Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 4 | 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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