Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Greenfields Of Geneva during CMS and state inspections, most recent first.
A resident with impaired mobility, osteoarthritis, and documented fall risk was dependent for toilet transfers and required assistance per the care plan and therapy notes, which described contact guard assistance but did not state that a gait belt was unnecessary. During an assisted toilet transfer, a CNA helped the resident stand and pivot without applying a gait belt, despite staff training and facility policy indicating gait belts should be used for transfers unless a mechanical lift is required. The resident later became lightheaded and fell in the bathroom, and was found on the floor without a gait belt in place, while other staff interviews confirmed inconsistent gait belt use and lack of clear documentation that this resident could be safely transferred without one.
Surveyors found that staff did not follow the facility’s Enhanced Barrier Precautions (EBP) policy or use appropriate PPE for several residents requiring device and wound care. An LPN discontinued and flushed a J‑tube feeding for a resident on ordered EBP while wearing only gloves, handling personal items and leaving the room with the same gloves. A resident with a sacral wound received a dressing change from an RN without a gown and without EBP signage or orders, despite facility policy requiring EBP and door signage for chronic wounds. Two other residents with chronic, full‑thickness wounds and moderate exudate had no EBP signage or PPE set up outside their rooms, and CNAs provided incontinence care and transfers without gowns and without performing required hand hygiene before or between glove use, while also stating that no residents on their hallway required EBP.
A resident with severe cognitive impairment, documented need for staff set-up/clean-up assistance at meals, and a care plan directing staff to anticipate her needs was observed eating pureed meals without a clothing protector on two occasions, resulting in repeated food spillage on her clothing. A CNA reported that this resident required prompting, cueing, and a clothing protector due to fatigue and unsteady utensil use, and the DON stated she expected staff to round during meals and provide clothing protectors to prevent spillage. This failure to provide a clothing protector during meals did not align with the resident’s assessed needs, care plan, or the facility’s Resident Rights policy requiring treatment with kindness, respect, and dignity.
Two residents were found with multiple medications stored at their bedsides and self-administering them without documented self-administration assessments, care plans, or appropriate physician orders for bedside use. One cognitively intact resident with age-related macular degeneration had PRN ophthalmic lubricant ordered but no order allowing bedside storage and no documented education on use. Another resident with multiple sclerosis, unsteadiness, and osteoarthritis, and with moderate cognitive impairment, kept and applied topical analgesic and antibiotic products that were not ordered on the POS and reported receiving no guidance on application amounts. The DON acknowledged that residents should be assessed for safe self-administration, demonstrate proper use, and have physician orders for medications kept at the bedside, as required by the facility’s self-administration policy.
Surveyors found that the facility did not reconcile or properly account for controlled substances for two discharged residents. During a Birch unit med cart observation with the DON, cards of Hydrocodone-Acetaminophen, Alprazolam, and Tramadol with remaining tablets were stored in the narcotic box with individual inventory sheets attached to the cards instead of being filed in the narcotic binder used for shift-change counts. The DON acknowledged that the inventory sheets were not kept in the binder because the residents had been discharged and stated that controlled count sheets should be in the binder for accurate counting and that narcotics should be destroyed upon discharge. Facility policy required end-of-shift controlled drug counts using narcotic records and reconciliation of controlled substance inventory to detect loss or diversion.
Surveyors found that two residents had unsecured medications left at their bedside, contrary to facility policy requiring drugs to be stored in locked compartments. A cognitively intact resident with COPD had two ordered inhalers left on her bedside table after a nurse administered one dose and failed to secure the inhalers, despite no bedside order. Another resident with dementia and moderate cognitive impairment had three tubes of a topical analgesic on her tray table, with no corresponding physician order or authorization for bedside medication storage.
The facility failed to properly label, date, seal, and store food items, leading to potential contamination risks. Expired and improperly stored food items were found in the kitchen and dry storage areas, with small black flies present. Additionally, a server was observed with inadequate hair restraint, risking food contamination. These actions violated the facility's food safety and personal hygiene policies.
The facility failed to safely store medications for four residents who were not assessed or ordered to have medications at bedside. Medications were found in residents' rooms without proper authorization or assessment for self-administration. Staff interviews revealed that facility policies requiring physician orders and assessments for bedside storage were not followed.
A medication administration deficiency occurred when an RN failed to administer prescribed medications to a resident with COPD and hypertension, yet documented them as given. This resulted in a medication error rate of 6.67%, exceeding the acceptable threshold. The resident's care plan required these medications to manage their conditions, and the DON confirmed the importance of accurate documentation.
A resident was continued on antibiotics despite not meeting criteria for continued use according to the facility's antibiotic stewardship program. The resident was admitted from the hospital on antibiotics, but a McGeer's assessment showed no evidence of infection. Despite this, the resident received antibiotics for several days, and documentation from the Medical Director was lacking. A late entry note was provided during the survey, backdated to justify the antibiotic use, contrary to the facility's policies.
Failure to Use Gait Belt During Assisted Toilet Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly and safely transferred with the use of a gait belt, as required to prevent or minimize the risk of falls. The resident had a history that included right quadriceps strain, orthopedic aftercare, difficulty walking, osteoarthritis, and a prior fall, and was assessed as being at risk for falls. The resident’s MDS documented dependence for toilet transfers, meaning the helper does all the effort or two or more helpers are required, and the care plan identified fall risk and ADL self-care deficits related to limited mobility, weakness, and prior tendon tear and repair. The care plan interventions included assistance with toileting and, after a fall, specified use of a gait belt during transfers, but prior to the fall there was no documentation that a gait belt was not required. Therapy documentation showed that physical therapy recorded supervision or touching assistance with toilet transfers and occupational therapy documented toileting with “CGA,” later clarified by a therapist as contact guard assistance, indicating the resident still required some contact assistance. There was no documentation in the medical record or therapy notes stating that a gait belt was not required for this resident’s transfers. The facility’s Safe Resident Handling/Transfers policy stated that all residents require safe handling when transferred, that handling aides may include gait belts, and that lifting and transferring are to be performed according to the resident’s individual plan of care. On the night of the fall, staff heard a noise consistent with a fall and found the resident on the bathroom floor in an upright position with both legs extended, without a gait belt in place. The resident reported that an aide had assisted him to stand and pivot to the toilet and later to stand after toileting, and he did not recall a gait belt being applied before standing; he also reported becoming lightheaded and falling. The CNA who assisted the resident stated she did not put a gait belt on the resident, described him as a one-assist transfer, and acknowledged staff were supposed to use a gait belt with transfers unless the resident was independent, and that she had never been told this resident did not require a gait belt. Another CNA reported that if a gait belt was not available, he would still transfer a resident without one and just be extra careful. Other staff, including a CNA and a PT, stated that a gait belt should always be used with transfers unless a mechanical lift is used, and the DON stated that gait belt use depends on therapy recommendations, though no documentation existed that a gait belt was not required for this resident.
Failure to Implement Enhanced Barrier Precautions and Proper PPE Use for Device and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) and appropriate use of personal protective equipment (PPE) for multiple residents. One resident with dysphagia had a jejunostomy (J‑tube) with continuous tube feeding and an order for EBP related to the feeding tube. An LPN entered this resident’s room without a gown, wearing only gloves, moved the resident’s personal belongings with the same gloved hands, disconnected the J‑tube feeding, flushed the tube, covered the port, and then left the room still wearing the same gloves. The resident’s physician orders and care plan documented the need for EBP for the J‑tube, and the facility’s EBP policy required gown and gloves for device care, including feeding tubes. The facility also failed to post EBP signage and ensure EBP implementation for residents with chronic wounds. One resident with a sacral wound had no EBP sign on the door, and a wound care RN entered without a gown and performed a pressure dressing change. The physician orders for this resident did not include EBP, and the care plan did not address EBP, despite the facility’s policy stating that EBP should be implemented for residents with chronic wounds and that clear signage indicating required PPE must be posted outside the room. The Infection Control Nurse stated that at that time they did not have wounds requiring EBP, and described EBP as needed for open wounds or pressure sores with significant exudate, while the written policy specified chronic wounds such as pressure ulcers and other long‑lasting wounds. Two additional residents with chronic, full‑thickness wounds and moderate serous exudate also did not have EBP signage or PPE set up outside their rooms. A CNA and another CNA assistant entered one resident’s room to provide incontinence care and transfer without performing hand hygiene before donning gloves, did not wear gowns, and one CNA changed gloves without hand hygiene before continuing care and using a mechanical lift. For another resident with a post‑surgical stump wound, a CNA provided incontinence care wearing gloves but no gown and did not perform hand hygiene before donning or after removing gloves. Both CNAs stated there were no residents on their hallway requiring EBP, while the DON stated that EBP is required for residents with chronic wounds present for more than 30 days and/or with biofilm, and the wound physician’s documentation showed both residents’ wounds had been present for more than 30 days with debridement of slough, biofilm, and devitalized tissue.
Failure to Provide Clothing Protector During Meals Compromising Resident Dignity
Penalty
Summary
Surveyors identified that staff failed to provide a clothing protector during meals to a resident with severe cognitive impairment, resulting in food spilling on her clothing. On the morning of 12/21/2025, the resident was observed in the dining room eating a pureed breakfast. She was severely cognitively impaired, fatigued, and had difficulty feeding herself, which led to multiple food residue spills on her shirt and pants. Despite this, she was not provided with a clothing protector. Later that day at lunchtime, the same resident was again observed in the dining room feeding herself pureed food with some unsteadiness using utensils, causing additional spillage on her shirt and pants, and again no clothing protector was provided. A CNA who routinely cared for the resident stated that the resident was able to feed herself but required prompting and cueing, especially when fatigued, and that she required the use of a clothing protector to protect her clothing from food spillage. The CNA also stated that due to the resident’s cognitive impairment, she was dependent on staff to provide a clothing protector at meals. The DON reported that she expected staff to provide resident-centered care during meals, including rounding and providing clothing protectors to prevent spillage on residents’ clothing. The resident’s MDS documented severe cognitive impairment and a need for staff set-up and clean-up assistance with meals, and the care plan indicated she was at risk for complications due to cognitive impairment, was dependent on staff for care, and that staff were to anticipate her care needs. The facility’s Resident Rights policy stated that employees shall treat all residents with kindness, respect, and dignity.
Failure to Assess and Authorize Resident Self-Administration of Medications at Bedside
Penalty
Summary
Surveyors identified that the facility failed to assess residents for self-administration of medications and failed to obtain physician orders for medications kept at the bedside. One resident had Systane lubricant eye drops and ointment on the bedside table and reported that no one at the facility had educated her on how to take the medications, stating she already knew how to use them and that they were always kept in her room. Her record showed a diagnosis of exudative age-related macular degeneration with active choroidal neovascularization and an MDS indicating she was cognitively intact. The POS contained an order for Systane ophthalmic gel to be instilled in both eyes every 24 hours as needed for dry eyes, but there was no order for the medication to be kept at the bedside. Her medical record contained no self-administration of medication assessment and no care plan addressing self-administration. Another resident had multiple tubes of topical analgesic and a topical antibiotic on the bedside table and stated she applied the analgesic to her knees for arthritis pain and the antibiotic to the sides of her nose where her eyeglasses rest, adding that the medications were always kept in her room and that no one had educated her on how much she could apply in a day. Her diagnoses included multiple sclerosis, unsteadiness on feet, and primary generalized osteoarthritis, and her MDS showed moderate cognitive impairment. The POS contained no orders for the topical analgesic or topical antibiotic, and her record lacked a self-administration of medication assessment and a care plan for self-administration. The DON stated that she did not currently have residents who self-administer medications, that nurses should assess residents and require them to demonstrate safe self-administration according to physician orders, and that there should be physician orders for medications to be kept at the bedside. The facility’s self-administration policy required IDT assessment of cognitive and physical abilities, documentation and care planning when self-administration is deemed safe, secure storage of self-administered medications, and turning over any unauthorized bedside medications to the nurse in charge.
Failure to Reconcile and Account for Controlled Substances After Resident Discharge
Penalty
Summary
The deficiency involves the facility’s failure to reconcile and properly account for controlled substances after residents were discharged. During a medication cart storage observation on the Birch unit with the DON, surveyors found a card of Hydrocodone-Acetaminophen 5-325 mg containing 30 tablets for resident R67 stored in the narcotic box with its individual controlled inventory sheet attached to the card rather than maintained in the cart’s controlled inventory binder. The DON stated that R67’s inventory sheet was not kept in the binder for counting because the resident had been discharged. Record review showed R67 had an as-needed order for Hydrocodone-Acetaminophen that started on 12/03/2025 and was discontinued on 12/08/2025, and the EMR documented that R67 was discharged on 12/16/2025. In the same observation, the Birch unit medication cart also contained a card of Alprazolam 0.25 mg with 14 tablets and a card of Tramadol HCL 50 mg with 15 tablets for resident R68 stored in the narcotic box, each with individualized controlled inventory sheets attached to the cards instead of being in the narcotic binder. The DON explained that R68’s inventory sheets were not maintained in the binder for count because the resident had also been discharged, and stated that individual controlled count sheets should be in the narcotic binder so all stored narcotics are accounted for during shift-change counts and that narcotics should be destroyed per policy when a resident discharges. EMR review showed R68 was discharged on 12/20/2025 and had as-needed orders for Alprazolam 0.25 mg and Tramadol HCL 50 mg. The facility’s controlled substances policy required nursing staff to count controlled medication inventory at the end of each shift using narcotic records to reconcile counts and to monitor and reconcile controlled substance inventory to identify loss or potential diversion.
Unsecured Medications Left at Bedside for Two Residents
Penalty
Summary
Surveyors identified a failure to secure and properly store medications when a cognitively intact resident admitted with chronic obstructive pulmonary disease was found with two inhalers on her bedside table. The resident reported she had been admitted the previous day and that both the Breztri Aerosphere and Airsupra inhalers had been in her room since admission. She stated a nurse had administered the Airsupra inhaler and then left it in the room, and that the Breztri inhaler was awaiting approval by the respiratory therapist. The resident’s physician orders included both inhalers but did not include any order for medications to be kept at the bedside. Facility policy required all medications and biologicals to be stored in locked compartments, and the DON stated that medications brought from home should be given directly to the nurse and not left in resident rooms. In a separate instance, surveyors observed three tubes of a brand name topical analgesic 1% on the tray table of another resident who had moderate cognitive impairment and diagnoses including unspecified dementia, cognitive communication deficit, and major depressive disorder. This resident was unable to comment on the medication due to impaired cognitive function as documented in her care plan. The resident’s physician orders did not contain any order for the topical analgesic or for any medication to be kept at the bedside. These observations showed that medications were not secured in locked storage as required by facility policy and accepted professional principles.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and storage protocols, as observed during a kitchen inspection. Several food items in the facility's kitchen were found improperly labeled, dated, and stored. For instance, packages of Canadian bacon and ground beef were past their expiration dates, with the latter leaking juices onto the cooler floor. Additionally, various food items, including chicken thighs, shrimp, and sauces, were not labeled, dated, or sealed, posing a risk of contamination. Expired items such as mozzarella slices, goat cheese, and smoked roasted bacon were also found in the walk-in cooler. In the dry storage area, small black flies were observed, and several food containers were improperly sealed or left open, exposing contents to potential contaminants. Sticky and expired items, such as a bottle of browning and season sauce and a gallon of apple cider vinegar, were noted, with flies present on some items. Dishes were stored improperly, right side up and dusty, increasing the risk of contamination. Additionally, dented cans, which pose a risk for botulism, were found on the circulation rack. The facility's staff also failed to comply with personal hygiene standards. A server was observed serving meals with a hairnet that did not fully cover her hair, risking contamination of the food. The facility's policies clearly state the need for proper labeling, dating, and sealing of food items, as well as the use of hair restraints to prevent contamination. However, these protocols were not followed, leading to the deficiencies noted during the inspection.
Failure to Safely Store Medications at Bedside
Penalty
Summary
The facility failed to ensure safe storage of medications for residents who were not assessed or ordered to have medications kept at bedside. This deficiency was observed in four residents who had medications stored in their rooms without proper authorization or assessment. Resident R24 had eye drops on his bedside table for cataract surgery, but there was no physician order or assessment for self-administration or bedside storage. Similarly, Resident R13 had various topical medications on his side table, including a discontinued Chlorhexidine solution, without orders for bedside storage or self-administration. Resident R7 had a bottle of Phenol oral spray in her room, which she used sporadically without a physician's order or assessment for self-administration. The spray was initially on her tray table and later found in her dresser drawer. Resident R19 had an unopened tube of hydrocortisone cream in her room, which she was unaware of how it got there. There was no order for bedside storage, and the cream was later removed from her room. None of these residents had assessments in their electronic medical records to indicate they were safe to self-administer medications or store them at bedside. Interviews with facility staff, including registered nurses and the Director of Nursing, revealed that the facility's policy required a physician's order and an assessment for residents to self-administer medications or store them at bedside. However, these procedures were not followed for the residents in question. The facility's policies on medication and treatment, as well as medication labeling and storage, were not adhered to, leading to the observed deficiencies.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 6.67%, which exceeds the acceptable threshold of 5%. During a medication pass observation, a registered nurse (RN) did not administer the prescribed medications, fluticasone-salmeterol and Metoprolol Succinate, to a resident with multiple diagnoses including COPD, asthma, and hypertension. Despite this, the RN documented in the electronic medical record that the medications were administered. The resident involved was admitted with conditions such as a fracture of the left femur, hyperlipidemia, hypertension, anxiety, obstructive sleep apnea, COPD, and asthma. The resident's care plan included interventions to manage these conditions, such as administering bronchodilators and anti-hypertensive medications as ordered. The Director of Nursing confirmed that medications should not be documented as administered if they were not given, and highlighted the potential outcomes of missing these medications, such as elevated heart rate or blood pressure and increased wheezing or shortness of breath.
Failure to Discontinue Unnecessary Antibiotics
Penalty
Summary
The facility failed to discontinue an antibiotic for a resident who did not meet the criteria to continue antibiotics, as part of their antibiotic stewardship program. The resident, identified as R242, was admitted to the facility from the hospital on antibiotics on October 9, 2024. The resident had started Augmentin 875-125 MG on September 28, 2024, while in the hospital. Upon admission, a McGeer's assessment was completed, which indicated that the resident did not meet the criteria to continue the antibiotics, as there was no evidence of infection and cultures were negative. Despite this, the resident continued to receive antibiotics until October 14, 2024. The facility's records showed that the resident received multiple doses of the antibiotic from October 10 to October 14, 2024. The Infection Preventionist, V8, noted that there was no evidence of infection and that the resident did not meet McGeer's criteria for antibiotic stewardship. However, there was a lack of documentation from the Medical Director, and a late entry note was provided during the survey, backdated to October 10, 2024, by the Infectious Disease Nurse Practitioner. This note stated that antibiotics were to be completed as per hospital discharge paperwork, despite the lack of evidence supporting the need for continued antibiotic use. The facility's policies on antibiotic stewardship and unnecessary drugs emphasize the importance of discontinuing medications when conditions have resolved, which was not adhered to in this case.
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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) |
|---|---|---|---|---|
| Bria Of Geneva | 1.4 mi | ★★★★★ | 0 | 0 |
| Batavia Rehabilitation And Health Care Center | 1.7 mi | ★★★★★ | 1 | 0 |
| Michaelsen Health Center | 1.8 mi | ★★★★★ | 3 | 0 |
| Alpine Care Of St. Charles Llc | 2.6 mi | ★★★★★ | 16 | 0 |
| Pearl Of St Charles, The | 3 mi | ★★★★★ | 2 | 0 |
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