Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Frankfort Terrace during CMS and state inspections, most recent first.
Several residents reported their rooms were uncomfortably warm, with temperature readings above the facility's comfort range. Despite policy requirements for monitoring and maintaining temperatures, staff did not consistently check resident rooms or increase monitoring frequency during hot weather, resulting in residents experiencing elevated room temperatures.
A resident with a history of aggressive behavior physically struck another resident in the mouth, resulting in a swollen and abraded lip. Despite prior incidents and interventions, the aggressive behavior continued, and the facility failed to prevent the physical abuse, violating residents' rights to be free from abuse.
The facility failed to properly label, date, seal, and store food items, and did not maintain proper sanitation while checking food temperatures. Observations included unlabeled and undated food items, expired milk, cluttered dry storage, and improper thermometer sanitation. The Dietary Manager acknowledged these deficiencies, which violated the facility's food safety policies.
The facility failed to implement and document measures to prevent Legionella and maintain an up-to-date infection control policy, affecting all 101 residents. The Maintenance Director was unaware of Legionella, and water temperatures had not been documented since March 2024. The Administrator confirmed reliance on city testing for Legionella and acknowledged the absence of a current infection control policy. The Infection Preventionist noted outdated infection control documents, and the Water Management Program lacked specific guidelines.
The facility's call light system was found to be malfunctioning, affecting all residents. A resident reported not receiving timely assistance, and staff confirmed the system's inconsistency, with some stating it hadn't worked properly for a month. The Maintenance Director admitted to not regularly testing the system, and the Administrator was unaware of the last check, indicating a lack of oversight.
The facility failed to provide adequate ADL care to four residents, resulting in unmet needs for personal hygiene and nail care. Two residents were observed with unshaved facial hair despite requests for assistance, and two others had long, jagged toenails due to a lack of podiatry care. The facility's DON admitted to oversights in nail care, and there was no documentation of ADL care or refusals in the residents' records.
The facility failed to invite two cognitively intact residents to their interdisciplinary care plan meetings, as confirmed by the MDS Coordinator and the Administrator. Both residents, with various medical conditions, reported not being aware of or invited to any care plan meetings, and there was no documentation of invitations or declinations, contrary to the facility's policy.
A resident with osteoarthritis was not assisted by staff to wear her prescribed wrist braces, despite her requests and a physician's order. The resident, who requires substantial assistance, was found without the braces, which were observed on her chair. Facility staff confirmed that they should have helped the resident, as per the physician's order and facility procedures.
A resident with upper extremity impairments was not provided with adaptive eating utensils as required, despite being indicated on their meal card. The resident, who has multiple health conditions, was observed being fed by CNAs without the special spoon needed for self-feeding. Staff interviews revealed a lack of awareness and availability of the required utensils, and the facility lacked a policy for adaptive utensils, relying instead on therapy department recommendations.
The facility failed to contain respiratory equipment for two residents, leading to a deficiency in infection control. One resident's BIPAP mask and oxygen nasal cannula were uncovered, despite their need for nightly use due to COPD, asthma, and sleep apnea. Another resident's CPAP mask and nasal cannula were also uncovered, although they require nightly CPAP for obstructive sleep apnea and oxygen for chronic respiratory failure. The facility's guidelines did not specify containment procedures, and both the Administrator and DON acknowledged the need for equipment to be covered.
A facility failed to properly store and label medications for a resident, leading to a deficiency. Medications, including Terconazole Cream, Ketoconazole Shampoo, and Albuterol Sulfate, were found improperly stored together in an unlabeled bag. The Director of Nursing confirmed that medications with different routes should be stored separately and labeled, as per the facility's policy. The resident had multiple diagnoses, including schizophrenia and COPD.
The facility failed to respect residents' dietary choices, affecting three cognitively intact residents who reported being denied additional food portions despite feeling hungry. Dietary staff confirmed that only residents with double portion orders received extra food, and no second helpings were provided to others. The facility lacked a policy on resident meal choices and restrictions.
A resident with serious mental health conditions did not receive necessary rehabilitative services, including group sessions and individual therapy, as required by their care plan. The resident was not encouraged or informed about available programs, and the facility lacked documentation of any refusal of services. The Psychiatric Rehabilitative Services Director confirmed the absence of a policy for therapy and group activities.
Failure to Maintain Comfortable Environmental Temperatures
Penalty
Summary
The facility failed to maintain a comfortable environment for residents, as evidenced by elevated temperatures in multiple resident rooms. Four out of six residents interviewed reported their rooms were too warm, with some stating that only common areas such as the dining room or lobby were comfortable. Temperature readings taken in these residents' rooms showed values ranging from 81.8°F to 82.2°F, exceeding the facility's stated comfort range of 71-80°F. One resident reported being provided with a fan that was insufficient, while another stated no fan was provided. Environmental temperature logs revealed that temperatures in resident halls and dining areas were consistently above 80°F on several days, with some readings as high as 85.5°F. However, there was a lack of consistent temperature monitoring in individual resident rooms, and hourly temperature logs were not maintained during periods of elevated temperatures as required by facility policy. The facility's Hot Weather / Heat Emergencies policy requires the administrator to be aware of extreme weather forecasts and for the Maintenance Director to monitor and ensure air conditioning is functioning and temperatures remain within the comfortable range. Despite this, the administrator stated she was not following a hot weather bulletin or receiving alerts, and the Maintenance Director indicated this was the first time temperatures were reported above 80°F. The documentation shows that temperature monitoring was not consistently performed in resident rooms, and the required increased frequency of monitoring during high temperatures was not followed. These actions and inactions resulted in residents experiencing uncomfortably high temperatures in their living spaces.
Failure to Protect Resident from Physical Abuse by Peer
Penalty
Summary
A resident with a history of schizoaffective disorder, depressive type, and other medical and behavioral diagnoses was involved in multiple incidents of physical aggression toward peers within the facility. The resident was noted to have moderate cognitive impairment and had previously exhibited aggressive behaviors, including striking other residents and being non-redirectable, which resulted in interventions such as counseling, administration of as-needed medication, and transfers to the hospital for psychiatric evaluation. Despite these interventions, the resident continued to display aggressive behavior toward others in the facility. On the date of the incident, the resident physically struck another resident in the mouth after perceiving that the peer had cut in front of him at the water cooler. The assaulted resident sustained a swollen and abraded lip, which required first aid and was reported to the physician. Witness accounts and progress notes confirmed that the aggressor had a pattern of similar incidents, including previous altercations with both staff and other residents, and that the behavior was escalating despite prior interventions. The facility's policy affirms the right of residents to be free from abuse, including physical abuse inflicted by anyone. However, the facility failed to protect the assaulted resident from physical abuse by another resident, as evidenced by the repeated aggressive incidents and the lack of effective measures to prevent further harm. The incident was reported to the appropriate authorities, and the aggressor was ultimately transferred out of the facility, but the deficiency centers on the failure to prevent the physical abuse from occurring.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to properly label, date, seal, and store food items in the kitchen, as well as maintain proper sanitation while checking food temperatures. During a kitchen tour, several deficiencies were observed, including an opened bag of shredded lettuce and a bag of unlabeled and undated diced meat, both with yellow liquid at the bottom. Additionally, a partially sliced yellow onion, half-empty and full gallons of milk past their best-by dates, and various deli meats were found unlabeled, undated, and sitting in liquid. A pork roast was defrosting without a defrost date, and the dry storage room was cluttered with boxes, preventing proper access and ventilation. Further inspection revealed a can of diced green sweet bell peppers with a large dent, a tub of grape jelly with an unsealed lid and sticky residue, and a flour bin with a Styrofoam cup used for scooping. The kitchen staff, specifically the cook, failed to sanitize the thermometer between checking the temperatures of different food items, using the same paper towel instead. These actions and inactions were contrary to the facility's policies on food storage and sanitation, which require labeling, dating, sealing, and proper storage of food items to prevent contamination and ensure food safety. The Dietary Manager acknowledged the deficiencies, stating that all foods should be labeled and dated for safety, sealed to prevent contamination, and stored according to the first in, first out rule. The manager also noted that dented cans should be removed from circulation, and expired foods discarded to prevent foodborne illness. The facility's policies emphasize the importance of proper food storage, rotation, and sanitation to maintain food safety and quality, which were not adhered to in this instance.
Failure to Implement Legionella Prevention and Infection Control Measures
Penalty
Summary
The facility failed to implement and document measures to prevent the waterborne pathogen Legionella and maintain an up-to-date infection control policy, affecting all 101 residents. The Maintenance Director, V4, was unaware of Legionella and stated that corporate was responsible for testing. V4 admitted to not documenting water temperatures since March 2024 due to issues with the water heaters. The Administrator, V1, confirmed that the facility uses well water and relies on the city for Legionella testing, but acknowledged that water temperatures should be tested daily. V1 also admitted that there was no infection control policy in place and was unsure when the infection control program was last reviewed. The Infection Preventionist, V17, confirmed that the facility's infection control policy was undated and included outdated documents. The Water Management Program for Legionella lacked specific frequency and temperature guidelines for control measures. The last documented water temperature check was in March 2024, and the village water report provided did not list Legionella testing. V4 mentioned performing random monthly water flushing without logging it, and the city’s Legionella test results were sent to corporate, not the facility.
Deficient Call Light System in LTC Facility
Penalty
Summary
The facility failed to maintain a fully functioning call light system, affecting all residents. Observations and interviews revealed that the call light system was inconsistent, sometimes not sounding or buzzing continuously as required. A resident expressed distress over the lack of timely assistance, and it was observed that the call light was on but not alarming. Staff members, including nurses and the Maintenance Director, acknowledged the malfunctioning system, with some stating that the system had not worked properly for at least a month. The Maintenance Director admitted to not keeping a log of system checks and had not tested the system recently. The facility's call light policy requires defective call lights to be reported to the nurse supervisor or maintenance director, but there was no evidence of regular checks or maintenance. Staff interviews indicated a lack of awareness about the system's proper functioning, with some staff relying on nurses to notify them of call lights. The Administrator was unaware of the last system check or the frequency of required checks, highlighting a gap in oversight and maintenance of the call light system.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to four residents who were dependent on staff assistance. Observations revealed that two residents had facial hair that had not been shaved despite their requests for assistance. One resident, who was dependent on staff for personal hygiene, had not been shaved for an extended period, and there was no documentation of ADL care in her records for the past six months. Another resident, who required partial to moderate assistance, also had facial hair and reported that it had been over a week since she was last shaved, with no documentation of ADL care or refusal in her records. Two other residents were observed with long, jagged toenails, indicating a lack of nail care. One resident reported that it had been about a month since her toenails were last cut, and there was no documentation of podiatry care or refusal in her records. Another resident had long toenails that touched her shoes and short, jagged fingernails, and she stated that staff did not file her nails after cutting them. The facility's Director of Nursing (DON) acknowledged that the resident's nails were long and jagged due to calluses and admitted to not filing them, which was an oversight. The facility's policy on nail care emphasizes the importance of routine grooming to prevent infection and promote well-being. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation and the residents' reports of unmet ADL needs. The DON and Assistant Director of Nursing (ADON) confirmed that the podiatrist visits every 6-8 weeks, but there was no current list for podiatry services, and staff did not document any refusals of care. The facility's failure to provide necessary ADL care and maintain accurate records contributed to the deficiency.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite residents to their interdisciplinary care plan meetings, as evidenced by the cases of two residents, R21 and R76. R21, who has a range of diagnoses including schizophrenia and bipolar disorder, was admitted to the facility and is cognitively intact with a BIMS score of 15. Despite her active participation in group programs and resident council, R21 stated she could not recall being invited to a care plan meeting. Similarly, R76, who has diagnoses including paranoid schizophrenia and type 2 diabetes, also has a BIMS score of 15 and reported not being aware of or invited to any care plan meetings. The MDS Coordinator, V11, confirmed that neither R21 nor R76 had been present at their care plan meetings and there was no documentation of them being invited or declining to participate. The facility's policy requires that the interdisciplinary team, in consultation with the resident, develops a person-centered care plan, but this was not adhered to in these cases. The Administrator, V1, acknowledged that residents should be invited to their care plan meetings and that there should be documentation of such invitations.
Failure to Follow Physician's Order for Wrist Braces
Penalty
Summary
The facility failed to follow a physician's order for a resident, identified as R92, who was observed without her prescribed wrist braces. R92, a female resident with diagnoses including schizophrenia, type 2 diabetes, and osteoarthritis, was admitted to the facility and had a physician's order for bilateral volar wrist braces to manage her wrist osteoarthritis. The order specified that the braces should be worn every day, with allowances for removal during bathing, eating, and breaks as needed. However, during an observation, R92 was found without the braces on her wrists, and they were instead seen on her chair. R92 expressed distress, stating that she was unable to put the braces on herself and that the CNAs did not assist her, despite her requests for help. The facility's documentation, including R92's MDS and progress notes, indicated that her cognition was intact and she required substantial to maximal assistance with personal hygiene. There was no documentation of R92 refusing care or exhibiting behaviors that would prevent the application of the braces. Interviews with the Director of Nursing and the Administrator confirmed that staff should assist residents in putting on their braces if requested. The facility's procedure for following physician orders emphasized the need to adhere to such orders, yet this was not followed in R92's case, leading to the deficiency.
Failure to Provide Adaptive Eating Utensils
Penalty
Summary
The facility failed to provide adaptive eating utensils to a resident with upper extremity impairments, which was necessary to maintain the resident's health. The resident, who has multiple diagnoses including dementia, diabetes, and intellectual disabilities, was observed on two occasions being fed by certified nursing assistants without the special spoon indicated on their meal card. The resident's Minimum Data Set (MDS) indicated cognitive impairment and impairments to both upper and lower extremities, necessitating the use of adaptive utensils for self-feeding. Interviews with staff revealed a lack of awareness and availability of the required adaptive utensils for the resident. The dietary manager and the director of nursing both stated they were unaware of the need for a special spoon, and the dietary manager confirmed that no special utensils were available in the kitchen. The director of nursing acknowledged that without the proper utensils, the resident might not receive adequate nutrition, potentially leading to weight loss. The facility did not have a policy for adaptive utensils and relied on the therapy department's recommendations, which were not being followed in this case.
Failure to Contain Respiratory Equipment for Infection Control
Penalty
Summary
The facility failed to properly contain respiratory equipment for two residents, leading to a deficiency in infection control practices. Resident 38's BIPAP mask and oxygen nasal cannula were observed uncovered, despite the resident's need for nightly BIPAP use and oxygen as needed due to chronic obstructive pulmonary disease, asthma, and sleep apnea. Similarly, Resident 42's CPAP mask and oxygen nasal cannula were also found uncovered, although the resident uses CPAP nightly for obstructive sleep apnea and requires oxygen for chronic respiratory failure. The facility's guidelines for CPAP and BIPAP equipment, dated March 2021, did not specify how the equipment should be contained when not in use. Both the Administrator and the Director of Nursing acknowledged that the equipment should be covered for infection control purposes, and staff are expected to ensure this during rounds.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to properly store and label medications for a resident, identified as R48, which was observed during a survey. On June 5, 2024, at 9:00 AM, a medication storage cabinet in the nursing office was found to contain a clear storage bag with three medications belonging to R48. These medications included Terconazole Cream 0.4%, Ketoconazole Shampoo 2%, and Albuterol Sulfate 0.083%. The Terconazole Cream, which was supposed to be used until June 1, 2024, was found without a cap and stored with other medications, contrary to the facility's policy that requires medications with different routes to be stored separately. Additionally, the storage bag was not labeled, which is against the facility's guidelines. The Director of Nursing (V2) confirmed that the vaginal medication should not have been stored with other medications and that medications should be labeled when stored in bags. R48, who is of an unspecified age, was admitted to the facility with multiple diagnoses, including schizophrenia, chronic obstructive pulmonary disease, and candidiasis of the skin and nail. The facility's Medication Storage Policy, dated March 2021, outlines that medications with different routes should be kept separate and labeled, and discontinued medications should be disposed of according to the facility's policy. However, these procedures were not followed in the case of R48's medications.
Failure to Respect Residents' Dietary Choices
Penalty
Summary
The facility failed to respect residents' rights to make choices about their diet, affecting three residents in a sample of 28. These residents, who are cognitively intact and have no caloric or food intake restrictions in their physician orders, reported being denied additional food portions despite feeling hungry. Resident R47, with diagnoses including schizophrenia and prediabetes, stated he was not given extra food when requested. Resident R57, diagnosed with major depressive disorder and type 2 diabetes, expressed that the meals were not filling and she was unable to get second helpings. Resident R101, with major depressive disorder and gastro-esophageal reflux disease, also reported insufficient food and mentioned resorting to vending machines for additional food, which she could not afford. The dietary staff, including a dietary aide and the dietary manager, confirmed that only residents with double portion orders received extra food, and no second helpings were provided to others, even if there was extra food available. The facility administrator stated that residents should be provided with a second helping if they are still hungry, and alternatives should be offered if there isn't enough for seconds. However, the facility did not provide a policy regarding resident meal choices and restrictions, indicating a lack of clear guidelines or communication regarding dietary practices.
Failure to Provide Mental Health Rehabilitation Services
Penalty
Summary
The facility failed to provide necessary mental health rehabilitation services to a resident with a serious mental health condition. The resident, identified as R74, was observed lying in bed and reported not attending group meetings or receiving encouragement from staff to participate. The resident expressed a lack of awareness about the schedule for group sessions and indicated a willingness to attend if invited. Interviews with the Psychiatric Rehabilitative Services Director revealed that R74 had not attended any group sessions since February 2024 and had not been invited to participate in any programming or seen by a psychologist. The director also noted the absence of documentation showing that R74 refused programming and confirmed that the facility lacked a policy for groups and therapy. R74, a resident with diagnoses including schizophrenia, generalized anxiety disorder, and early-onset Alzheimer's Disease, was admitted to the facility with a PASRR II indicating the need for specific rehabilitative services. These services included structured socialization activities, daily living skills programs, and psychotherapy. However, a review of R74's social services progress notes from January to June 2024 showed only two instances of 1:1 anger management sessions, with no other documentation of group or individual therapy. The resident's care plans included interventions to encourage participation in activities and psychosocial programming, but these were not effectively implemented, leading to the deficiency.
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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 Frankfort
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Generations At Applewood | 4 mi | ★★★★★ | 12 | 0 |
| Landmark Of Richton Park Rehab & Nsg Ctr | 4.4 mi | ★★★★★ | 25 | 0 |
| Elevate Care Country Club Hill | 4.6 mi | ★★★★★ | 6 | 0 |
| Smith Crossing | 4.8 mi | ★★★★★ | 1 | 0 |
| Alden Estates Of Orland Park | 6.2 mi | ★★★★★ | 7 | 1 |
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