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 Allure Of Geneseo during CMS and state inspections, most recent first.
A cognitively impaired resident with multiple fall risk factors, including ataxia, osteoporosis, and muscle weakness, was left in a wheelchair near the nurse’s cart close to a shower room while a CNA was showering another resident. The CNA left the shower room door open with the water running while preparing to return to clean up, even though the door is normally kept closed and requires a code. During this time, the resident, known to wander and get up without permission, entered the open shower room unsupervised and was later found on the floor between the toilet and her wheelchair with a head laceration. She was assisted back to her wheelchair, monitored near the nurse’s station, and later reported right leg pain; hospital evaluation showed a closed displaced fracture of the right femoral neck requiring surgery.
Surveyors found that the facility’s Dietary Manager did not hold the Food Handler Certification or Certified Food Protection Manager certification required by the facility’s own job description. Review of the job description confirmed that such certification is a qualification for the role, and facility census records showed that 62 residents were in the facility. During a kitchen tour, the Dietary Manager stated that since being hired several months earlier, he had not obtained the required certification, creating a deficiency related to ensuring sufficient staff with appropriate competencies and skill sets in the food and nutrition service.
The facility failed to follow its antibiotic stewardship and infection surveillance policies by not consistently applying McGeer criteria, not completing required infection assessment forms, and not accurately tracking infections and culture data. Multiple residents received antibiotics for pneumonia, sepsis, skin infections, and UTIs, yet their infections were often missing from the infection logs, and culture results—when obtained—were not reliably recorded or trended. In several UTI cases, antibiotics were started based only on urinalysis or without any culture, and documentation in the infection reports conflicted with progress notes regarding whether cultures were completed and which organisms were identified.
A resident with dementia, insomnia, and a history of falls was prescribed quetiapine (Seroquel) 25 mg at bedtime for “dementia with behavioral disturbance,” despite the facility’s psychotropic policy requiring specific, documented indications and the drug reference stating it should not be used in elderly patients with dementia-related psychosis. The MDS showed the resident was cognitively intact with no documented behaviors, while the care plan listed psychotropic use for dementia with behavioral disturbance and insomnia. Staff described the resident as mainly exit seeking with lack of safety awareness, usually easily redirected, and requiring supervision at night. The DON acknowledged that antipsychotics should not be used in dementia patients and felt the resident was appropriate for dose reduction, but there was no clear, appropriate indication documented for the ongoing antipsychotic use.
A resident with multiple urologic conditions, including BPH, urinary retention, prostate cancer, hematuria, and a history of UTIs, had an indwelling urinary catheter and was on Enhanced Barrier Precautions. Surveyors observed the urinary drainage bag hanging from the bed frame, uncovered and facing the hallway, despite facility policy requiring catheter bags to be covered with privacy bags. During observed catheter care, a CNA performed hand hygiene and used PPE but did not retract the foreskin while cleansing the uncircumcised penis, contrary to facility expectations later confirmed by the administrator and DON. These actions resulted in a failure to provide appropriate catheter care and to maintain the resident’s privacy and dignity.
Staff failed to follow infection prevention and control practices during wound and catheter care for two residents on Enhanced Barrier Precautions. In one case, nurses performed sacral pressure ulcer treatment using the same pair of gloves from room entry through removal of soiled materials, wound cleansing, medication application, and placement of a clean dressing, without changing gloves or performing hand hygiene between dirty and clean tasks. In another case, CNAs provided catheter and incontinence care with an untied gown, reused contaminated gloves to handle clean washcloths and water, discarded stool-contaminated water and urine into the resident’s sink, placed a urine container on the bedside table, changed gloves multiple times without hand hygiene, and left the room without disinfecting the bedside table or bathroom sink.
A resident with severe cognitive impairment and multiple health conditions experienced new onset pain that was not properly assessed, documented, or communicated to the provider. Nursing staff administered pain medication without a thorough assessment and failed to notify the provider in a timely manner, resulting in a delay in identifying a femur fracture. The facility did not follow its policy for notification of significant changes in condition.
The facility did not follow its policy for labeling and dating opened food items, as observed in the reach-in cooler where a bag of shredded cheese and a salad bag were undated. Additionally, the walk-in cooler had dust and debris on the fan covers and surrounding areas. The Dietary Manager confirmed these issues, which could impact all 63 residents.
A facility failed to maintain a resident's dignity by not ensuring her clothing was clean and free of debris. The resident, who was severely cognitively impaired, was observed with dried food debris on her pants. Her husband expressed concern about the lack of clothing protectors during meals, leading to frequent soiling. The facility administrator confirmed that staff should change soiled clothing after meals.
A resident with chronic heart failure and edema did not receive physician-ordered compression stockings, as staff failed to apply them. Observations showed significant bilateral pitting edema, and the resident confirmed the stockings were not put on by staff. The facility's RN/Administrator verified the existence of the order, highlighting a lapse in care.
The facility failed to provide adequate range of motion exercises and contracture care for three residents. One resident with a contracted hand did not receive therapy or devices, another resident's splint was inconsistently applied, and a third resident did not receive restorative exercises after therapy discharge. The facility's staff acknowledged deficiencies in care planning and execution.
A facility failed to change and properly store a resident's nebulizer mask and tubing every 72 hours and oxygen tubing weekly, as per its policies. The nebulizer mask was found undated and unbagged, and the oxygen tubing was undated. A nurse confirmed these lapses, indicating non-compliance with the facility's respiratory care protocols.
An LPN failed to disinfect a shared glucometer between uses on three residents with diabetes, contrary to the facility's infection control policy. The glucometer was used consecutively on residents requiring regular blood glucose monitoring without being cleaned, as confirmed by the LPN.
The facility failed to provide written notices of transfer to residents and their representatives, as required. Two residents were transferred to a hospital without receiving the necessary documentation. The administrator confirmed the lack of a process to ensure these notifications are given.
The facility failed to provide bed hold policy notices to residents or their representatives during hospital transfers, as required by their policy. This was confirmed through interviews and record reviews, revealing a lack of documentation in residents' medical records and an ineffective process to ensure compliance.
Failure to Keep Shower Room Door Closed Leads to Unsupervised Fall and Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to keep a shower room door closed, allowing a cognitively impaired resident to access the room unsupervised and fall. The resident had diagnoses including ataxia, cognitive communication deficit, macular degeneration, depression, chronic kidney disease, and protein calorie malnutrition, and was assessed as having moderate cognitive impairment, requiring partial to moderate assistance for transfers, and using a manual wheelchair. Her care plan identified her as at risk for falls due to a history of falls, osteoporosis, difficulty walking, muscle weakness, unsteadiness, and other musculoskeletal issues. On the evening of the incident, the resident was placed in her wheelchair near the nurse’s cart close to the shower room after being taken to the bathroom. A CNA was in the process of showering another resident and had left the shower room door open while warming the water and preparing to return to clean up towels and supplies. The shower water was running, and the door, which normally required a code and was usually kept closed, was left open or propped open. During this time, the cognitively impaired resident, known to wander and get up without permission, moved from the area near the nurse’s cart into the open shower room without staff immediately noticing. Staff later found the resident on the floor of the shower/bathroom area, positioned between the toilet and her wheelchair, on her right side, with a laceration to the right temple and the shower water still running. She was initially assessed as alert and oriented to person, with vital signs stable, and treatment was provided for the head laceration. She was assisted from the floor back into her wheelchair by staff and kept near the nurse’s station, where she was monitored and given acetaminophen for pain. By the following morning, she complained of right leg pain, and subsequent evaluation at an acute care hospital revealed a closed displaced fracture of the right femoral neck, for which she was admitted and underwent surgery before returning to the facility.
Dietary Manager Lacks Required Food Safety Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager possessed the required Food Handler Certification or Certified Food Protection Manager certification as specified in the facility’s Dietary Manager job description. The undated job description states that Food Handler Certification or Certified Food Protection Manager certification is required for the position. CMS Form 671, signed by the Administrator, documents that 62 residents reside in the facility. During the initial kitchen tour, the Dietary Manager reported that since being hired in October 2025, he had not yet obtained the required certification, resulting in a deficiency related to employing sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service, including a qualified dietitian. This failure was identified through record review of the job description and facility census information, as well as an interview with the Dietary Manager confirming the lack of required certification since the start of his employment. The report notes that this deficiency has the potential to affect all 62 residents residing in the facility.
Failure to Implement Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship and infection surveillance programs as required by its own policies. The Infection Surveillance policy required collection of data to identify infections, including infection site, pathogen, signs and symptoms, resident location, and tracking of all resident infections, as well as use of laboratory reports, antibiotic use, and culture results. The Antibiotic Stewardship Program policy required use of McGeer criteria to define infections, completion of assessment and data collection forms, and measurement of antibiotic use by monthly prevalence, antibiotic starts, and/or days of therapy. Despite these policies, the facility did not consistently complete McGeer forms, did not consistently obtain or document culture results, and did not consistently include infections and culture data on the Monthly Report of Resident Infections. For multiple residents who received antibiotics, there was no documentation that McGeer criteria were applied or that required surveillance forms were completed. One resident received Levaquin for pneumonia, another received antibiotics for sepsis secondary to a UTI with a documented Proteus mirabilis urine culture, and another received Ciprofloxacin for a UTI with a urine culture showing >100,000 cfu/mL Escherichia coli; none of these cases had McGeer forms completed, and several were not entered on the Monthly Report of Resident Infections. Additional residents received antibiotics for a thigh abscess, UTIs treated with Ciprofloxacin, Rocephin, Keflex, Ampicillin, Bactrim DS, and Macrobid, yet their records similarly lacked McGeer forms, and their infections or culture results were either omitted or incompletely documented on the Monthly Report of Resident Infections. In some cases, urine cultures were obtained but the organism and results were not incorporated into the infection logs, and in other cases antibiotics were started without any urine culture being completed prior to treatment. One resident’s progress notes documented that urology advised starting Ampicillin for a positive urinalysis and later confirmed that the current antibiotic was sensitive to the culture, but the Monthly Report of Resident Infections stated no urine culture was completed and did not list an organism. Two other residents received antibiotics for UTIs without any urine culture obtained before treatment, and their infections were not captured on the Monthly Report. During interview, the Chief Nursing Officer acknowledged that infection surveillance was not thoroughly conducted, did not meet the required criteria for antibiotic use, and that culture results were not obtained or reviewed to track and trend infections.
Inappropriate Use of Antipsychotic Medication Without Clear Indication
Penalty
Summary
The deficiency involves the facility’s failure to provide an appropriate indication for the use of an antipsychotic medication for one resident. Facility policy on psychotropic medications states that such drugs are to be used only when nonpharmacological interventions are clinically contraindicated, to treat specific, diagnosed, and documented conditions, and not as chemical restraints. The drug reference used by the facility lists quetiapine (Seroquel) as an antipsychotic indicated for schizophrenia, with certain off-label uses, and specifies it is not to be given to elderly patients with dementia-related psychosis. The resident in question was admitted with diagnoses including unspecified dementia with other behavioral disturbance, cognitive communication deficit, insomnia, and a history of falls. The MDS assessment documented that the resident was cognitively intact and had no behaviors, while the care plan documented that the resident was on psychotropic medications for dementia with other behavioral disturbance and insomnia. Physician orders dated at admission documented Seroquel 25 mg at bedtime for dementia with behavioral disturbance. During interviews, an RN described the resident’s behaviors mainly as exit seeking and lack of safety awareness, noting that the resident was usually easily redirected and required supervision, especially at night. The DON stated that the resident had been “good” since admission, with dementia and lack of safety awareness as the primary issues, and indicated a belief that the resident was appropriate for dose reduction to discontinue Seroquel. The DON agreed that antipsychotic medications should not be used in dementia patients but did not clearly state that the indication for Seroquel in this case was inappropriate. Overall, the documentation and staff interviews did not establish an appropriate, specific, and documented indication for the antipsychotic medication consistent with facility policy and the drug reference.
Failure to Provide Proper Catheter Care and Maintain Privacy for a Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to follow its catheter care policy and to maintain privacy and dignity for a resident with an indwelling urinary catheter. The facility’s undated catheter care policy states that residents with indwelling catheters are to receive appropriate catheter care, with dignity and privacy maintained, and specifies that privacy bags will be available and catheter drainage bags will be covered at all times while in use. During observation, the resident’s urinary collection bag was hanging on the bed frame facing the hallway, visibly showing pink-tinged urine, and was not covered by a dignity/privacy bag as required by the policy. The resident involved was admitted with diagnoses including hematuria, chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, urinary retention, presence of urogenital implants, prostate cancer, and a history of UTIs, and had an indwelling urinary catheter ordered for urinary retention. The care plan documented that the resident was on Enhanced Barrier Precautions due to the indwelling catheter. During observed catheter care, the CNA performed hand hygiene, donned gloves and a gown, and cleansed the resident’s penis; however, the resident was uncircumcised and the CNA did not retract the foreskin during cleansing, contrary to the facility’s policy and accepted practice as later confirmed by the administrator and DON. The CNA also acknowledged that the catheter bag should have been covered, confirming the failure to provide appropriate catheter care and to maintain privacy and dignity for this resident.
Failure to Follow Hand Hygiene and PPE Protocols During Wound and Catheter Care
Penalty
Summary
The deficiency involves failures in infection prevention and control practices, specifically improper hand hygiene, glove use, and PPE use during care of residents on Enhanced Barrier Precautions. Facility policies require changing gloves and performing hand hygiene between clean and dirty tasks, when moving from one body part to another, and during wound care after removing soiled dressings and after cleansing the wound. Policies also require gowns to be fastened in the back and wound care to be performed in a manner that decreases potential for infection and cross-contamination. For one resident with severe cognitive impairment, morbid obesity, type 2 diabetes with hyperglycemia, and an unstageable sacral pressure ulcer, nurses performed sacral wound treatment while on Enhanced Barrier Precautions. The RN entered the room wearing gown, gloves, and mask, used her gloved hands to move the bed, and then proceeded directly to wound cleansing without changing gloves. Another RN, also wearing her initial pair of gloves, handled clean gauze, applied saline, and prepared a cotton swab with Santyl, handing these items to the first RN, who continued to use the same gloves throughout the procedure. The clean abdominal dressing was also handled and applied while both nurses continued to wear their original gloves placed upon room entry, without any glove change or hand hygiene between dirty and clean steps of the wound care. For another resident on Enhanced Barrier Precautions due to an indwelling urinary catheter, two CNAs performed catheter and incontinence care without adhering to PPE and hand hygiene standards. One CNA’s gown was not tied while providing care. After cleaning stool from the catheter with washcloths, the CNA used the same contaminated gloves to wet new washcloths in a pan of water, then emptied the stool-contaminated water into the resident’s bathroom sink, removed gloves, and donned new gloves without hand hygiene. The CNA then cleansed the resident’s bottom, removed a soiled brief, and again changed gloves without hand hygiene. The second CNA emptied urine from the catheter bag into a plastic container, placed the container on the bedside table, and then emptied it into the bathroom sink. Both CNAs removed PPE and exited the room without performing hand hygiene, and the bedside table and bathroom sink were not disinfected after being used for contaminated materials.
Failure to Assess, Document, and Notify Provider of New Onset Pain
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident with severe cognitive impairment and multiple comorbidities, including generalized osteoarthritis, dementia, and a history of right lower femur fracture. The resident, who was dependent on staff for most activities of daily living, experienced new onset pain that was not properly assessed, documented, or communicated to the provider in a timely manner. On the evening when the resident first exhibited significant pain, the nurse administered acetaminophen but did not perform or document a thorough pain assessment, nor did she notify the provider of the new onset pain. The following day, another nurse was alerted to the resident's pain, conducted an assessment, and identified pain in the right leg with movement, which was not typical for the resident. The nurse changed the resident's transfer method to accommodate the pain and attempted to notify the provider, but did not ensure that the provider received the notification before the end of her shift. The provider was not made aware of the situation until the next day, when an X-ray was ordered, ultimately revealing a right lower femur fracture. Throughout this period, there was a lack of documentation regarding the initial pain episode and insufficient communication with the provider about the resident's change in condition. The facility's policy required notification of significant changes in a resident's condition, but this was not followed. The delay in assessment, documentation, and provider notification contributed to a delay in identifying the cause of the resident's pain and in initiating appropriate interventions.
Failure to Date Opened Food Items and Maintain Kitchen Cleanliness
Penalty
Summary
The facility failed to adhere to its Labeling and Dating policy, which requires that leftovers and opened food items be clearly labeled with the date they are to be discarded. During an inspection, it was observed that the walk-in cooler had multiple areas with dust and debris on the fan covers and surrounding walls and ceiling. Additionally, in the reach-in cooler, a large bag of shredded mild cheddar cheese and a large opened salad bag with browning lettuce were found without any indication of the date they were opened. The Dietary Manager confirmed these observations and acknowledged that the items should have been labeled with the date they were opened. This deficiency has the potential to affect all 63 residents currently residing in the facility.
Failure to Maintain Resident Dignity by Ensuring Clean Clothing
Penalty
Summary
The facility failed to maintain a resident's dignity by ensuring that clothing attire was clean and free of debris for a resident who was severely cognitively impaired. During an observation, the resident was found sitting in a high back wheelchair with dried, crusted debris on the lap of her pants. The resident's husband expressed concern that the facility was not using clothing protectors during meals, as he frequently found the resident wearing dirty pants with food spills. He noted that the pants worn on a previous day were similarly soiled. The facility administrator acknowledged that staff should change a resident's clothing if it becomes soiled after a meal.
Failure to Apply Physician-Ordered Compression Stockings
Penalty
Summary
The facility failed to apply physician-ordered compression stockings for a resident with a known history of acute/chronic heart failure, atrial fibrillation, chronic kidney disease, and edema. The resident's physician order sheet and care plan both specified the need for compression stockings to be worn on the bilateral lower extremities in the morning and removed at bedtime to manage edema. However, observations on multiple occasions revealed that the resident was not wearing the compression stockings as ordered, and the resident reported that staff did not put them on her. On two separate days, the resident was observed with significant bilateral pitting edema in the lower extremities, and the compression stockings were not in place. The resident's feet and legs were not elevated, which could have contributed to the worsening edema. The facility's registered nurse and administrator confirmed the existence of the physician's orders for the compression stockings, yet they were not applied as required, indicating a failure in following the prescribed care plan for the resident.
Deficiencies in Range of Motion and Contracture Care
Penalty
Summary
The facility failed to provide adequate range of motion exercises and contracture alleviation devices for three residents, leading to deficiencies in their care. One resident, who had a history of cerebrovascular accident and muscle weakness, was observed with a contracted left hand that had not been addressed in her care plan. Despite having an active range of motion program documented, she did not receive any therapy or devices to manage her contracture since her admission. The facility's Chief Nursing Operations director confirmed the lack of a formal therapy evaluation and the absence of specific interventions for the resident's contracted hand. Another resident, with a history of hemiplegia following a cerebral infarction, was supposed to wear a splint on his left hand to prevent worsening contractures. However, the resident reported that the splint was not consistently applied, and staff confirmed the lack of a consistent schedule for its use. The Director of Nursing acknowledged the deficiency in the restorative programming and the need for clear orders regarding the splint's application. A third resident, who had been discharged from skilled physical therapy, expressed a desire to continue exercises to regain mobility. Despite having a documented plan for restorative exercises, there was no evidence that these exercises were provided after the discharge from therapy. The Chief Nursing Officer was unable to provide documentation confirming the resident's participation in the restorative program, highlighting a gap in the facility's follow-through on care plans.
Failure to Maintain and Store Respiratory Equipment Properly
Penalty
Summary
The facility failed to adhere to its own policies regarding the maintenance and storage of respiratory care equipment for a resident. Specifically, the nebulizer mask and tubing for a resident were not changed every 72 hours as required, nor were they stored in a bag between uses. Additionally, the oxygen tubing was not changed every seven days as stipulated by the facility's Oxygen Administration Policy. These lapses were observed during a survey, where the nebulizer mask was found lying undated and unbagged on the resident's dresser, and the nasal cannula oxygen tubing was also undated. A registered nurse confirmed these observations, acknowledging that the nebulizer masks and medication cups should be changed, dated, and bagged after each use, and that oxygen tubing should be changed weekly and dated. The failure to follow these protocols indicates a lack of compliance with the facility's policies designed to ensure safe and appropriate respiratory care for residents, potentially compromising the quality of care provided to the resident involved.
Failure to Disinfect Shared Glucometer Between Uses
Penalty
Summary
Facility staff failed to disinfect a shared glucometer between resident use, which was observed during a survey. The facility's policy on glucometer disinfection requires that the device be cleaned and disinfected after each use with an EPA-registered healthcare disinfectant effective against HIV, Hepatitis C, and Hepatitis B. However, a Licensed Practical Nurse (LPN) was observed using the glucometer on three residents without disinfecting it between uses. This was noted during blood glucose monitoring for residents diagnosed with diabetes mellitus, who required regular finger stick blood glucose tests. The LPN was seen performing blood glucose tests on three residents consecutively without cleaning the glucometer. The LPN first used the glucometer on a resident with diabetes mellitus and hyperglycemia, then proceeded to use the same device on another resident with diabetic polyneuropathy, and finally on a resident with diabetic retinopathy. Each time, the LPN returned the glucometer to the medication cart without disinfecting it, confirming the failure to adhere to the facility's infection control policy. This oversight was confirmed by the LPN during the survey.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide residents and their representatives with a written notice of transfer, which is a requirement for ensuring proper communication and rights awareness. This deficiency was identified through interviews and record reviews, revealing that two residents, R12 and R219, were transferred to a local hospital without receiving the necessary written notification. R12's medical record showed a transfer on 11/5/24, but there was no evidence of notification to R12 or their representative. Similarly, R219 was sent to the emergency room due to a change in condition, yet their electronic medical record lacked documentation of a written notice of transfer. The facility's administrator confirmed the absence of a process to provide these notifications, acknowledging that residents have not been receiving them.
Failure to Provide Bed Hold Policy Notices
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to residents or their representatives when residents were transferred to the hospital. This deficiency was identified through interviews and record reviews, revealing that the facility did not have a proper process in place to ensure that residents or their representatives received the necessary bed hold notices. The facility's policy requires that written information regarding bed hold practices be provided well in advance and at the time of transfer for hospitalization or therapeutic leave. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the medical records of residents who were transferred. Specifically, the medical record of one resident, who was hospitalized, did not contain documentation of the bed hold policy being provided to the resident or their representative. Similarly, another resident's electronic medical record lacked documentation of a bed hold notice when the resident was sent to the emergency room due to a change in condition. The facility administrator confirmed that the residents had not been receiving bed hold notices upon discharge to the hospital, acknowledging the absence of an effective process to ensure compliance with the policy.
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What surveyors actually found near you
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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 Geneseo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Home | 1.1 mi | ★★★★★ | 0 | 0 |
| Hammond-henry District Hsp | 1.1 mi | ★★★★★ | 3 | 2 |
| Avenues At Quad Cities | 14.2 mi | ★★★★★ | 0 | 0 |
| Silvis Center For Nursing Rehab & Care | 14.4 mi | ★★★★★ | 6 | 0 |
| Celebrate Sr Living Of Moline | 15.1 mi | ★★★★★ | 1 | 0 |
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