Above 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 Hammond-henry District Hsp during CMS and state inspections, most recent first.
A CNA was physically rough and abusive while providing incontinence care to a resident with Alzheimer's and other conditions, causing the resident visible distress and pain. The abusive behavior included forceful handling and rough adjustment of clothing and incontinence briefs. Another CNA confirmed this was a pattern of behavior with multiple residents, and the incident was captured on video and confirmed by the DON.
Two residents experienced rough and abusive care from a CNA, including forceful handling and inappropriate comments, which caused physical and emotional distress. Despite clear signs of abuse and staff awareness, the facility failed to report the allegations to the abuse coordinator and State Agency as required, allowing the abusive behavior to continue.
A CNA failed to change gloves while providing incontinence care to a resident, handling both soiled and clean items and moving between soiled and clean body sites without replacing gloves. The DON was unable to confirm the requirement for glove changes between dirty and clean areas, despite CDC guidelines indicating this is necessary.
The facility failed to monitor active infections and perform perineal care properly, affecting 34 residents. The Infection Control Practitioner did not track infections per resident, and the Antibiotic Stewardship Program lacked effective monitoring. Staff did not follow hand hygiene protocols during perineal care, leading to potential cross-contamination. These deficiencies were confirmed by the DON and ADON.
Two CNAs failed to follow hand hygiene protocols during incontinence care for a resident. Despite the facility's policy requiring handwashing and glove changes between contaminated and clean body sites, the CNAs did not perform hand hygiene or change gloves appropriately, leading to potential cross-contamination. One CNA acknowledged the oversight during the care process.
Failure to Protect Resident from Physical Abuse During Care
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) was physically rough and abusive while providing incontinence care to a resident with multiple diagnoses, including Alzheimer's Disease, osteoarthritis, anxiety disorder, and depression. The resident was not cognitively intact and exhibited distress during care, such as clenching teeth, grimacing, moaning, crying, covering her face, and attempting to take a defensive position. The CNA pressed and held the resident's hand down on her chest, adjusted her legs roughly, and wiped her perineal area forcefully, causing visible discomfort and pain. The CNA also pulled on the resident's incontinence brief with enough force to cause the resident's body to jerk upwards in bed. Further observations showed the CNA continued to be rough during care, including pulling the resident's shirt off firmly and tying a gown without lifting the resident's head, which caused additional distress and grimacing. Another CNA present during the incident reported that the abusive behavior was not isolated to this resident but was a pattern with other residents as well. The witness described the CNA as harsh, rough, overly aggressive, and unkind, and stated that the resident became combative as a result of the harsh treatment. The witness did not report the abuse immediately, citing concerns about being an agency staff member and fear that her word would not be believed over the CNA's. The facility's abuse policy defines abuse as any action causing physical harm, pain, or mental anguish, including physical and mental abuse. The incident was captured on video and confirmed by the Director of Nursing, who acknowledged the abusive behavior. The failure to protect the resident from abuse and mistreatment resulted in the identification of Immediate Jeopardy, as the resident was subjected to physical and emotional harm during routine care.
Removal Plan
- V3's employment with the facility was terminated.
- V2/DON and V15/Risk Manager performed a visual assessment of resident (R1) for signs of physical and emotional abuse; no physical marks noted and patient's emotional status unchanged.
- V1/Chief Nursing Officer, V2, and V15 reviewed LTC/Long Term Care Abuse and Neglect Procedures Policy as well as the organization's Behavior Standards.
- V2 reviewed the LTC Abuse and Neglect Procedures Policy and Behavior Standards with the V18/Assistant Director of Nursing and then all staff on shift was educated.
- Staff not working day shift were called by V18 and V2 and the LTC Abuse and Neglect Policy and Behavior Standards, specific to compassion and empathy, were reviewed.
- Remainder of staff not working or reached by phone will be required to receive education on LTC Abuse and Neglect Policy and Behavior Standards, specific to compassion and empathy, prior to working next shift by the V2 or V18 and will be tracked on sign-in sheet.
- Long Term Care Abuse and Neglect Procedures Policy was added by the V2 to contracted staff orientation packet for review prior to first shift.
- An Emergency QAPI/Quality Assurance Performance Improvement discussion was held with V1/Chief Nursing Officer, V2, V17/Social Services Director, V20/Medical Director, and V15 to review the resident audit findings performed and review investigation.
- On-going audit plan was created: Five residents a month will be interviewed by Social Services or V2 or designee about cares received and any concerns regarding cares. These audit findings will be reported monthly on the QAPI scorecard and reported at the quarterly Quality Assurance meetings.
Failure to Report Abuse Allegations Resulting in Continued Resident Harm
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the abuse coordinator and the State Agency, as required by their own policy and federal regulations. One resident, who was not cognitively intact and had diagnoses including Alzheimer's Disease and agitation, was subjected to rough and forceful care by a CNA during incontinence and clothing changes. Video evidence showed the CNA pressing the resident's hand to her chest, roughly adjusting her legs, and forcefully wiping her perineal area, causing the resident to grimace, moan, cry, and take a defensive posture. The CNA also made inappropriate comments about the resident's family and disregarded the use of required equipment during care. Another resident, who was cognitively intact, reported that the same CNA was rough during care, pulled her clothes off roughly, and ignored her attempts to hold onto a safety bar, resulting in distress and fear for her safety. Despite these incidents, the facility did not immediately report the allegations to the State Agency or escalate them according to policy. Documentation showed that concerns about the CNA's rough handling had been previously discussed verbally, but no formal report was made following new allegations. Staff who witnessed the abusive behavior did not report it, with one agency CNA stating she did not report the incident because she felt it would be her word against the other CNA's. The failure to report allowed the abusive behavior to continue, resulting in further distress and harm to the residents involved. The deficiency was identified as Immediate Jeopardy due to the ongoing risk and harm to residents from unreported abuse. The facility's lack of timely reporting and failure to follow established procedures for handling abuse allegations directly contributed to the continuation of abusive behavior by the CNA. The survey findings were based on observation, record review, and staff and resident interviews, which confirmed that the required notifications and protective actions were not taken in a timely manner.
Removal Plan
- Terminate V3's employment with the facility.
- V2 and V18/Assistant Director of Nursing perform education on LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information.
- V15/Risk Manager review with V2 (designated abuse coordinator) policy Abuse and Neglect Procedures specifically for reporting and escalating abuse allegations immediately for review and reporting.
- V1/Chief Nursing Officer, V2, and V15 review LTC Abuse and Neglect Procedures Policy as well as the organization's Behavior Standards.
- V2 review with the V18 the LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information. V2 and V18 then educate all staff on shift on the above stated policy.
- Staff not working day shift are called by V18 and V2 and the LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information.
- Remainder of staff not working or reached by phone will be required to receive education on LTC Abuse and Neglect policy specifically focused on reporting any concerns of abuse to the V2 or Administrator on call, reporting immediately of any concerns related to abuse and where to find the leadership contact information, as well as the remainder of the policy information prior to working next shift by V2 or V18 and will be tracked on sign-in sheet.
- LTC Abuse and Neglect Procedures Policy is added by the V2 to contracted staff orientation packet for review prior to first shift.
- An Emergency QAPI/Quality Assurance and Performance Improvement discussion is held with V1, V2, V17/Social Services, V20/Medical Director and V15 to review the resident audit findings performed and reviewed investigation. On-going audit plan is created, to include monitoring of any concerns/complaints to ensure appropriate follow-up to include reporting of any abuse per policy. Five residents a month will be interviewed by Social Services or V2/designee about cares received and any concerns regarding staff. These audit findings will be reviewed by V17 and the V2 and reported monthly by the V2 on the QAPI scorecard and at the quarterly Quality assurance meeting.
- V15 will monitor all incidents of patient injury and meet monthly with V2 to review for trends for further review.
Failure to Change Gloves During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to change gloves during the process of providing incontinence care to a resident. Video evidence showed the CNA performing multiple tasks, including adjusting bedding, handling clean and soiled items, and cleaning the resident's perineal and buttocks areas, all without changing gloves between tasks. The CNA touched various surfaces and moved between soiled and clean body sites without removing or replacing gloves, contrary to standard infection control practices. The incident involved a resident receiving incontinence care with the assistance of another CNA. The CNA in question handled both soiled and clean items, as well as the resident's body, without changing gloves at any point during the care process. The Director of Nursing was unable to confirm that glove changes were required between soiled and clean body sites, instead referencing hand hygiene expectations. However, CDC guidelines specify that gloves should be changed when moving from a soiled to a clean body site on the same patient.
Inadequate Infection Control and Perineal Care Practices
Penalty
Summary
The facility failed to adequately monitor active infections within the unit, which has the potential to affect the 34 residents currently residing there. The Infection Control Practitioner (ICP) was responsible for most aspects of the Infection Control Program, including surveillance and implementing procedures for reporting infections. However, it was revealed that there was no monitoring of infections per resident, no tracking of symptoms, and no trending of infection locations or types within the facility. The facility's Antibiotic Stewardship Program (ASP) was also not effectively monitoring antibiotic usage patterns, as confirmed by the Director of Nursing and Assistant Director of Nursing. The facility also failed to perform perineal care in a manner that prevents cross-contamination for one resident. During the survey, it was observed that staff members did not adhere to proper hand hygiene protocols. For instance, a Licensed Practical Nurse (LPN) was seen applying cream to a resident's perineal area without changing gloves or performing hand hygiene between applications. Additionally, Certified Nurse Aides (CNAs) were observed not performing hand hygiene after removing soiled gloves and before donning new ones, and they improperly handled personal items and supplies with contaminated gloves. These observations were confirmed by the Director of Nursing and Assistant Director of Nursing, who acknowledged that the staff did not follow the facility's hand hygiene policy. The policy required hand hygiene to be performed at each of the five moments outlined by the World Health Organization, regardless of glove use. The failure to adhere to these protocols during perineal care increased the risk of cross-contamination and infection among residents.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during incontinence care for one resident out of three reviewed for urinary incontinence care. The facility's hand hygiene policy requires handwashing when hands are visibly soiled, before eating, after using the bathroom, when there is a significant build-up of alcohol-based hand rub, and when caring for a patient on enteric isolation. Additionally, gloves are to be discarded or changed after use on a contaminated body site before moving to a clean body site. On the specified date, two Certified Nurse Aides (CNAs) transferred a resident from the toilet to the bed and performed incontinence care without following proper hand hygiene procedures. One CNA changed gloves without washing hands or performing any hand hygiene and continued to assist the resident without changing gloves or performing hand hygiene, leading to potential cross-contamination. The CNA later confirmed the failure to perform hand hygiene during the care process.
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Illustrative
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.
Illustrative
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Illustrative
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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 | 0.3 mi | ★★★★★ | 0 | 0 |
| Allure Of Geneseo | 1.1 mi | ★★★★★ | 6 | 0 |
| Avenues At Quad Cities | 13.6 mi | ★★★★★ | 0 | 0 |
| Silvis Center For Nursing Rehab & Care | 13.8 mi | ★★★★★ | 6 | 0 |
| Celebrate Sr Living Of Moline | 14.7 mi | ★★★★★ | 1 | 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.