Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bria Of Geneva during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and documented allergies to peach and lactose was served a meal containing peach, despite allergy information being clearly listed on admission records and meal cards. The error was identified by the resident's family, and dietary staff acknowledged missing the allergy information due to a busy day. Facility policy requires allergy information to be communicated and checked during meal preparation.
A resident on hospice care with COPD was found with an empty portable oxygen tank while it was set to deliver 3 liters of oxygen. The DON and a surveyor confirmed the tank was empty, and the resident's oxygen saturation was 91%. The CNA admitted to not replacing the low tank after breakfast, and the hospice nurse had previously noted issues with the oxygen supply. The resident's care plan required consistent oxygen therapy, which was not adequately provided.
A facility failed to report an alleged abuse incident involving two residents to the appropriate authorities. One resident, with a history of cognitive impairment, reportedly shoved another resident, causing a fall from a wheelchair. Despite the resident's report of pain and an X-ray, the administrator did not report the incident, doubting its credibility due to inconsistent statements and lack of witnesses, contrary to the facility's policy requiring immediate reporting of abuse allegations.
A resident with multiple health conditions fell from a wheelchair during transport in a facility van due to improper use of seatbelts. The Activity Director used only a shoulder belt, leaving the lap belt unattached, which led to the resident's fall and subsequent pain. The facility's restraint instructions were not followed, compromising the resident's safety.
The facility failed to maintain wheelchairs in safe condition for two residents. One resident's wheelchair had a loose brake, allowing movement when locked, while another's wheelchair could move despite locked brakes. The Maintenance Director admitted to a lack of documentation and policy for wheelchair maintenance.
The facility failed to ensure dietary staff wore beard guards and covered food to prevent contamination. Observations revealed uncovered mandarin oranges and several staff members handling food without beard guards, contrary to facility policies requiring beard covers and covered food storage.
A facility failed to monitor and assess a wheelchair seatbelt used as a physical restraint for a resident with cerebral palsy. The resident's care plan lacked documentation of a medical need or physician's order for the seatbelt, and no assessments were recorded. Staff interviews revealed a lack of awareness and responsibility for assessing the seatbelt, contrary to the facility's policy requiring quarterly reassessments.
Three residents requiring assistance with incontinence care were not provided timely care, resulting in prolonged exposure to urine and skin issues. One resident with cerebral palsy had a rash due to a soiled brief not changed since early morning. Another resident with dementia had a saturated brief and red buttocks, while a third resident had a new open area on his buttock. Care was not provided every two hours as required.
The facility failed to provide necessary treatments for a resident's rash and for residents with leg edema. A resident with cerebral palsy was left in a soiled brief for hours, leading to a fungal rash. Two other residents with leg edema were not given prescribed compression therapy, despite medical orders. These deficiencies highlight lapses in following care plans and physician orders.
A resident at high risk for pressure injuries developed a new sacral injury due to the facility's failure to implement necessary pressure-relieving interventions. Despite being identified as high risk, the resident was observed on a standard mattress instead of a low air loss mattress, and was not repositioned every two hours as required. The Wound Nurse was not informed of the new skin condition, preventing timely assessment and intervention.
A resident with dementia, known for wandering, eloped from the facility due to inadequate supervision, while another resident had an unsecured oxygen tank in her room, posing a safety hazard. Staff were unaware of the elopement risk, and facility policies on elopement prevention and oxygen storage were not effectively implemented.
A resident with essential hypertension and heart failure was found with an unadministered Metoprolol pill on his chest, despite the LPN believing the medication had been taken. The facility's policy requires nurses to ensure residents swallow their medication, which was not followed.
A facility failed to obtain informed consent for a resident prescribed sertraline hydrochloride for major depressive disorder. The resident, with multiple diagnoses including dementia and amnesia, was started on the medication in January without consent. The ADON confirmed the lack of consent, and the facility could not provide a policy for psychotropic medication use when requested.
Resident Served Allergen Despite Documented Food Allergy
Penalty
Summary
A resident with severe cognitive impairment and multiple medical diagnoses, including allergies to peach and lactose, was served a food item containing peach despite clear documentation of these allergies on the resident's admission records, face sheet, and meal card. The resident's family member identified the error when peach was found on the lunch tray and reported it to staff. The family member stated that the resident experiences severe skin irritation and throat closure when exposed to peach. Interviews with dietary staff and the Dietary Manager revealed that the kitchen staff are required to refer to the meal card, which documents food allergies, when setting up meal trays. On the day of the incident, dietary aides admitted to missing the allergy information due to a busy day, resulting in the resident being served peach. The Director of Nursing confirmed that staff are expected to follow the meal card instructions to prevent such occurrences. Facility policy requires that food allergies be communicated to dining services and identified on individual tray assembly tickets.
Failure to Provide Adequate Oxygen Supply for Resident
Penalty
Summary
The facility failed to provide a full portable oxygen tank for a resident, identified as R1, who was on hospice care with a diagnosis of COPD. During an observation by a surveyor and the Director of Nursing (DON), it was found that R1's portable oxygen tank was empty while it was set to deliver 3 liters of oxygen. The resident confirmed that she did not feel any air from the nasal cannula, and her oxygen saturation was recorded at 91%. The DON acknowledged that the tank should have been full or replaced and that R1 should have been connected to her concentrator upon returning to her room from the dining room. The Certified Nursing Assistant (CNA) responsible for R1 on the day of the incident admitted to switching R1 to the portable oxygen tank for breakfast and noted that the tank was on yellow, indicating it was low. The CNA expressed regret for not changing the tank. Additionally, the DON mentioned that the hospice nurse had previously informed them that the staff was not using the portable oxygen concentrator provided by hospice for R1 when she was in the dining room. The concentrator was reportedly not charging properly, and the hospice nurse had observed the oxygen tank turned off on previous occasions. R1's medical history includes severe COPD, cognitive communication deficit, heart failure, schizophrenia, dementia, and Parkinson's disease. The resident's care plan indicated the need for oxygen therapy due to COPD and other respiratory issues, with specific instructions for oxygen administration. The facility's policy on oxygen therapy requires a physician's order for the amount and route of oxygen administration. Despite these guidelines, the facility's staff failed to ensure the availability of a full oxygen tank or the use of the concentrator, leading to the deficiency noted by the surveyor.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents to the abuse coordinator and the Illinois Department of Public Health as required by their policy. One resident, with a history of acute kidney failure, vascular dementia, and other conditions, reported that another resident, who had severe cognitive impairment, entered his room and shoved him, causing him to fall from his wheelchair. Despite the resident's report of pain and receiving an X-ray, the facility administrator did not report the incident to the authorities, believing the allegation was not credible due to a lack of witnesses and the resident's initial inconsistent statements. The incident was initially reported by the resident to a nurse, who then informed another nurse, but the progress notes did not reflect the resident's claim of being physically touched. The facility's policy mandates immediate reporting of any allegations of abuse, but the administrator chose not to report the incident, citing doubts about its occurrence. This inaction was contrary to the facility's abuse policy, which requires any allegation of abuse to be reported to the appropriate authorities within two hours.
Failure to Secure Wheelchair Resident in Facility Van
Penalty
Summary
The facility failed to provide secure wheelchair transportation for a resident during a trip in the facility van. The resident, who has diagnoses including morbid severe obesity, gait and mobility abnormalities, generalized muscle weakness, a history of falling, lack of coordination, and peripheral vascular disease, was being transported in a wheelchair. During the trip, the Activity Director had to brake hard, causing the resident to fall out of the wheelchair. The resident reported pain in her left foot following the incident and had been taking Tylenol for the pain. The investigation revealed that the seatbelt used to secure the resident was not properly fastened. The Activity Director demonstrated that she only used a shoulder belt, leaving one side of the lap belt unattached, which was not a three-point restraint. The resident and another witness confirmed that there were difficulties in latching the seatbelt correctly before the trip. The facility's Administrator acknowledged that the seatbelt was not used correctly, attributing the incident to user error. Further interviews and demonstrations showed that the correct procedure for securing a wheelchair resident in the van was not followed. The facility's restraint user instructions specify that both a lap belt and a shoulder belt should be used to secure a wheelchair resident properly. However, the Activity Director had been using only the shoulder belt for the front wheelchair passenger, which compromised the safety of the resident during transportation.
Deficient Wheelchair Maintenance
Penalty
Summary
The facility failed to ensure that resident wheelchairs were maintained in a safe and operable condition, affecting two residents. One resident, recently admitted, demonstrated that the brake on the left wheel of his facility-provided wheelchair was loose, allowing the wheel to move even when locked. Another resident showed that her wheelchair could still move forward and backward despite both brakes being locked, with the right wheel brake handle also being loose. The Maintenance Director acknowledged that a wheelchair wash and maintenance event occurred recently but could not confirm if these residents' wheelchairs were serviced, as no documentation was kept. Additionally, the facility lacked a policy for wheelchair maintenance.
Failure to Ensure Food Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food sanitation practices were followed by dietary staff, specifically regarding the use of beard guards and the covering of food to prevent contamination. During an initial tour of the kitchen, it was observed that a full tray of mandarin oranges was left uncovered in the fridge and on a food cart in the dining room. Additionally, several dietary staff members, including V14, V15, V13, and V12, were observed handling food without wearing beard guards despite having varying degrees of facial hair. The facility's policies require food handlers with beards to wear beard covers to minimize the risk of hair contamination and mandate that all foods be stored wrapped or in covered containers to prevent cross-contamination. However, these policies were not adhered to, as confirmed by V12, the Interim Dietary Manager, who acknowledged that male staff were not wearing beard guards and that food should be covered during storage and transport.
Failure to Monitor and Assess Wheelchair Seatbelt Use
Penalty
Summary
The facility failed to provide ongoing monitoring and assessments for the use of a wheelchair seatbelt, which was considered a physical restraint, for a resident diagnosed with cerebral palsy and contractures. The resident, who required staff assistance for all activities of daily living, was observed with a seatbelt securely fastened around their waist while seated in a wheelchair. The resident's care plan indicated the use of a seatbelt but lacked documentation of a medical need or physician's order for the restraint. Additionally, there were no records of restraint or seatbelt assessments in the resident's electronic medical records. Interviews with facility staff, including the Director of Nursing, a Certified Nursing Assistant, the Administrator, and the Restorative Nurse, revealed a lack of awareness and responsibility regarding the assessment of the resident's seatbelt use. The Restorative Nurse, who was new to the position, admitted to not realizing the responsibility for assessing the seatbelt, which should have been reviewed quarterly according to the facility's policy. The facility's policy required a Physical Device Observation to be completed if a device might be considered a restraint, with reassessments at least quarterly or with any significant change.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents who required staff support for toileting and incontinence care. Resident 12, diagnosed with cerebral palsy and completely dependent on staff for incontinence care, was observed with a soiled incontinence brief and a red, raised rash on her buttocks, vaginal area, and inner thighs. The rash was attributed to prolonged exposure to urine, as the resident had not received incontinence care since 6 AM, despite being observed at 9:40 AM. The resident expressed discomfort by scratching the rash and repeatedly stating it was itchy. Resident 64, who required staff assistance for toileting due to dementia, was found with a saturated incontinence brief that had not been changed since 7 AM, despite being observed at 10:53 AM. The resident's brief was heavy with dark yellow urine, and his buttocks appeared red. Similarly, Resident 53, also diagnosed with dementia and dependent on staff for incontinence care, was found with a large amount of urine in his brief and a new, small, red, open area on his inner right buttock. The last incontinence care provided to him was before breakfast, around 7-7:30 AM. The facility's wound nurse confirmed that incontinence care should be provided every two hours and as needed for residents requiring assistance.
Failure to Provide Necessary Treatments for Rash and Edema
Penalty
Summary
The facility failed to provide necessary treatments for a resident's rash and for residents with leg edema. One resident, diagnosed with cerebral palsy and completely dependent on staff for incontinence care, was observed with a fungal rash due to prolonged exposure to a wet incontinence brief. Despite the care plan indicating the need for regular changes to prevent skin damage, the resident was left in a soiled brief for several hours, leading to a red, raised rash on the buttocks, vaginal area, and inner thighs. The wound nurse confirmed that the resident's condition could worsen if left in a wet brief for too long, highlighting a lapse in the facility's adherence to its skin management policy. Additionally, two other residents with leg edema were not provided with the prescribed compression therapy. One resident, with a history of peripheral arterial disease and venous disease, was observed without the required TED hose, resulting in visible edema. Similarly, another resident with a vascular foot ulcer and edema was not wearing the necessary compression dressings, despite medical orders and a recent vascular consultation recommending compression therapy. These observations indicate a failure to follow physician orders and provide essential care for residents with specific medical needs.
Failure to Implement Pressure Ulcer Prevention Protocols
Penalty
Summary
The facility failed to implement necessary pressure-relieving interventions for a resident at high risk for pressure injuries, resulting in the development of a new sacral injury. The resident, who had a history of dementia and incontinence, was assessed using the Braden Scale and identified as being at high risk for pressure injuries. Despite this, the resident was observed lying on a standard hospital mattress instead of a low air loss mattress, which was ordered by the Director of Nursing (DON) to help prevent further skin complications. Additionally, the resident was not repositioned every two hours as required by the facility's pressure injury prevention protocol. The facility's Wound Nurse was not informed of the resident's new skin condition, which was discovered on a previous date. This lack of communication prevented timely assessment and intervention, as the Wound Nurse was unaware of the need for a low air loss mattress and other necessary treatments. The facility's policy on pressure injury treatment emphasizes the importance of implementing prevention protocols according to resident needs, including the use of appropriate pressure-reducing devices and regular repositioning. The failure to adhere to these protocols contributed to the resident's new pressure injury and highlighted a breakdown in communication and care coordination within the facility.
Supervision and Safety Deficiencies in Resident Care
Penalty
Summary
The facility failed to adequately supervise a resident with dementia, who had a known history of wandering and was at high risk for elopement. The resident, identified as R29, had multiple documented instances of attempting to leave the facility, including trying to access the elevator and expressing a desire to go to the airport due to delusional beliefs. On one occasion, the resident managed to exit the facility and was found in the parking lot attempting to enter a locked car. Staff members, including a CNA and an RN, were unaware of the resident's elopement risk, and there was no incident report or investigation conducted at the time of the event. Additionally, the facility failed to ensure the safe storage of oxygen tanks, posing a potential hazard. A resident, identified as R16, had an unsecured oxygen tank leaning against a dresser in her room. The tank had been in this position for at least two weeks, according to the resident's roommate. The facility's policy requires oxygen tanks to be stored in a holder or designated storage room to prevent mechanical shock or falling objects, but this was not adhered to in this instance. The facility's policies on elopement prevention and oxygen storage were not effectively implemented, leading to these deficiencies. The elopement binder, which lists residents at risk, was not utilized by staff, and the oxygen storage policy was not followed, as evidenced by the unsecured tank in the resident's room. These lapses in protocol contributed to the safety risks observed during the survey.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered per standards of practice for one resident, identified as R28, who was reviewed for medication services. R28, a male resident with diagnoses including essential hypertension and heart failure, had an order for Metoprolol Succinate ER 25 mg tablet. On the morning of June 24, 2024, R28 was observed lying in bed with a white oval pill on his chest, which was identified as his Metoprolol dose. The Licensed Practical Nurse (LPN) responsible for administering the medication stated she believed R28 had taken all his medications around 9 AM. However, the facility's medication administration policy requires nurses to remain with the resident to ensure the medication is swallowed, which was not adhered to in this instance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to provide informed consent for the administration of psychotropic medication to a resident, identified as R22, who was part of a sample of 19 residents reviewed for unnecessary medication. R22's physician orders dated June 25, 2024, indicated the prescription of sertraline hydrochloride, 25 milligrams, to be taken orally once a day for major depressive disorder. However, during an interview on June 26, 2024, the Assistant Director of Nursing (ADON) confirmed that R22 had been started on sertraline hydrochloride in January 2024 without obtaining informed consent. Additionally, R22's psychiatry note from January 26, 2024, listed multiple diagnoses, including amnesia, unspecified dementia without behaviors, and major depressive disorder. The facility was unable to provide a policy for psychotropic medication use when requested during the survey.
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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 Geneva
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenfields Of Geneva | 1.4 mi | ★★★★★ | 6 | 0 |
| Michaelsen Health Center | 2.4 mi | ★★★★★ | 3 | 0 |
| Batavia Rehabilitation And Health Care Center | 2.4 mi | ★★★★★ | 1 | 0 |
| Pearl Of St Charles, The | 2.7 mi | ★★★★★ | 2 | 0 |
| Alpine Care Of St. Charles Llc | 2.8 mi | ★★★★★ | 16 | 0 |
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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.