Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Michaelsen Health Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities was placed in a sit-to-stand mechanical lift while a CNA provided incontinence care. The CNA, positioned to the resident’s side and bent over fastening briefs, could not see the resident’s hands as the resident moved her arms inside the sling, raised them, and slid between the sling belt, falling to the floor and sustaining a head laceration requiring staples. Staff reported that cognitively impaired residents using sit-to-stand lifts require close supervision and constant cueing to keep their hands on the hand grips, and that providing incontinence care while in the lift is not safe. The lift manual required that arms remain outside the sling, and the facility could not provide a toileting policy.
A deficiency occurred when the facility failed to follow its own policies for contact isolation and Enhanced Barrier Precautions (EBP). A resident with a history of C. diff, ongoing loose stools, and Vancomycin therapy was not placed on contact precautions, had no isolation or EBP signage or PPE outside the room, and staff entered without PPE. The ID NP was not notified of the change in the resident’s bowel pattern despite facility policy requiring contact precautions for symptomatic C. diff. In addition, multiple residents on the facility’s EBP list for wounds, indwelling urinary catheters, central lines, PEG tubes, and IV access had EBP signage and PPE bins placed inside their rooms instead of outside, and none had EBP orders on their POS. Staff interviews showed inconsistent understanding of EBP implementation, while the IP acknowledged that the facility did not obtain EBP orders and was not following its written EBP policy requiring signage and PPE outside resident rooms.
A resident received continuous topical triamcinolone and miconazole for groin fungal dermatitis over many months without stop dates, despite the skin condition being intermittent and having resolved about a month before surveyors’ observation. MAR review showed the steroid was given twice daily for five months and the antifungal daily for nine months. An LPN reported continuing to apply both medications even when the skin was clear, and the Infection Preventionist confirmed the orders were written as continuous rather than PRN. The Infectious Disease NP noted that long-term triamcinolone use can cause adverse effects and that both medications are typically temporary treatments, while facility policy requires contacting the prescriber when a medication may be inappropriate or excessive, which did not occur.
A resident with multiple comorbidities experienced a fall and reported hip pain, but staff failed to perform a thorough post-fall assessment or timely pain evaluation. The resident's pain worsened over several hours without adequate intervention or prompt transfer for imaging, resulting in a delayed diagnosis of a hip fracture that required surgical repair.
A resident with multiple complex medical conditions experienced a fall resulting in injury, but the facility failed to notify the resident's emergency contact and POA as required. Nursing staff documented the incident and notified the physician, but did not inform the family until the resident's spouse arrived the next day. The resident's pain worsened, leading to hospital transfer and surgical repair of a hip fracture. The administrator and DON confirmed the lack of timely family notification.
A resident with significant mobility limitations and poor bone quality, who required two-person assistance for incontinence care, was rolled and changed by a single CNA. During the process, the resident slid off the bed and sustained bilateral femur fractures, as confirmed by clinical and hospital records. Staff interviews verified that two-person assistance was required but not provided at the time of the incident.
The facility failed to provide necessary ADL assistance and personal hygiene care for residents. A resident was left with her meal out of reach, resulting in her expressing hunger and not eating, despite needing extensive assistance due to severe cognitive impairment. Additionally, two residents were observed with long, unkempt nails, indicating a lack of personal hygiene care, despite their care plans requiring staff assistance.
The facility failed to securely store medications for four residents. Medications were found in residents' rooms without proper orders or secure storage, including eye drops, pain creams, and a pill organizer with unknown pills. The Director of Nursing was unaware of some medications being unsecured, contrary to facility policy.
The facility failed to ensure proper infection control practices, including hand hygiene between resident feedings, handling of soiled linen, and educating visitors on PPE use for a resident under isolation. CNAs were observed not following hand hygiene protocols, and soiled linen was improperly managed. Visitors were not informed about PPE requirements, despite the facility's policy to educate them.
A resident missed significant medications for four days due to the facility's failure to transcribe physician orders upon admission. The resident, with multiple cardiac conditions, did not receive Eliquis and Atorvastatin as prescribed. The error was discovered when the family requested a medication review, revealing missed doses. The oversight was attributed to the nursing staff's failure to review entered orders.
A CNA was observed standing over three residents with severely impaired cognition while feeding them, contrary to the facility's policy requiring staff to sit next to residents during meals to ensure dignity. The DON confirmed that staff should be seated to promote a dignified dining experience.
A resident with multiple medical conditions was found with a mattress that did not fit the bed frame, exposing eight inches of metal and creating a potential hazard. Despite being reported by a CNA and acknowledged by a nurse, the issue remained unaddressed for several days. The Facilities Management Director confirmed the frame required a bariatric mattress, but a regular-sized one was in use. The DON stated it was everyone's responsibility to ensure proper equipment, and a work order should have been sent.
The facility failed to address monthly pharmacy recommendations for two residents, as the DON did not provide the necessary pharmacy regimen reviews and physician responses. The DON admitted to being behind in submitting these reviews to the physician, which is part of the facility's policy to ensure medication efficacy and safety. Documentation for the residents was unavailable, indicating a lapse in the medication review process.
A facility failed to check a resident's blood glucose level before a meal, leading to a potentially inaccurate reading and insulin administration. The resident had multiple diagnoses, including type 2 diabetes and chronic kidney failure. The DON confirmed the correct procedure was not followed and that no policy was in place.
A resident with multiple diagnoses, including pneumonia, received one dose of IV Ampicillin instead of the ordered IV Zosyn due to a delay in medication delivery from the pharmacy. The nurse administered the incorrect antibiotic from the facility's convenience box, and the physician was informed. The facility's medication administration policy was not followed.
Unsafe Sit-to-Stand Lift Use During Incontinence Care Leads to Resident Fall and Head Injury
Penalty
Summary
The facility failed to ensure safe use of a sit-to-stand mechanical lift when a resident’s arms were not kept outside the sling during a transfer, resulting in a fall and head injury. The resident had diagnoses including dementia, anemia, major depressive disorder, degenerative disc disease, GERD, history of falling, cognitive communication deficit, and dysphagia, and the MDS documented severe cognitive impairment and a need for substantial/maximal assistance with transfers. On the day of the incident, a CNA was providing incontinence care to the resident while the resident was positioned in a sit-to-stand mechanical lift. The CNA stood on the resident’s left side and bent over to fasten the right side of the incontinence brief, during which time she could not see the resident’s upper body or hands. While the CNA was bent over, the resident moved her arms inside the sling, raised them, and slid between the belt of the sit-to-stand sling, falling to the floor and sustaining a head laceration that bled and later required five staples at the hospital. The RN who responded found the resident lying on her right side on the floor with a pool of blood under her head and active bleeding from the right side of the head. Staff interviews, including with an RN and the Restorative Nurse, indicated that the resident required close supervision and constant cueing to keep her hands on the lift’s hand grips due to cognitive impairment, and that it was not considered safe to provide incontinence care while a cognitively impaired resident was in a sit-to-stand lift because of balance and visibility issues. The sit-to-stand lift manual specified that the patient’s arms must remain outside the sling, and the facility was unable to provide a policy on toileting.
Failure to Follow Contact Isolation and Enhanced Barrier Precaution Policies
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control policies for contact isolation and Enhanced Barrier Precautions (EBP). One resident with a known history of Clostridium difficile (C. diff) infection was not placed on contact precautions despite having loose bowel movements and receiving Vancomycin for a gastrointestinal issue. On multiple observations, there was no EBP or contact isolation signage on or outside this resident’s room, and no PPE bin was present outside the room. A registered nurse was observed in the room without PPE and stated the resident was not on isolation, even though the resident’s medication administration record showed ongoing Vancomycin therapy and the physician order sheet documented Firvanq for a history of C. diff. The Assistant DON/Infection Preventionist later stated that contact isolation orders for this resident had been discontinued when loose bowel movements had stopped, but that the resident began having loose bowel movements again on subsequent days. The Infection Preventionist acknowledged that the infectious disease nurse practitioner (ID NP) should have been notified when the loose bowel movements resumed so that contact isolation could be reinstated. The ID NP confirmed the resident’s history of C. diff and current Vancomycin treatment and stated he had not been informed of the recent loose bowel movements. He stated that the resident should have been placed back on contact isolation when the loose bowel movements began, consistent with the facility’s Clostridium Difficile Policy, which requires residents with diarrhea associated with C. difficile to be placed on contact precautions. The deficiency also includes the facility’s failure to implement its own EBP policy for multiple residents identified on the facility’s EBP list. For 16 residents on EBP for conditions such as wounds, indwelling urinary catheters, central lines, PEG tubes, and IV access, surveyors observed that EBP signage and PPE bins were placed inside the residents’ rooms rather than on the door or wall outside the room, contrary to facility policy and CDC guidance. Additionally, none of these residents had physician orders for EBP documented on their physician order sheets, despite being listed by the facility as on EBP. Staff interviews revealed inconsistent understanding of where EBP signage and PPE bins should be located, with some nurses stating they should be at the door and others explaining they were placed inside the room so staff could distinguish EBP from contact precautions. The Infection Preventionist confirmed that the facility did not obtain orders for EBP and that signage and PPE bins were intentionally placed inside rooms, even though the written EBP policy required signs and PPE to be posted and available outside resident rooms.
Unnecessary Prolonged Use of Topical Steroid and Antifungal Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s medication regimen was free from unnecessary drugs. Review of the physician order sheet showed continuous orders for triamcinolone acetonide 0.1% ointment twice daily for fungal dermatitis starting 9/17/25 with no stop date, and miconazole nitrate 2% cream daily for groin fungus starting 5/27/25 with no stop date. Medication administration records from May 2025 through February 2026 showed both topical medications were administered as ordered for extended periods, with triamcinolone given twice daily for five consecutive months and miconazole given daily for nine consecutive months. During interviews and observations, an LPN reported that the resident’s groin redness was intermittent and related to hygiene, and that he continued to apply both ointments daily even when the skin appeared clear. On observation, the resident’s bilateral groin was clear with no redness, and the resident stated the redness had resolved about a month earlier while staff continued applying both medications. The Infection Preventionist RN confirmed the orders were written as continuous rather than as needed despite the intermittent nature of the condition. The Infectious Disease NP stated that triamcinolone has potential side effects when used long term and that both triamcinolone and miconazole are usually temporary treatments, indicating triamcinolone should be discontinued and miconazole used only as needed. The facility’s own medication administration policy requires staff to contact a prescriber if a medication is believed to be inappropriate, excessive, or associated with potential adverse consequences, which was not done in this case.
Failure to Provide Timely and Comprehensive Post-Fall Assessment and Pain Management
Penalty
Summary
A resident with a complex medical history, including cancer, heart disease, chronic kidney disease, neurocognitive disorder, and a history of falls, experienced a fall in the facility. The resident reported pain in the left hip and was found sitting on the floor by staff. Nursing documentation indicated that the resident rated the pain as moderate initially, but there was no evidence of a comprehensive post-fall assessment, such as evaluation for range of motion, limb alignment, or a detailed pain assessment. The nurse on duty confirmed that she did not assess for musculoskeletal injury or conduct a complete pain assessment following the incident. Over the next several hours, the resident's pain escalated to severe and was unrelieved by Tylenol. Despite the resident's increasing pain and the absence of timely x-ray imaging, the transfer to the hospital was delayed for approximately five hours. The attending physician stated that she had ordered a hospital transfer based on facility policy for residents on anticoagulants after an unwitnessed fall, but was not aware the resident remained in the facility overnight. The resident was eventually transferred to the hospital, where an acute left hip fracture was diagnosed and surgically repaired.
Failure to Notify Emergency Contact After Resident Fall
Penalty
Summary
The facility failed to notify a resident's emergency contact and legal representative following a significant fall incident. The resident, who had a complex medical history including B cell lymphoma, lung cancer, intracerebral hemorrhage, atrial fibrillation, and other serious conditions, experienced a fall in his room, resulting in head, upper body, and left hip trauma with moderate pain. Nursing documentation confirmed that the physician was notified, but there was no documentation that the resident's emergency contacts were informed of the incident. The incident report also validated that no family notification was made regarding the fall. Subsequent nursing notes indicated that the resident's pain worsened, and the resident was eventually sent to the hospital, where an acute left hip fracture was diagnosed and surgically repaired. Interviews with nursing staff and the resident's spouse and daughter confirmed that neither the emergency contact nor the POA were notified of the fall or the change in the resident's condition until the spouse arrived at the facility the following day. The facility's administrator and DON acknowledged that the family was not notified of the incident, which was contrary to the facility's policy on resident rights.
Resident Fall and Fractures Due to Inadequate Assistance During Incontinence Care
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of osteitis deformans and poor bone quality, who was bedbound and required substantial/maximal assistance for mobility and incontinence care, was not provided adequate supervision and assistance during incontinence care. The resident's care plan and MDS indicated the need for two staff members to assist with rolling and hygiene activities. However, on the day of the incident, a single CNA attempted to change and roll the resident alone. During this process, the resident's legs, described as heavy and difficult to manage, slid off the bed due to the slippery air mattress and lack of control, resulting in the resident falling to the floor. Multiple staff interviews confirmed that the resident required two-person assistance for such care, and the CNA involved acknowledged she was alone at the time. The fall led to the resident sustaining bilateral femur fractures, as confirmed by clinical notes, hospital records, and an orthopedic surgeon. The incident was directly linked to the failure to follow the required two-person assist protocol for a resident with significant mobility limitations and high risk for injury.
Failure to Provide Adequate ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for residents requiring staff support. One resident, identified as R52, was observed in bed with her lunch placed out of reach, resulting in her meal remaining untouched despite expressing hunger. Her care plan indicated a need for extensive assistance with eating due to severe cognitive impairment and risk of weight loss. The Director of Nursing (DON) acknowledged that R52's care needs had changed to hospice, necessitating staff attempts to feed her and provide adequate time for eating. Additionally, the facility did not provide necessary personal hygiene care for several residents. R11 was observed with long, jagged fingernails and reported not receiving nail care for weeks, despite his care plan indicating a need for supervision in personal hygiene. R46 had long toenails and could not recall his last toenail care, although his care plan required moderate assistance with personal hygiene. R60 also had long, jagged fingernails and expressed a desire for staff assistance with nail care. The DON confirmed that staff should provide nail care as needed for infection control, dignity, and safety.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were safely and securely stored for four residents. For one resident, medications including eye drops, pain-relieving cream, and gas relief tablets were found on end tables in her room without a physician's order for them to be unlocked and at the bedside. The resident's sister confirmed she brought these medications from home. Another resident had a pill organizer with unknown pills, which she believed the nurses were administering, but the assigned nurse stated she did not use medications from the organizer. The Director of Nursing was unaware of the pill organizer's presence. A third resident had a glycerin laxative suppository and cortisone cream on her end table, which were brought from home, but there were physician orders for these medications. The facility's policy requires home medications to be collected and locked until a physician's order is obtained. Lastly, a fourth resident had two bottles of lubricant eye drops in his room, which were not ordered in his electronic health record. The Director of Nursing acknowledged that these should not have been in the resident's room unsecured.
Infection Control Deficiencies in Hand Hygiene, Linen Handling, and Visitor Education
Penalty
Summary
The facility failed to ensure proper hand hygiene and handling of soiled linen, as well as educating visitors on isolation practices, leading to multiple deficiencies in infection control. During a dining observation, a CNA was seen feeding multiple residents without cleaning her hands between assisting each resident, contrary to the facility's hand hygiene policy. Another CNA provided incontinence care without changing gloves or performing hand hygiene after moving from a contaminated area to a clean area. Additionally, soiled linen was improperly handled by being carried against a CNA's clothing and left on the floor, violating the facility's policy on handling soiled laundry. Furthermore, the facility did not adequately educate visitors on the use of PPE for a resident under isolation precautions for rhinovirus. Despite the presence of a registered nurse, visitors were observed not wearing PPE while in close proximity to the resident, and they reported not being informed about the requirement. The facility's policy mandates that visitors be educated on PPE use and that any refusal be documented, which was not adhered to in this instance.
Failure to Transcribe Medication Orders Leads to Missed Doses
Penalty
Summary
The facility failed to transcribe physician medication orders upon admission, resulting in a resident missing significant medications for four days. The resident, who was admitted with conditions including atrial fibrillation, hypertensive heart diseases with heart failure, and other cardiac issues, did not receive her prescribed Eliquis and Atorvastatin. The omission occurred because the registered nurse, who was busy with nighttime medication administration, delegated the task of entering the medication orders to the unit manager. Both nurses failed to review the entered orders, leading to the oversight. The resident's family member discovered the error when they requested a review of the medication list, revealing that the resident had missed eight doses of Eliquis and three doses of Atorvastatin. The Director of Nursing confirmed that the oversight was due to the nursing staff's failure to transcribe the prescribed orders. The resident's physician acknowledged the oversight, noting that it could have led to severe consequences, although fortunately, no adverse events occurred.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to provide care with dignity to three residents during a dining observation. A CNA was observed standing over residents while feeding them, which is contrary to the facility's policy that requires staff to sit next to residents during meals to promote a dignified and home-like environment. This practice was observed with three residents, all of whom have severely impaired cognition and require partial to moderate assistance with eating. The facility's policies on Assistance with Meals and Dignity emphasize the importance of providing meal assistance in a manner that meets individual needs and promotes dignity. The CNA's actions of standing over the residents while feeding them did not align with these policies, as confirmed by the Director of Nursing, who stated that staff should be seated while assisting residents with meals. The residents involved in this deficiency were identified as having severely impaired cognition, highlighting the need for careful and respectful assistance during meals.
Improper Mattress Fit on Bed Frame
Penalty
Summary
The facility failed to ensure a resident's mattress fit the bed frame, creating a potential hazard for injury. This deficiency was observed in a resident with multiple medical conditions, including streptococcal sepsis, urinary tract infection, atrial fibrillation, pulmonary embolism, heart failure, spinal stenosis, and a history of transient ischemic attack and cerebral infarction. The resident's care plan identified them as at risk for falls due to impaired mobility, balance, and cognitive impairment. During observations, it was noted that approximately eight inches of the metal bed frame was exposed on the right side of the bed, indicating that the mattress was too small for the frame. Despite the issue being reported by a CNA to a nurse, and the nurse acknowledging the problem and intending to notify maintenance, the exposed bed frame remained unaddressed for several days. The Facilities Management Director and Associate Director confirmed that the frame was designed for a bariatric mattress, but a regular-sized mattress was in use. The Director of Nursing stated that it was everyone's responsibility to ensure the resident had the appropriate equipment, and a work order should have been sent. The facility's policies on hazardous areas and bed safety emphasize the importance of identifying and addressing equipment-related hazards to ensure resident safety.
Failure to Address Monthly Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly pharmacy recommendations were addressed for two residents, R21 and R51, as part of a sample of 23 residents reviewed for medication review. On December 19, 2024, the surveyor requested the Director of Nursing (DON), identified as V2, to provide all pharmacy monthly medication reviews and physician responses to pharmacy recommendations for these residents from March 2024 to the current date. V2 admitted that he did not have any monthly pharmacy regimen reviews to provide and acknowledged that it was his responsibility to submit the pharmacy reviews to the physician for review. However, he had fallen behind in this process. The facility's policy, dated April 2018, outlines that the consultant pharmacist should use monthly and interim drug regimen reviews to identify potentially problematic medications. The policy requires the physician to adjust medications based on their efficacy, indications, and the presence of clinically significant risks, providing a rationale when necessary. Despite this policy, V2 stated that the process involved the pharmacy emailing him the recommendations, which he was supposed to place in a binder for the physician to sign off on. The physician would then leave the addressed recommendations in the binder for V2 to follow up on. However, documentation for R21 and R51 was not available, indicating a lapse in the established procedure for medication review and follow-up.
Failure to Monitor Blood Glucose Levels Before Meals
Penalty
Summary
The facility failed to obtain a resident's blood glucose level for sliding scale insulin administration prior to the resident eating a meal. This deficiency was observed in a resident who was admitted with diagnoses including sepsis due to MRSA, paroxysmal atrial fibrillation, type 2 diabetes mellitus without complication, non-pressure chronic ulcer on the right foot, and chronic kidney failure. The Physician Order Sheet indicated that blood sugar should be monitored, and insulin aspart administered per sliding scale at 8 AM and 5 PM. On the morning of the incident, the RN checked the resident's blood glucose level after the resident had already finished breakfast, resulting in a reading of 222 and the subsequent administration of 2 units of insulin aspart. The Director of Nursing confirmed that blood glucose levels should be checked prior to eating to avoid false high readings and acknowledged that the facility lacked a policy regarding this procedure.
Failure to Administer IV Antibiotics According to Physician Orders
Penalty
Summary
The facility failed to administer intravenous (IV) antibiotics according to physician orders for one resident. The resident, who had diagnoses including hypertensive heart disease, rhabdomyolysis, acute kidney failure, and pneumonia, was admitted to the facility and had an order for IV Zosyn every 8 hours for 17 days starting on 3/14/24. However, on 3/15/24, the resident received one dose of IV Ampicillin instead of Zosyn because the ordered medication had not arrived from the pharmacy. The nurse administered the incorrect antibiotic from the facility's convenience box, and the physician was informed of the incident. The facility's policy on administering medications, which requires verifying the right medication, dosage, time, and method, was not followed in this instance. The Director of Nursing (DON) confirmed that the resident was sent to the hospital on 3/1/24 due to symptoms including not eating, being only alert and oriented to self, and being sweaty and clammy. The resident was diagnosed with pneumonia and returned to the facility on 3/14/24 with the IV Zosyn order. The Registered Nurse (RN) who administered the incorrect antibiotic acknowledged the error, and the Medical Director confirmed that the resident received one dose of Ampicillin instead of Zosyn before the correct medication was resumed. The facility's failure to follow the physician's orders and its own medication administration policy led to this deficiency.
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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 Batavia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Batavia Rehabilitation And Health Care Center | 0.3 mi | ★★★★★ | 1 | 0 |
| Greenfields Of Geneva | 1.8 mi | ★★★★★ | 6 | 0 |
| Bria Of Geneva | 2.4 mi | ★★★★★ | 0 | 0 |
| North Aurora Living & Rehab Ctr | 3.2 mi | ★★★★★ | 1 | 0 |
| Alpine Care Of St. Charles Llc | 4.3 mi | ★★★★★ | 16 | 0 |
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