Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Batavia Rehabilitation And Health Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia-related behavioral issues was physically abused by a CNA, who was witnessed pulling the resident's hair and pushing her into a chair. The incident was substantiated based on an RN's eyewitness account, and the resident, due to her cognitive status, could not be interviewed. The facility's abuse policy prohibits such actions and requires reporting and investigation.
The facility did not provide the required 8 hours of RN coverage on multiple days over a six-month period, with only LPNs available on some days due to staffing shortages and last-minute call-offs. The DON, who is an RN, was not present on all required days, resulting in gaps in RN coverage for all residents.
The facility did not have a comprehensive QAPI plan in place. The administrator provided a policy document as the QAPI plan, but it lacked details on identifying and correcting quality deficiencies, tracking performance, setting goals, analyzing root causes, and monitoring corrective actions. This deficiency affected all residents in the facility.
The facility did not follow its Legionella water management plan, failing to document control measures or include interventions when limits were not met, and did not regularly clean or disinfect shower heads as required. Additionally, the DON, acting as Infection Preventionist, stopped using standardized infection surveillance tools and did not document a recent COVID-19 outbreak in the infection log, contrary to facility policy.
The facility did not have an active Antibiotic Stewardship Program or a standardized tool to assess infections among all residents. The DON/Infection Preventionist stopped using McGeer's Criteria and did not track antibiotic use, citing workload issues. The facility's policy referenced antibiotic stewardship, but no current program or monitoring system was in place.
Three residents received psychotropic medications without proper documentation or evaluation, including extended use of as needed antipsychotics and antianxiety drugs without timely practitioner assessments, and continued daily antipsychotic use despite pharmacist recommendations for dose reduction and no documented behaviors.
Two residents did not have comprehensive care plans addressing their specific needs: one resident's care plan lacked details on oxygen therapy despite physician orders and documented use, while another resident with PTSD had no assessment or interventions for trauma-informed care, contrary to facility policy.
A resident with an active order for oxygen therapy was found with undated and improperly stored oxygen tubing and nasal cannula, which were draped over the concentrator and touching the floor. Additionally, there was no 'oxygen in use' sign posted on the door, contrary to facility policy. The DON confirmed these requirements were not met.
A resident with a documented history of PTSD, dementia, anxiety, and depression was not properly assessed for trauma triggers, and her PTSD was not documented in social service assessments or addressed in physician orders. Staff interviews revealed a lack of awareness regarding the resident's trauma history and ongoing symptoms, resulting in a failure to provide trauma-informed care as required by facility policy.
A resident with a history of UTIs received both Bactrim for prophylaxis and Keflex for treatment at the same time, without clinical documentation supporting concurrent use or the extended duration of Keflex. The DON confirmed that the Bactrim should have been held during Keflex therapy and that the prolonged antibiotic administration resulted from an order entry error and lack of timely antibiotic tracking.
Three residents on pureed diets were served food that was not processed to a smooth, pudding-like consistency as required by facility policy. The cook prepared pureed spaghetti with meat sauce and green beans, but both items contained unblended pieces that required chewing, and the green beans had pieces of skin. The Food Service Manager confirmed the food did not meet the required texture and instructed the cook to reprocess the items, but the green beans could not be made suitable for serving.
The facility's kitchen failed to comply with food safety and sanitation protocols, as observed during a survey. The Dietary Manager did not wear hair or beard restraints, and several food items were improperly labeled, stored, or expired. Additionally, expired test strips were used for sanitation checks, leading to inaccurate results. These actions violated the facility's policies on personal hygiene, storage, and equipment sanitation.
The facility failed to document and implement the correct code status for two residents. One resident was marked as DNR but lacked proper documentation, leading to confusion among staff. Another resident's advance directives conflicted with their expressed wishes, showing full code with comfort-focused treatment, which was inconsistent with facility policy.
A CNA failed to maintain a resident's privacy during incontinence care by leaving the window curtains open, exposing the resident to view from outside. The resident, with multiple health conditions, was left exposed from the waist down while the CNA retrieved supplies. The facility's policy requires curtains to be closed and residents to be draped for privacy.
A resident with severe cognitive impairment was inaccurately assessed for fall risk after a fall, as the facility failed to account for antihypertensive medication in the assessment. The absence of a visual alert and incorrect risk classification by the DON contributed to the deficiency.
The facility failed to provide adequate ADL care for two residents. One resident had excessively long nails due to inconsistent staff responsibilities and lack of care planning for refusal. Another resident, dependent on staff for hygiene, was found with a saturated incontinence brief and improper care techniques, leading to potential skin irritation. The facility's policies on nail and incontinence care were not followed.
A resident with type 2 diabetes was served meals high in carbohydrates and sugar, contrary to her dietary needs. The facility's dietary staff failed to differentiate between regular and diabetic diets, resulting in the resident receiving inappropriate meals. The resident's care plan and physician orders specified a low concentrated sweets, carbohydrate-controlled diet, but this was not followed.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A resident with severe cognitive impairment and a history of dementia-related behavioral disturbances was subjected to physical abuse by a Certified Nurse Assistant (CNA). The resident's care plan indicated a need for staff redirection and time to manage her behaviors, and her abuse risk assessment identified her as at risk due to her mental and behavioral changes. On the date of the incident, a Registered Nurse (RN) witnessed the CNA pulling the resident's hair and pushing her back into a chair. The CNA denied the incident, but the RN reported it to the appropriate parties and conducted a skin check, which revealed no injuries or signs of distress in the resident. The facility's investigation, based on the RN's eyewitness account, substantiated the abuse allegation. The resident was unable to be interviewed due to her cognitive impairment, but documentation confirmed her vulnerability and the need for specialized care. The facility's abuse policy prohibits all forms of abuse and outlines procedures for screening, training, prevention, identification, investigation, protection, and reporting. The incident was reported and documented as required, and the abuse was confirmed through the facility's internal processes.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage on 20 days over a six-month period, affecting all 37 residents. Payroll Based Journal (PBJ) records and staffing schedules revealed specific dates in December, January, February, March, April, and May when no RN was present in the facility. The Director of Nursing (DON), who is an RN, typically worked Monday through Friday and provided RN coverage on those days, but was absent on several occasions, resulting in no RN coverage. On days when the DON was not present, only Licensed Practical Nurses (LPNs) were available, as the facility was unable to secure RN coverage due to staffing shortages and last-minute call-offs. The administrator acknowledged that reductions in nurse staffing contributed to these RN shortages.
Failure to Develop and Present Comprehensive QAPI Plan
Penalty
Summary
The facility failed to develop and present a comprehensive QAPI (Quality Assurance Performance Improvement) plan as required. During the survey, the administrator provided a QAPI Policy document dated January 2024, stating it was the facility's QAPI plan. However, upon review, the document did not detail how the QAPI committee would identify and correct quality deficiencies, nor did it reflect specific aspects unique to the facility's population and programs. The policy also lacked information on tracking and measuring performance, establishing goals and thresholds, analyzing root causes of quality concerns, and monitoring or evaluating the effectiveness of corrective actions. This deficiency applied to all 37 residents in the facility at the time of the survey.
Failure to Implement Legionella Water Management and Infection Surveillance
Penalty
Summary
The facility failed to maintain and implement an effective water management plan for Legionella prevention and did not follow its own infection prevention and control program for infection surveillance. The Maintenance Director reported that while hot water heaters are emptied monthly, the kitchen's hot water heater is not emptied due to the presence of a water softener, and shower heads are only replaced when broken rather than being regularly cleaned or disinfected. The facility's water management plan outlined specific control measures such as maintaining water heater temperatures, annual cleaning, quarterly disassembly and cleaning of shower heads, and regular temperature checks and flushing of unused water outlets. However, there was no documentation to show that these control measures were being monitored, and the plan did not include interventions for when control limits were not met. The Administrator acknowledged that although a Legionella environmental assessment was completed, no further action was taken based on its findings. Additionally, the facility's Infection Preventionist, who is also the DON, stated that she had stopped using McGeer's Criteria for infection surveillance and did not utilize a standardized tool for collecting infection data. During a recent COVID-19 outbreak, the infection log did not include residents who tested positive, despite the facility's policy requiring ongoing surveillance and systematic data collection to identify and control infections. The policy emphasized the importance of surveillance in identifying communicable diseases and outbreaks, but the facility failed to follow these procedures, resulting in incomplete infection tracking and reporting.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an Antibiotic Stewardship Program with a standardized tool and criteria to assess residents for infections, affecting all 37 residents. The Director of Nursing, who also serves as the Infection Preventionist, reported discontinuing the use of McGeer's Criteria for infection assessment and not utilizing any standardized tool for data collection regarding resident infections. Additionally, the facility did not have a current Antibiotic Stewardship Program policy in place, and tracking of resident antibiotic use was not maintained due to competing work demands. The facility's existing Infection Prevention and Control Program policy referenced the need for an antibiotic stewardship program and monitoring system, but these elements were not operational at the time of the survey.
Failure to Prevent Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the care of three residents. One resident with multiple neurocognitive and psychiatric diagnoses was prescribed as needed Haloperidol for agitation and restlessness, but there was no documentation that the prescribing practitioner directly examined the resident every 14 days to assess the continued need for the medication, as required. The resident received the medication on multiple occasions, and the as needed order remained active for an extended period without the necessary evaluations or new orders. Another resident with severe cognitive impairment and psychiatric diagnoses received frequent doses of as needed Lorazepam for anxiousness, but the facility lacked documentation from the prescribing practitioner justifying the extended use or specifying the duration for the medication. Additionally, a third resident with dementia and psychiatric conditions was maintained on a daily antipsychotic medication despite a consultant pharmacist's recommendation for gradual dose reduction due to the absence of documented behaviors. The recommendation was not communicated to the prescriber, and the resident continued to receive the medication without documented indication for its ongoing use.
Failure to Develop Comprehensive Care Plans for Oxygen Use and Trauma-Informed Care
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents regarding their oxygen use and trauma-informed care needs. For one resident with chronic obstructive pulmonary disease, diabetes, and a history of pneumonia, the care plan did not address the use of oxygen, monitoring parameters for when to use oxygen, or safety precautions, despite physician orders for oxygen therapy and documented episodes of shortness of breath requiring oxygen. The care plan only referenced asthma and shortness of breath while lying flat, omitting critical details related to oxygen management. Another resident with diagnoses including dementia, anxiety, depression, and PTSD did not have an assessment or care plan interventions addressing PTSD, its triggers, or support strategies. The resident reported a history of significant trauma and ongoing symptoms such as nightmares and anger issues, but these were not reflected in the care plan or social service assessments. The facility's own policies require trauma-informed care planning and regular reassessment, but these were not followed for this resident.
Failure to Properly Label and Store Oxygen Equipment and Post Required Signage
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes, a history of pneumonia, and bipolar disorder, was observed to have an oxygen concentrator in their room with tubing and a nasal cannula that were undated and stored improperly, draped over the concentrator and touching the floor. The resident had an active physician order for oxygen administration as needed for shortness of breath, and had recently experienced an episode of low oxygen saturation requiring oxygen use and hospitalization for pneumonia before returning to the facility. On two separate occasions, surveyors observed that there was no 'oxygen in use' sign on the door to the resident's room, despite the presence of the oxygen concentrator and an active order for oxygen therapy. The Director of Nursing confirmed that facility policy requires an 'oxygen in use' sign to be posted whenever oxygen is present in the room, and that oxygen tubing should be labeled with the date of the last change and replaced weekly. The facility's policy also specifies these requirements, but they were not followed in this instance.
Failure to Assess and Identify PTSD Triggers for Resident
Penalty
Summary
The facility failed to assess and identify trauma triggers for a resident diagnosed with PTSD, as required for trauma-informed care. The resident's electronic medical record documented a history of PTSD, dementia with psychotic disturbances, anxiety, and depression. However, quarterly social service assessments did not mention PTSD, and there were no physician orders to monitor for PTSD-related triggers or behaviors. Interviews revealed that the resident had experienced significant trauma, including childhood abuse, sexual assault, and domestic abuse, and continued to experience symptoms such as nightmares and anger issues. Despite this, staff were either unaware of the resident's trauma history or did not recognize or document her triggers. The facility's policy required identification of trauma survivors and assessment of trauma and triggers during admission and at least annually, but this was not followed for the resident in question. The social worker acknowledged the resident's PTSD diagnosis and history of trauma but stated she was unaware of any triggers, despite evidence of ongoing symptoms. The MDS nurse also confirmed the PTSD diagnosis from hospital records but did not know the specifics of the trauma or triggers. This lack of assessment and documentation resulted in a failure to provide trauma-informed care as outlined in the facility's policy.
Failure to Prevent Unnecessary Concurrent Antibiotic Use
Penalty
Summary
A resident with a history of urinary tract infections (UTIs) was prescribed Bactrim for UTI prophylaxis to be administered on Mondays, Wednesdays, and Fridays, starting April 1, 2025, with no specified end date. Following a hospital admission for weakness and lack of responsiveness, the resident returned to the facility with a new order for Keflex, intended for a 7-day course, but the order was entered into the system without a stop date and was continued for 30 days. During this period, the resident continued to receive Bactrim concurrently with Keflex, despite no clinical documentation supporting the simultaneous use of both antibiotics or the extended duration of Keflex therapy. The facility's records and infection control log confirmed that both antibiotics were administered together, and there was a lack of documentation justifying this practice. The DON acknowledged that the Bactrim order should have been placed on hold while the resident was receiving Keflex and that the extended duration of Keflex was due to an error in order entry. Additionally, the DON reported being behind on tracking antibiotic use during this period, which contributed to the oversight.
Failure to Prepare Pureed Foods to Required Consistency
Penalty
Summary
The facility failed to properly prepare pureed food items to a smooth consistency as required by their own policy. During observation, the cook prepared pureed spaghetti with meat sauce and pureed green beans for three residents on pureed diets. The food was processed according to the recipe, but both the spaghetti and green beans contained small, unblended pieces that required chewing, and the green beans had pieces of skin remaining. The Food Service Manager confirmed that the foods did not meet the required smooth, pudding-like consistency and instructed the cook to reprocess the items. Despite additional attempts, the green beans could not be pureed to the correct consistency and were deemed unsuitable for serving. The facility's policy on pureed foods specifies that items should be processed until very smooth, like pudding, with commercial thickener or stabilizer added as directed. The deficiency was identified for three residents who required pureed diets, as the food provided did not meet the necessary texture requirements. The issue was observed directly by surveyors and confirmed by staff during the meal preparation process.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation protocols, as observed during a kitchen tour. The Dietary Manager, identified as V11, did not wear a hair or beard restraint while in the kitchen, which is against the facility's policy. During the tour, several issues were identified, including an opened package of turkey breast deli meat that was not sealed, labeled, or dated, and expired vanilla wafers in the dry storage. Additionally, the quaternary sanitizer bucket and the low-temperature dishwasher were tested with expired strips, leading to inaccurate results. V11 admitted to not ordering new testing strips since assuming the role of Dietary Manager. The facility's policies on personal hygiene, storage, and equipment sanitation were not followed. The Personal Hygiene and Dress Code policy requires food service employees to wear hair and facial hair coverings, which V11 did not comply with. The Storage policy mandates that opened food products be sealed, labeled, and dated, which was not done for the turkey breast deli meat. The In-place Equipment policy requires the use of appropriate test strips to check sanitizer levels, which were expired in this case. V11 acknowledged the importance of these practices to prevent contamination and potential illness among residents.
Failure to Document and Implement Residents' Code Status
Penalty
Summary
The facility failed to accurately document and implement the physician's orders reflecting the residents' chosen code status for two residents. Resident R7 was identified as a Do Not Resuscitate (DNR) by a red sticker on their chart, but there was no advanced directive, POLST form, or current DNR physician's order in the chart. Despite the POLST form being signed by the resident's health care power of attorney, it was not placed in the physician's folder, and the physician signed it approximately two months later. This discrepancy led to confusion among the nursing staff, with some considering R7 a full code due to the lack of documentation. Resident R21's advance directives form indicated a full code status but also mentioned comfort-focused treatment, which led to conflicting interpretations among the staff. The resident expressed a desire for full resuscitation efforts, but the POLST form showed a full code with comfort-focused treatment, which was not consistent with the resident's wishes. The Director of Nursing and Medical Director clarified that a resident could not be full code with comfort-focused treatment, highlighting a misalignment between the documented preferences and the resident's actual wishes. The facility's policy required that advance directives be prominently displayed in the medical record and that the plan of care aligns with the resident's documented treatment preferences.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to preserve a resident's privacy and dignity during incontinence care. A Certified Nursing Assistant (CNA) provided care to a resident with multiple diagnoses, including transient ischemic attack and heart failure, without closing the bedroom window curtains. The resident's room was on the first floor, and the window was visible to parked cars outside. During the care, the CNA left the resident exposed from the waist down while retrieving supplies, leading the resident to express concern about being on display. The Director of Nursing confirmed that the standard practice is to close curtains to ensure privacy, and the facility's policy on incontinence care requires draping residents for privacy.
Inaccurate Fall Risk Assessment After Resident Fall
Penalty
Summary
The facility failed to conduct an accurate fall risk assessment for a resident after a fall incident. The resident, a female with severe cognitive impairment, was admitted with a documented high risk for falls. However, the facility did not place a visual alert (red star) on the resident's name plaque, which is part of their fall prevention policy. The Director of Nursing incorrectly stated that the resident was not at high risk for falls, which led to the absence of the visual alert. Further review revealed that the fall risk assessment conducted after the resident's fall did not account for the antihypertensive medication the resident was receiving, resulting in an inaccurate low-risk score. This oversight was acknowledged by the MDS Coordinator, who confirmed that an accurate assessment would have identified the resident as high risk, allowing for appropriate interventions. The corrected assessment later confirmed the resident's high fall risk status.
Deficiencies in ADL and Incontinence Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents who required assistance. One resident, identified as R15, had excessively long fingernails and toenails, which were not trimmed despite his requests. The staff, including a CNA and an RN, provided conflicting information about who was responsible for nail care, especially for residents with diabetes. The resident's care plan did not address his refusal of nail care, and the facility's nail care policy was not followed, as it required nails to be trimmed and clean. Another resident, R8, who was completely dependent on staff for personal hygiene, was found with an overly saturated incontinence brief and reddened skin, indicating inadequate incontinence care. The CNA responsible for R8's care used improper techniques during incontinence care, which could contribute to skin irritation. The Director of Nursing acknowledged that the resident should have received care every two hours, but this was not done, leading to prolonged exposure to urine and potential skin breakdown. The facility's incontinence care policy was not adhered to, as it required regular and as-needed care to prevent skin irritation and odor.
Failure to Provide Appropriate Diabetic Diet
Penalty
Summary
The facility failed to provide meals that meet a resident's health care needs as ordered by the physician. This deficiency was identified for a resident with a diagnosis of type 2 diabetes, among other conditions, who reported being served meals high in carbohydrates and sugar, contrary to her dietary needs. The resident's meal card indicated a regular diet, and she received the same food items as other residents, despite her diabetic condition. The meals included items such as potatoes, pastries, and regular pudding, which are not suitable for a diabetic diet. The dietary manager and staff were unaware of the specific dietary requirements for diabetic residents, as evidenced by the lack of differentiation between regular and diabetic diets, except for the omission of regular sugar packets. The facility's policies on diet orders and dietary services communication were not effectively implemented, leading to the resident receiving inappropriate meals. The resident's care plan and physician orders specified a low concentrated sweets, carbohydrate-controlled diet, but this was not reflected in the meals provided, indicating a breakdown in communication and adherence to dietary protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 711 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Batavia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Michaelsen Health Center | 0.3 mi | ★★★★★ | 3 | 0 |
| Greenfields Of Geneva | 1.7 mi | ★★★★★ | 6 | 0 |
| Bria Of Geneva | 2.4 mi | ★★★★★ | 0 | 0 |
| North Aurora Living & Rehab Ctr | 3.4 mi | ★★★★★ | 1 | 0 |
| Alpine Care Of St. Charles Llc | 4.2 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Batavia Rehabilitation And Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.