administration. The resident, identified as R281, had multiple diagnoses including dependence on supplemental oxygen, hypertension, chronic kidney disease, and chronic obstructive pulmonary disease, among others. The physician's order specified that the resident should receive 7 liters of oxygen continuously. However, observations on two consecutive days revealed that the resident was using a regular flow nasal cannula instead of a high flow nasal cannula, which is necessary for administering more than 5 liters of oxygen. The respiratory therapist confirmed that the resident's cannula was not suitable for high flow oxygen, as it lacked the larger bore size required for such administration. The facility's policy on oxygen administration did not specify when a high flow nasal cannula should be used, contributing to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure proper administration of medications to a resident, leading to a deficiency in pharmaceutical services. A resident, a [AGE] year old female with multiple diagnoses including congestive heart failure, type 2 diabetes, and hypertension, was observed with a cup of crushed medications left on her bedside table. The resident confirmed that the medications were hers and that they were crushed to aid swallowing. Despite this, the medications remained on the table when the surveyor left the room. The Director of Nursing acknowledged that medications should not be left at the bedside and confirmed that the resident did not have an assessment to self-administer medications. The resident's physician orders included several medications for her conditions, but her self-administration safety screen only listed a nasal spray as approved for self-administration.
Medication Administration Delay for Parkinson's Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Carbidopa-Levodopa for a resident with Parkinson's disease. The resident, a female with a history of Parkinson's disease, congestive heart failure, and other conditions, reported that her medication was not administered at the scheduled time. On one occasion, the medication, which was supposed to be given at 11:00 AM, was administered at 1:47 PM, approximately three hours late. This delay was confirmed by the Medication Administration Audit Report. The Director of Nursing acknowledged the importance of administering medications on time, especially for residents with Parkinson's disease, as delays can affect their movements and cause increased stiffness. The nurse responsible for administering the medication reported that the resident was in the dining room at the scheduled time, which coincided with lunch preparations. The facility's Medication Administration Policy and Procedure emphasizes the need for medications to be administered in a safe and timely manner, in accordance with prescriber orders, which was not adhered to in this instance.
Failure to Securely Store Medications for a Resident
Penalty
Summary
The facility failed to ensure medications were securely stored for one resident, identified as R121, who was observed with a fluticasone-salmeterol respiratory inhaler and an azelastine nasal decongestant spray on the bedside table. These medications were prescribed to be administered twice daily. The resident confirmed that the medications were kept on the bedside table, which was corroborated by a Licensed Practical Nurse (LPN), who mentioned that R121 needed reminders on how to use the medications properly. Further investigation revealed that the facility's policy required medications to be stored in locked compartments unless an assessment determined that a resident could safely self-administer and store medications. The Director of Nursing (DON) stated that an assessment should be present in the resident's electronic medical record to allow for bedside storage of medications. However, no such assessment was found for R121, indicating a failure to comply with the facility's medication storage and self-administration policies.
Infection Control Deficiencies in Hand Hygiene and EBP
Penalty
Summary
The facility staff failed to adhere to proper infection control protocols during the provision of incontinence care to a resident identified as R20. On the observed date, two CNAs, V9 and V10, were involved in providing care to R20, who had a bowel movement. V10, after completing the incontinence care, did not change her soiled gloves or wash her hands before proceeding to apply a new incontinent pad and assist R20 into a wheelchair using a mechanical stand lift. V10 continued to touch multiple surfaces and adjust R20 without changing gloves or performing hand hygiene until all tasks were completed. This action was contrary to the facility's hand hygiene policy, which emphasizes the integration of glove use with routine hand hygiene to prevent healthcare-associated infections. In another instance, the facility staff failed to comply with Enhanced Barrier Precautions (EBP) for a resident identified as R12. A sign outside R12's door indicated the need for EBP, which includes wearing gloves and a gown during high-contact care activities. However, V12, a wound nurse, only donned gloves and did not wear a gown while providing wound treatment to R12's sacral wound. This was against the facility's EBP policy, which is designed to reduce the transmission of multi-drug resistant organisms and other pathogens during high-contact resident care activities.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility staff failed to provide timely incontinence care for two residents who required assistance with activities of daily living (ADLs). Resident R2's care plan indicated a need for staff assistance with toileting and transferring, and the resident was frequently incontinent of urine and stool. On the morning of the observation, a strong odor of urine was noted in R2's room, and the resident reported not having received incontinence care since the previous night. When a CNA finally attended to R2, the resident's incontinence brief was found to be saturated with urine, which had leaked onto her clothing and bedding. Similarly, Resident R1 required staff assistance with toileting and was frequently incontinent of urine and stool. R1 reported being gotten out of bed without being toileted or having her incontinence brief changed, despite wearing a diaper and feeling wet. Later, when a CNA provided care, R1's incontinence brief was also saturated with urine, and urine had leaked onto the pad on her wheelchair. The CNA claimed R1 had refused care, which R1 immediately denied. The facility's policy indicated that toileting and incontinence care should be provided every two hours and as needed, but this was not adhered to in these cases.
Failure to Provide Nutritional Support for Resident with Weight Loss
Penalty
Summary
The facility failed to assist a resident, identified as R4, with eating and did not implement a nutritional intervention for significant weight loss. R4, who has Alzheimer's Disease, dementia, and diabetes, was at nutritional risk due to inadequate oral intake and significant weight loss. The care plan for R4 included providing 8 ounces of a house shake twice a day with lunch and dinner, along with supervision and assistance during meals. However, observations showed that R4 was not assisted with eating during breakfast, and the prescribed house shake was not provided during lunch. On multiple occasions, staff failed to provide the necessary nutritional supplements to R4, despite the resident's documented weight loss and the care plan's directives. Dining room servers and the Dietary Director confirmed that R4 did not receive the required house shake at lunch. Additionally, R4's weight continued to decline, with a recorded weight of 115 pounds, indicating further weight loss. This lack of adherence to the care plan and failure to provide necessary nutritional support contributed to R4's ongoing weight loss.
Failure to Monitor Psychotropic Medication Use Leads to Hospitalization
Penalty
Summary
The facility failed to properly monitor and manage the use of psychotropic medications for a resident, leading to adverse effects and hospitalization. The resident, a female with a history of vascular dementia and behavioral disturbances, was receiving multiple psychotropic medications, including Depakote, Seroquel, and Clonazepam, three times a day. Despite orders to hold these medications if the resident showed signs of lethargy, the facility did not consistently follow these instructions, resulting in the resident experiencing excessive drowsiness and being sent to the hospital for evaluation of stroke-like symptoms. Observations and interviews revealed that the resident was frequently lethargic, unable to express her needs, and required assistance with meals due to her sedated state. The facility staff, including an agency nurse, failed to hold the medications as ordered and did not notify the physician of the adverse effects. The resident's daughter expressed concern about her mother's condition, noting that she was unusually sleepy and drooling, which prompted the decision to send her to the hospital. The facility's documentation showed inconsistencies in following the orders to hold medications and a lack of communication with the physician regarding the resident's condition. The Medication Administration Record did not reflect the orders to hold the medications, and there was no documentation of physician notification when the resident exhibited lethargy. This oversight in medication management and monitoring contributed to the resident's hospitalization and the subsequent adjustment of her medication regimen.
Misappropriation of Resident's Medication by LPN
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, specifically involving the theft of medication. A resident, who is cognitively intact and has a medical history including urine retention, urinary tract infection, atrial fibrillation, heart failure, and osteoarthritis, reported that her pain medication, Norco, was stolen. The incident was reported by the unit manager after the PM nurse could not locate the medication, which had been delivered two days prior. The resident denied feeling dizzy or requesting a change in medication, contradicting the LPN's initial claim that the medication was discontinued due to dizziness. The investigation revealed that the LPN had taken the Norco home, citing personal financial and health struggles as the reason. The LPN initially lied about the situation, claiming the medication was discontinued and replaced with Tramadol after consulting with a doctor, which was later proven false. The LPN admitted to the theft in an email to the unit manager, acknowledging the wrongdoing and apologizing for the actions. The facility's policy on abuse, neglect, exploitation, and misappropriation of property emphasizes the residents' right to be free from such incidents. However, the LPN's actions directly violated this policy, leading to the misappropriation of the resident's medication. The facility's failure to prevent this incident highlights a significant deficiency in protecting residents' property rights.
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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 Schaumburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bella Terra Schaumburg | 1 mi | ★★★★★ | 7 | 0 |
| Abbington Vlge Nrsg & Rhb Ctr | 3 mi | ★★★★★ | 24 | 0 |
| Pearl Of Elk Grove, The | 3 mi | ★★★★★ | 7 | 0 |
| Alden Poplar Creek Rehab & Hcc | 3.3 mi | ★★★★★ | 9 | 0 |
| Ignite Medical Hanover Park | 4 mi | ★★★★★ | 2 | 0 |
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