Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Franklin Grove Living And Rehab during CMS and state inspections, most recent first.
Menu Not Followed for Pureed Diet Residents: A facility failed to serve pureed bread with margarine to four residents on pureed diets during the noon meal, even though it was listed on the planned menu. The Cook said she did not know why the bread was not served, while the Dietary Manager and Dietician stated the menu is carefully planned, reviewed, and must be followed as scheduled to provide adequate nutritional value.
The facility failed to notify a resident's POA of a change in condition for one resident with severe cognitive impairment. The resident developed hematuria and later had urine culture results showing an E. coli UTI, and Macrobid was started for UTI symptoms. Progress notes showed no contact with the POA about the hematuria, lab results, or antibiotic, and the POA stated they were unaware the resident was being treated for a UTI.
A resident with dementia, anxiety disorder, depression, insomnia, restlessness, agitation, and a history of falls had a PRN Ativan order for agitation/anxiety/restlessness that did not include a stop date. The DON stated PRN Ativan should have a 14-day stop date, and the facility’s psychotropic medication policy required licensed nurses to enter all PRN orders with a 14-day stop date.
Failure to Monitor Right Heel Wound: A resident with paraplegia, weakness, and a stage 4 sacral PU had a right heel callus/wound that was ordered for daily monitoring and treatment. Staff documented heel treatment, but an LPN and WCN changed other dressings and replaced the heel boot without removing or observing the heel dressing. The WCN later stated the ordered triad paste had not been entered in the MD orders and that staff should have been checking the wound daily by removing the dressing.
A resident with multiple pressure injuries and a stage 4 sacral ulcer had wound care performed with the same gauze used across several open wounds, with yellow drainage present on the gauze. Two high-risk residents with heel boot orders were also observed without heel boots in place, including one in a wheelchair and one in bed, despite care plans and orders for heel protection.
Catheter Tubing Left on Floor: A resident with a suprapubic urinary catheter was observed in a wheelchair with the catheter tubing dragging and resting on the floor while self-propelling and sitting in common areas, and at one point the resident was stepping on the tubing. A CNA stated the drainage bag and tubing should be kept off the floor for infection control, and the facility policy said catheter tubing should be kept off the floor to help prevent CAUTIs.
Failure to Provide Ordered Plate Guard: A resident with limited ROM in both UEs and limited finger movement was served a meal without the ordered plate guard. During observation, the resident had to use one hand to push food onto a spoon and some food fell onto the table. The resident said the facility had previously provided the plate guard, which helped keep food from sliding off the plate, and the DM stated plate guards are used for residents who have trouble scooping food and are listed on the meal ticket.
Failure to use required PPE during Enhanced Barrier Precautions: Staff provided care to two residents on EBP without wearing gowns. One CNA emptied a urinary drainage bag for a resident with a suprapubic catheter while wearing only gloves, and two CNAs transferred and provided incontinence care to another resident with a facial wound without gowns. The facility policy stated gowns and gloves should be worn for high-contact care involving indwelling devices and other EBP situations.
Surveyors found that the facility failed to implement and maintain fall-prevention interventions and adequate supervision for four residents with documented fall risks. A newly admitted resident with a history of falls and multiple medical conditions was allowed to sit on the edge of the bed to eat without a mechanical lift or other safeguards and was later found face down on the floor with bleeding facial and knee injuries requiring hospital evaluation. Three other residents with dementia and other comorbidities, all care-planned for fall risk, were observed with their call lights on the floor and out of reach; one of these residents also lacked floor mats at the bedside despite prior falls and a care plan and ADON statement indicating that floor mats and an in-reach call light were part of his fall-prevention interventions. These conditions occurred despite a facility policy requiring implementation of fall-prevention measures for high-risk residents and ongoing staff observation for safety.
A resident with severe hand contractures and a prior thumb amputation did not receive a physician-ordered referral to a hand specialist due to the facility's failure to arrange and document necessary transportation and referral processes. Staff interviews revealed confusion over responsibilities, lack of documentation, and no follow-through on either specialist referral or transportation arrangements, resulting in unmet medically-related social service needs.
During a norovirus outbreak, staff at the facility failed to adhere to infection control protocols. A CNA did not wear the required PPE or wash hands after assisting a resident on contact isolation. Additionally, a Hospice Social Worker entered a room with two isolated residents without PPE and used ineffective hand sanitizer instead of washing hands. The facility was in outbreak status, and proper procedures were not followed, as confirmed by the DON and Infection Control Preventionist.
The facility failed to maintain a safe and comfortable environment, with issues such as a loose toilet seat, scraped paint, unsecured chair railings, and damaged bathroom doors reported by residents. The Maintenance Director was unaware of these problems, despite conducting monthly rounds, indicating a lapse in the facility's preventative maintenance plan. Additionally, baseboard heating units had unsecured face plates, further compromising resident safety.
Two residents in an LTC facility experienced deficiencies in pressure ulcer management. One resident developed a stage 3 pressure ulcer due to delayed intervention and lack of an air mattress, while another had an air mattress set incorrectly, affecting wound healing. The facility failed to implement timely and appropriate care as per their policies.
Two residents in a facility experienced deficiencies in care. One resident with severe cognitive impairment was not provided timely incontinence care, resulting in saturated clothing and a strong urine smell. Another resident with an indwelling catheter had the urine collection bag improperly positioned above bladder level, despite staff presence. The facility's policies on incontinence and catheter care were not followed, and there was a lack of documentation on education or non-compliance related to catheter care.
A resident with a history of dysphagia and cerebral infarction alleged sexual abuse during a trauma assessment. The facility failed to notify the resident's physician, police, or state surveying agency, as required by their abuse prevention policy. The Administrator did not conduct a thorough investigation or follow the necessary procedures, resulting in a deficiency.
Menu Not Followed for Pureed Diet Residents
Penalty
Summary
The facility failed to ensure the menu was followed for the noon meal for residents on pureed diets, affecting 4 of 8 residents reviewed for dietary services: R10, R59, R62, and R69. The Week at a Glance Menu for 4/13/26 showed rotisserie chicken, crispy fried potato with bacon, mixed vegetables, bread with margarine, and cranberry short cake, but during the noon meal the four residents were served the meal without the pureed bread with margarine. At 1:00 PM, the Cook said she did not know why the bread was not served to pureed residents even though it was part of the noon meal. At 1:15 PM, the Dietary Manager said the menu is carefully planned to ensure residents get the right balance of diet and must be served as scheduled at each meal. The Dietician later stated that she reviews and approves the facility menu to ensure residents receive adequate nutritional value, including the right amount of protein, carbohydrates, and fats, and that the menu must be followed as planned. The facility policy on menu planning states that nutritional needs of individuals will be provided in accordance with recommended dietary allowances through nourishing well balanced diets unless contraindicated by medical needs.
Failure to Notify POA of Change in Condition and New Antibiotic
Penalty
Summary
The facility failed to notify a resident's POA of a change in condition for 1 of 4 residents reviewed for change of condition. The resident had severe cognitive impairment and developed hematuria on 4/5/26. Urine culture results on 4/10/26 showed Escherichia coli UTI, and a physician order was placed for Macrobid 100 mg by mouth every morning and bedtime for UTI symptoms for 7 days. The progress notes showed no contact was made with the resident's POA regarding the hematuria, the urinalysis results, or the start of the antibiotic. On 4/14/26, the POA stated they did not know the resident was being treated for a UTI or receiving an antibiotic, and facility leadership stated that POAs should be contacted for changes in condition and/or new medications.
Missing Stop Date for PRN Ativan Order
Penalty
Summary
The facility failed to ensure that an as needed Ativan order for one resident had a stop date. The resident was admitted with diagnoses including palliative care, insomnia, restlessness and agitation, history of falling, dementia, major depressive disorder, and anxiety disorder. The resident’s order summary showed an Ativan oral tablet 0.5 mg, to give one tablet by mouth every three hours as needed for agitation, anxiety, or restlessness, started on February 10, 2026, and the order did not include a stop date. The DON stated that PRN Ativan should have a 14-day stop date and that if the medication was still needed, the prescription would need to be written again. The facility’s psychotropic medication policy stated that licensed nurses shall enter all PRN orders with a 14-day stop date.
Failure to Monitor Right Heel Wound
Penalty
Summary
The facility failed to monitor a non-pressure wound on a resident’s right heel. The resident was admitted with diagnoses including history of pulmonary embolism, unsteadiness on feet, contact dermatitis, muscle weakness, a stage 4 sacral pressure ulcer, major depressive disorder, and paraplegia. An order had been entered to monitor a callus on the right heel every day and evening shift, and the treatment record showed staff signed off on treatment to the right heel twice daily from April 1 through April 14, 2026. On April 13, 2026, an LPN and the wound care nurse entered the resident’s room to change wound dressings. The wound care nurse removed the heel boot from the resident’s right foot, and a bordered gauze dressing dated April 8, 2026 was in place on the right heel. The staff changed the dressings to the resident’s buttocks wounds and then replaced the heel boot without removing or observing the right heel dressing. The wound weekly observation tool showed the right heel callus had de-roofed, revealing pink non-granulating tissue with serous drainage, measuring 0.5 cm by 0.5 cm by 0.1 cm, and the current treatment plan was triad paste with an island dressing daily and as needed. The wound care nurse later stated the right heel treatment should be triad paste and bordered gauze, said the wound was not draining as much as before, could not remember whether it was a daily treatment, and acknowledged that the triad paste order had not been entered in the physician orders so it had not been done since April 8, 2026. She also stated staff should be monitoring the wound daily by removing the dressing to ensure it was not getting worse.
Improper wound cleansing and missing heel protection
Penalty
Summary
The facility failed to clean a pressure injury in a manner to prevent cross contamination for a resident with multiple wounds. R4 was admitted with diagnoses including paraplegia, muscle weakness, unsteadiness on feet, contact dermatitis, major depressive disorder, and a stage 4 sacral pressure ulcer. His orders included wound cleanser and specific dressings for wounds on the left gluteal area, right gluteal area, right inferior buttock, and sacrum, and his pressure risk score identified him as high risk for developing pressure injuries. During wound care, an LPN removed the soiled dressings from R4’s buttocks area, noted four open wounds, applied wound cleanser to 4 x 4 gauze, and used the same gauze to wipe each wound from wound to wound while yellow drainage was present on the gauze. The WCN stated that a new gauze should be used to clean each wound so infection is not spread from one wound to another. The facility also failed to have pressure injury prevention interventions in place for two residents who were identified as high risk. R30 had diagnoses including muscle weakness, history of falling, dementia, Alzheimer’s disease, and cognitive communication deficit, and his care plan called for heel boots to both feet at all times. He was observed in a wheelchair with socks on and no heel boots, and later with his left foot on the metal part of the wheelchair footrest without heel boots. R69 had diagnoses including palliative care, dementia, heart failure, and history of falling, and her orders called for heel protectors at all times as tolerated. She was observed in bed with a heel boot on her nightstand but no heel boots on and her heels not elevated, and later was observed in a chair with no heel boots on. The WCN stated that pressure injury prevention interventions include turning, pressure reduction mattresses, wheelchair cushions, heel boots, and geri sleeves, and that residents with heel boot orders should have the heel boots in place.
Catheter Tubing Left on Floor
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter tubing was kept off the floor for 1 of 4 residents reviewed for indwelling urinary catheters. R37's care plan, initiated on 4/9/24, showed that R37 had a suprapubic urinary catheter. During observations on 04/13/2026, R37 was in a wheelchair and the catheter tubing was dragging on the floor while the resident self-propelled, including when entering the dining room and while in a common area. On 04/14/2026, R37 was again observed in the dining room with the catheter tubing resting on the floor, and later the resident was stepping on the tubing with the left foot. On 04/14/2026, a CNA stated that an indwelling urinary catheter drainage bag and tubing should be kept off the floor for infection control issues. The facility's Catheter Care, Urinary policy stated the purpose of the procedure is to prevent catheter-associated urinary tract infections and that catheter tubing should be kept off the floor.
Failure to Provide Ordered Plate Guard
Penalty
Summary
The facility failed to provide a resident with a plate guard despite an order allowing its use and documentation indicating the resident needed assistive dining equipment. A facility assessment showed the resident had limited range of motion in both upper extremities, and the resident’s order summary listed that it was okay to use a plate guard. During a meal observation, the resident was served without a plate guard and used one hand to hold a spoon while using the other hand to push mixed vegetables onto the spoon, with some food falling onto the table. The resident stated the facility had previously provided a plate guard but had stopped, said the plate guard helped keep food from sliding off the plate, and reported limited finger movement. The Dietary Manager stated plate guards are used for residents who have issues scooping food and that the kitchen knows to provide one when it is listed on the meal ticket; the resident’s meal ticket listed instructions to provide a plate guard, and the dietary profile noted the resident preferred to eat in the room because he was a messy eater.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff wore the required PPE when providing care to residents on Enhanced Barrier Precautions. For R37, the care plan dated 4/9/24 showed the resident was on Enhanced Barrier Precautions for a suprapubic urinary catheter, and a sign was posted outside the room. On 4/13/26, a CNA emptied R37’s urinary drainage bag while wearing gloves but no gown. When interviewed, the CNA said she only wore gloves and believed gloves were the only PPE needed for emptying a urinary drainage bag. Another CNA later stated that a gown and gloves are to be worn when emptying a urinary drainage bag. The facility’s Infection Control policy stated that residents with indwelling medical devices, including urinary catheters, are generally indicated for Enhanced Barrier Precautions and that gowns and gloves should be worn for high-contact resident care activities, including device care or use. For R50, the order summary showed the resident had diagnoses including right femur fracture, repeated falls, and need for assistance with personal care, and an order was in place for daily wound care to a small open area on the left side of the face. Enhanced Barrier Precautions were entered on 4/6/26, and a sign was posted on the room door. On 4/13/26, two CNAs transferred R50 into bed using a mechanical lift and provided incontinence care while a dressing was partially on the left side of the face, but neither CNA wore a gown. The DON stated that residents with urinary catheters, PEG tubes, IV lines, and wounds should be on Enhanced Barrier Precautions and that staff should wear a gown if they are touching the resident during care.
Failure to Implement Fall-Prevention Measures and Maintain Accessible Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions and adequate supervision for four residents identified as being at risk for falls. One resident was admitted with multiple diagnoses including encephalopathy, diabetes, cardiomegaly, nicotine dependence, and a history of falling, and was assessed as a moderate fall risk on the day of admission. He had no care plan in place because he discharged the same day, yet nursing notes show he was transferred to bed with existing bruises and a scabbed right knee, and later found face down on the floor with a pool of blood, lacerations to his eyebrow and nose, and a reopened knee abrasion, requiring transfer to the emergency room. Staff interviews revealed that this new admission was allowed to sit on the side of the bed to eat, unclothed except for socks, without use of a mechanical lift or other fall-prevention measures, despite staff acknowledging that new residents are typically transferred with a mechanical lift until therapy evaluates them and that he had a history of falls. Additional deficiencies were identified for three other residents with documented fall risks and care plans requiring that call lights be within reach. One resident with pneumonitis, sepsis, acute respiratory failure, anxiety disorder, restlessness, agitation, and bipolar disorder was assessed as high risk for falls and had a care plan directing that his call light be within reach and used for assistance. During observation, his call light was on the floor at the foot of his bed and not accessible, and floor mats that were part of his fall-prevention interventions were not in place at his bedside but instead folded and stored near his roommate’s bed. Facility accident/incident logs showed this resident had prior falls on two separate dates. Two other residents, both with dementia and additional diagnoses including Alzheimer’s disease, depression, anxiety disorder, osteoporosis, difficulty in walking, and a need for assistance with personal care, were also observed with their call lights on the floor and out of reach, despite care plans and fall scales indicating moderate to high fall risk and specifying that call lights should be within reach and used for assistance. The facility’s Fall Prevention and Management Policy required that interventions be implemented for residents assessed as high risk at admission for up to 72 hours and that all staff observe residents for safety. Observations and interviews showed that these interventions, including accessible call lights and appropriate environmental safety measures, were not consistently implemented or maintained for these residents.
Failure to Facilitate Physician-Ordered Specialist Referral and Transportation
Penalty
Summary
The facility failed to ensure that a physician-ordered referral to a specialist was initiated and facilitated for a resident who required evaluation and possible surgical intervention for severe bilateral hand contractures and a prior thumb amputation. The resident had a documented history of significant hand impairment, including a right thumb amputation and contractures that were not passively correctable. Despite a physician's order for a referral to an academic hand specialist for consideration of a great toe transfer/pollicization, the referral process was not completed, and the resident did not receive the necessary specialist evaluation. The resident reported being unable to attend the scheduled orthopedic appointment at a distant medical center due to lack of transportation, as the facility van only provided local transport. The administrator informed the resident that he would need to arrange his own transportation because the destination was outside the facility's usual service area. Although the resident requested a transfer to another facility closer to the medical center, the social services director sent referrals to several facilities, all of which declined, and no further action or documentation regarding transportation or the specialist referral was found. Interviews with facility staff revealed a lack of clarity and communication regarding responsibility for arranging the referral and transportation. The social services director was not involved in the referral to the medical center and did not maintain records of the attempted facility transfers. The director of nursing was unaware of the status of the referral and had not communicated with the resident's insurance. Documentation of efforts to facilitate the referral and address transportation or payment issues was absent from the care plan and progress notes, indicating a failure to provide necessary medically-related social services to help the resident achieve the highest possible quality of life.
Inadequate Infection Control During Norovirus Outbreak
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during a norovirus outbreak. Observations revealed that a Certified Nursing Assistant (CNA) did not wear the required gown and gloves while assisting a resident on contact isolation for norovirus. Additionally, the CNA did not wash her hands upon exiting the resident's room, despite acknowledging the necessity of handwashing for norovirus cases. The isolation cart containing necessary personal protective equipment (PPE) was located two rooms away, which may have contributed to the oversight. Further observations showed that a Hospice Social Worker entered the room of two residents on contact isolation without wearing a gown or gloves and did not wash her hands upon exiting, instead using hand sanitizer, which is ineffective against norovirus. The Director of Nursing and Infection Control Preventionist confirmed that residents with norovirus symptoms should be on contact isolation, requiring staff to wear gowns and gloves and perform handwashing. The facility was considered to be in outbreak status by the Health Department Infection Disease Coordinator based on the facility's line list.
Facility Maintenance Deficiencies Impact Resident Safety and Comfort
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for residents, as evidenced by several maintenance issues observed during a survey. In one instance, a resident reported a loose toilet seat that had been a concern for some time, causing feelings of unsafety when using the bathroom. The Housekeeping & Laundry Director acknowledged the issue and indicated that a work requisition form should have been completed and submitted to maintenance, highlighting a lapse in the facility's maintenance request process. Additionally, multiple rooms were found with significant damage, including scraped paint, unsecured chair railings with exposed nails, and bathroom doors with deep scrapes and holes. Residents reported that these issues had been present since their admission, some for over a year, indicating a lack of timely maintenance and repair. The Maintenance Director was unaware of these issues, despite claiming to conduct monthly rounds to identify needed repairs, suggesting a failure in the facility's preventative maintenance plan. Furthermore, baseboard heating units in several rooms were observed with face plates that were not securely attached, leaving exposed metal grids. This issue had been present for a long time, according to residents and visitors, yet the Maintenance Director was unaware of the problem. The facility's preventative maintenance policy requires regular maintenance to ensure safety and operability, but the observed deficiencies indicate a failure to adhere to this policy, compromising the residents' living environment.
Deficiency in Pressure Ulcer Management for Two Residents
Penalty
Summary
The facility failed to implement appropriate interventions to prevent and manage pressure ulcers for two residents, leading to a deficiency in care. Resident R39 was admitted with a risk for pressure ulcers, as indicated by the Braden scale, but did not have an air mattress until several days after a stage 3 pressure ulcer was identified. The wound was not assessed by the wound care provider promptly, and the resident's combative behavior was cited as a challenge in providing care. Despite being at risk, the facility did not ensure regular skin checks or timely intervention, resulting in the worsening of R39's condition. Resident R27 also experienced inadequate care related to pressure ulcer management. Although preventative measures were in place, including an air mattress, the mattress was incorrectly set at a weight higher than the resident's actual weight. This improper setting affected the mattress's ability to alleviate pressure effectively, potentially hindering the healing process of R27's pressure ulcers. The staff acknowledged the error and adjusted the setting, but the deficiency in care was noted due to the initial oversight. The facility's policies required regular skin assessments and appropriate interventions for residents at risk of pressure ulcers. However, these policies were not effectively implemented, as evidenced by the delayed response to R39's pressure ulcer and the incorrect air mattress setting for R27. The facility's failure to adhere to its own protocols and ensure timely and appropriate care for residents at risk of pressure ulcers resulted in deficiencies that were identified during the survey.
Deficiencies in Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident with severe cognitive impairment and frequent incontinence. The resident was observed with urine puddled on her wheelchair cushion, saturated pants, and a strong urine smell, indicating a lack of adherence to the care plan that required assistance with toileting every two hours or as needed. The Director of Nursing acknowledged the expectation for regular incontinence care, especially in the memory unit, to prevent skin breakdown and urinary tract infections. Another resident with an indwelling catheter was observed multiple times with the urine collection bag not maintained below the level of the bladder, contrary to the facility's policy. The resident, who has a history of severe urinary tract infections, was seen self-propelling in a powered wheelchair with the catheter tubing laid across his thighs and the collection bag improperly positioned. Despite the presence of staff, no attempts were made to adjust the bag's position or educate the resident on proper catheter care. The Director of Nursing admitted that the resident's non-compliance and aggressive behavior were not initially care planned, although they were later addressed. The facility's policy emphasizes the importance of keeping the drainage bag below the bladder to prevent backflow and infections, yet there was no documentation of education provided to the resident or any record of non-compliance related to catheter care.
Failure to Report and Investigate Abuse Allegation
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the reporting of an abuse allegation involving a resident. The resident, who has a history of dysphagia, adult failure to thrive, and a cerebral infarction, made an allegation of sexual abuse during a trauma assessment. The resident's Power of Attorney and daughter was present when the allegation was made, and the facility staff, including the Administrator, were informed. However, the facility did not notify the resident's physician, the police, or the state surveying agency about the allegation, as required by their abuse prevention policy. The Administrator acknowledged receiving the allegation but did not conduct a thorough investigation or follow the facility's abuse prevention program, which mandates contacting the physician, police, and state surveying agency. The physician was only informed of the allegation two weeks later when another allegation was made. The facility's policy requires that any allegation of abuse be reported to the state surveying agency within specific timeframes, depending on the severity of the injury, and that the physician and law enforcement be contacted in cases of sexual abuse. These steps were not taken, leading to a deficiency in the facility's handling of the abuse allegation.
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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 Franklin Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dixon Rehab & Hcc | 8.6 mi | ★★★★★ | 0 | 0 |
| Manor Court Of Rochelle | 8.9 mi | ★★★★★ | 3 | 0 |
| Heritage Square | 9.4 mi | ★★★★★ | 9 | 0 |
| Oregon Living And Rehabilitation Center | 11.2 mi | ★★★★★ | 28 | 0 |
| Rochelle Rehab & Health Care Center | 13.5 mi | — | 0 | 0 |
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