Below 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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Geneva Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
A resident with multiple chronic conditions expressed a desire to leave the facility and live in the community, but the care plan was not updated to reflect this preference, and staff did not assist with community discharge planning or document referrals to local agencies, as required by facility policy. The resident ultimately left the facility without a formal discharge plan, and her representative reported a lack of support for her discharge goals.
A resident with impaired cognition and bowel incontinence was admitted with a coccyx pressure ulcer, but the facility failed to document or provide necessary wound care. This led to the resident being hospitalized for an extensive pressure ulcer with cellulitis. Upon readmission, wound care was again delayed, despite the resident's complex medical history. Interviews confirmed the lack of timely wound care, contrary to facility policy.
The facility failed to maintain kitchen cleanliness and did not properly monitor the dish machine for effective sanitization. Staff were unaware of the correct temperature and chemical levels for the dish machine, and incorrect test strips were used. The monthly records were inaccurately filled, and the kitchen equipment was found dirty. This affected the potential safety of 63 residents.
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling medical devices, as required by guidelines. Observations revealed that a resident with a PICC line and another with an indwelling urinary catheter lacked EBP signage and PPE at room entrances. Staff placed PPE on the floor due to improper setup. Additionally, a resident with an enteral feeding tube and another with a PICC line had EBP signage, but staff did not wear gowns during procedures, contrary to policy.
The facility did not ensure that STNAs received annual performance evaluations, as confirmed by a review of employee files and an interview with the HR Director. This affected two STNAs hired in December 2022 and had the potential to impact all 63 residents.
The facility failed to maintain comprehensive care plans and Kardexes for residents, resulting in deficiencies in care. A resident with edema did not have a care plan for her midline IV catheter, and her embolic stockings were not applied as ordered. Another resident with hemiparesis was not wearing prescribed embolic stockings due to incomplete documentation. A third resident's oxygen use was not addressed in his care plan, and safety measures were lacking. Additionally, a resident with a hand contraction did not have a care plan for a prescribed orthotic.
The facility failed to prepare pureed green beans correctly, affecting five residents on pureed diets. A staff member added excessive cooking water to the blender, resulting in a thin mixture. To correct this, a thickener was added multiple times, diluting the taste and nutrient density. The staff member confirmed the error in preparation.
The facility failed to provide privacy for urinary catheter drainage bags for three residents, affecting their right to a dignified existence. Observations showed that the catheter bags were exposed to public view without privacy coverings, as confirmed by staff interviews. Despite care plans indicating the need for privacy, the facility did not ensure the catheter bags were covered or positioned out of public view.
Two residents in the facility did not have embolic stockings applied as ordered by their physicians, despite having edema. One resident with congestive heart failure and another with hemiparesis were observed without the stockings, and staff interviews revealed a lack of awareness of the orders due to missing information in the Kardex and care plans. The facility's policy required verification of orders and application of stockings in the morning, which was not followed.
A facility failed to obtain physician's orders and provide adequate care for a resident's indwelling urinary catheter. The resident, with conditions including pneumonia and chronic kidney disease, had no orders for catheter care upon admission, and records showed no evidence of care being provided. This deficiency was confirmed by the ADON.
A facility failed to monitor and maintain a midline IV catheter for a resident with congestive heart failure, hypertension, and COPD. The resident's care plan lacked details on the catheter, and there were no orders for its maintenance or monitoring. Staff interviews revealed a lack of awareness and documentation, and the facility's policy for catheter maintenance was not followed, affecting the resident and potentially another with IV access.
The facility failed to provide proper respiratory care for two residents, including missing oxygen orders, unsecured oxygen cylinders, and absent safety signage. One resident with cognitive impairment was observed with an unsecured oxygen cylinder and no care plan for oxygen use. Another resident with chronic respiratory issues received oxygen without physician orders or safety signage, contrary to facility policy.
The facility failed to address pharmacy recommendations in a timely manner for three residents. A resident continued to receive trazadone in half tablets despite recommendations to change the dosing regimen. Another resident was prescribed Seroquel without a proper diagnosis, and recommendations to discontinue or add a diagnosis were ignored. A third resident's PRN medication orders lacked specific usage parameters, and recommendations to clarify them were not addressed.
The facility failed to conduct reference checks for four newly hired staff members, including an LPN, two STNAs, and a Maintenance Director. This oversight was confirmed by the HR Director and had the potential to affect all 63 residents in the facility.
The facility failed to obtain signed and witnessed authorizations before managing funds for three residents. One resident had $50.00 deposited without a witness signature, another had $5.00 deposited without any authorization form, and a third had previously managed funds without documented authorization. These issues were confirmed by the HR Director.
Failure to Revise Care Plan and Assist with Community Discharge Planning
Penalty
Summary
A deficiency was identified when the facility failed to revise a resident's comprehensive care plan to reflect her expressed desire to live in the community and did not provide adequate discharge planning assistance. The resident, who had multiple diagnoses including multiple sclerosis, diabetes, anxiety disorder, bipolar disorder, schizoaffective disorder, and major depression, was admitted with an initial care plan indicating long-term placement. Although the resident initially agreed to stay at the facility, she later communicated her wish to leave and live independently in an apartment, despite previous eviction issues. Documentation showed that after the resident expressed her intent to leave, the facility offered referrals to other facilities, which she declined, but did not explore or document other community-based options. There was no evidence in the care plan or nursing notes that her request to return to the community was addressed or that interventions were implemented to support her discharge goal. The facility's own policy required documentation of the resident's preferences and referrals to local contact agencies, but this was not done. Interviews with the social service designee and the resident's mother confirmed that the resident's preference for community living was not incorporated into her care plan, and no efforts were made to assist her in finding community options. The resident ultimately left the facility without a formal discharge plan, and her mother reported that the facility did not provide support for her daughter's goal to live outside the facility.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide comprehensive and individualized pressure ulcer care for a resident, leading to actual harm. The resident, who had impaired cognition and bowel incontinence, was admitted with a coccyx pressure ulcer. Despite the presence of a wound, the facility did not document any wound care or treatment being initiated from the time of admission. This lack of action resulted in the resident being transferred to the emergency room, where an extensive coccyx/sacral pressure ulcer with surrounding cellulitis was identified, necessitating hospitalization for wound care intervention and intravenous antibiotic treatment. Upon the resident's readmission to the facility, there was again a failure to initiate wound care promptly. The resident was readmitted for continued wound care and treatment, but no wound care was documented until several days later. The facility's inaction persisted despite the resident's complex medical history, which included diabetes mellitus type II, chronic obstructive pulmonary disease, and protein-calorie malnutrition, all of which could complicate wound healing. Interviews with facility staff confirmed the absence of wound care or treatment during critical periods, both after the initial admission and following the resident's readmission. The facility's policy required examination and treatment of pressure ulcers upon admission, but this protocol was not followed, resulting in the resident's condition worsening and requiring hospitalization.
Kitchen Sanitation and Dish Machine Monitoring Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner and did not ensure that the dish machine was monitored for effective sanitization. During an initial kitchen tour, it was observed that the dietary staff, including the Dietary Manager and workers, were not knowledgeable about the correct temperature and chemical levels required for the dish machine. The Dietary Manager used an incorrect test strip meant for Quaternary solutions, which did not provide any results for the dish machine's chemical level. Additionally, the dietary worker was observed using the same gloves for handling both dirty and clean dishes, and the kitchen equipment, such as utensil drawers and carts, were found to be dirty with crumbs and food debris. Further investigation revealed that the monthly records for the dish machine's temperature and chemical levels were inaccurately filled out, indicating a consistent final rinse of 50 to 100 ppm, despite the facility not having the correct test strips available. Interviews with the Dietary Manager confirmed that the dish machine sanitization levels had not been tested correctly, and the records for May 2024 were inaccurate or falsified. The Dietary Manager admitted to using the wrong test strips for an unspecified duration, which could potentially affect the 63 residents residing in the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for residents with indwelling medical devices, as required by the guidelines from the Centers for Medicare & Medicaid Services. Observations revealed that Resident #262, who had a PICC line for IV antibiotic therapy, did not have EBP posted or personal protective equipment (PPE) available at the room entrance. Similarly, Resident #264, with an indwelling urinary catheter, lacked EBP signage and PPE at the room entrance. Staff members were observed placing PPE on the floor due to the absence of proper setup. Resident #56, who required an enteral feeding tube, had EBP signage, but the registered nurse administering medications did not wear a gown as required. Additionally, Resident #313, with a PICC line for IV antibiotic administration, had EBP signage, but the Assistant Director of Nursing did not wear a gown during medication administration. The facility's policy on Disease-Specific Isolation/Precautions, initiated on 04/01/24, required the use of EBP for residents with indwelling medical devices, even if the infectious status was unknown. The failure to adhere to these guidelines was confirmed through interviews with staff members, who acknowledged the absence of EBP and the lack of gown usage during high-contact resident care activities.
Failure to Conduct Annual Performance Evaluations for STNAs
Penalty
Summary
The facility failed to ensure that state-tested nursing aides (STNAs) received their required annual performance evaluations. This deficiency was identified during a review of employee files, which revealed that two STNAs, hired in December 2022, did not have documented evidence of receiving annual performance evaluations. The absence of these evaluations was confirmed during an interview with the Human Resources Director, who acknowledged that the facility did not conduct annual evaluations for their employees. This oversight had the potential to impact all 63 residents residing in the facility.
Incomplete Care Plans and Kardexes Lead to Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure comprehensive care plans and Kardexes were complete for several residents, leading to deficiencies in care. Resident #16, who had diagnoses including congestive heart failure and hypertension, was on diuretic therapy for edema but did not have a care plan addressing her midline IV catheter. Despite having orders for embolic stockings, these were not applied, and the Kardex did not reflect this requirement. Staff interviews revealed a lack of awareness and responsibility for updating the Kardex, resulting in the resident not receiving the necessary care. Resident #50, with a history of hemiparesis and cognitive impairment, also had orders for embolic stockings due to edema, which were not documented in the care plan or Kardex. Observations confirmed the resident was not wearing the stockings, and staff were unaware of the order, relying solely on the incomplete Kardex for guidance. This oversight led to the resident not receiving the prescribed treatment for her condition. Resident #52, who was cognitively impaired and required oxygen therapy, did not have a care plan addressing his oxygen use. Observations noted the absence of safety measures, such as signage and proper storage for oxygen cylinders. Similarly, Resident #14, with a hand contraction, lacked a care plan for the use of a prescribed hand orthotic. Staff interviews indicated a lack of communication and documentation regarding the orthotic, resulting in the resident not using it as intended.
Improper Puree Preparation Affects Nutrient Density
Penalty
Summary
The facility failed to properly prepare pureed green beans in a manner that preserved their nutrient value and taste, affecting five residents who required pureed consistency foods. During an observation, a staff member added green beans and a large amount of cooking water to a blender, resulting in a mixture that was too thin. To correct the consistency, the cook added a thickener multiple times, which diluted the taste and nutrient density of the green beans. The staff member acknowledged that too much water had been used, necessitating the addition of thickener to achieve the correct consistency.
Failure to Ensure Privacy for Urinary Catheter Drainage Bags
Penalty
Summary
The facility failed to provide privacy for urinary catheter drainage bags for three residents, affecting their right to a dignified existence and privacy. Observations revealed that the urinary catheter drainage bags for Residents #25, #56, and #264 were positioned in a manner that exposed them to public view from the hallway, without any privacy covering. This was confirmed through interviews with staff members, including a State Tested Nursing Assistant (STNA) and a Registered Nurse (RN), who acknowledged the lack of privacy coverings and improper positioning of the catheter bags. Resident #25, diagnosed with neuromuscular dysfunction of the bladder, multiple sclerosis, and diabetes mellitus type II, had a suprapubic catheter, with care plans indicating the need for privacy. Similarly, Resident #56, with urinary retention and diabetes mellitus type II, had an indwelling urinary catheter, and Resident #264, recently admitted with chronic kidney disease and pneumonia, also had an indwelling catheter. Despite care plans specifying the need for privacy, the facility did not ensure the catheter bags were covered or positioned out of public view, leading to the deficiency.
Failure to Apply Embolic Stockings as Ordered
Penalty
Summary
The facility failed to ensure that embolic stockings were applied as ordered by the physician for two residents, Resident #16 and Resident #50, who were reviewed for edema. Resident #16, diagnosed with congestive heart failure, hypertension, and chronic obstructive pulmonary disease, had a physician's order for TED hose to be applied in the morning and removed at night due to bilateral lower extremity edema. However, observations on multiple occasions revealed that Resident #16 was without embolic stockings, despite having moderate edema. Interviews with staff, including a State tested Nurse Aide (STNA) and an Agency Registered Nurse (RN), confirmed that the embolic stockings were not applied as ordered, and the Kardex did not include instructions for the stockings. Similarly, Resident #50, who had difficulty walking, hypertension, hemiplegia, and hemiparesis following a cerebral infarction, also had a physician's order for embolic stockings to be applied in the morning and removed at night. Observations showed that Resident #50 was without embolic stockings and had swelling in her lower extremities. Interviews with the STNA and Agency RN revealed that they were unaware of the order for embolic stockings, as it was not documented in the Kardex or care plan. The RN admitted to signing off on the application of the stockings without verifying their use. The facility's policy on applying anti-emboli stockings, dated October 2010, required staff to verify orders for stockings and review care plans for any special needs of residents. The policy also stated that stockings should be applied in the morning before residents get out of bed. The failure to adhere to these procedures resulted in the deficiency, as the residents did not receive the prescribed care to manage their edema.
Failure to Provide Adequate Catheter Care
Penalty
Summary
The facility failed to obtain physician's orders and provide adequate care for an indwelling urinary catheter for a resident. The resident, who was recently admitted, had diagnoses including pneumonia, chronic kidney disease stage III, and diabetes mellitus. Upon admission, the baseline plan of care indicated the presence of an indwelling urinary catheter. However, there were no physician's orders to monitor, maintain, or care for the catheter from the time of admission. Additionally, the medication and treatment administration records showed no evidence of catheter care being provided during this period. This deficiency was confirmed through an interview with the Assistant Director of Nursing.
Failure to Monitor and Maintain Midline IV Catheter
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of a midline intravenous catheter for Resident #16, who was admitted with diagnoses including congestive heart failure, hypertension, and chronic obstructive pulmonary disease. The resident's comprehensive care plan did not include any information regarding the midline IV catheter, and the quarterly Minimum Data Set assessment did not reflect any IV therapy. Despite orders for IV fluids, there were no subsequent orders or documentation for maintaining or monitoring the midline catheter, such as flushing or checking for signs of infection. Interviews with facility staff revealed a lack of awareness and documentation regarding the midline catheter's maintenance. The Assistant Director of Nursing confirmed that there were no physician orders or documented evidence of monitoring the catheter per facility policy or manufacturer guidelines. The facility's policy required flushing and assessing catheter function at least every 24 hours, but this was not followed. The oversight affected Resident #16 and had the potential to affect another resident with IV access.
Deficiency in Respiratory Care and Oxygen Management
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, which included the absence of oxygen orders, unsecured oxygen cylinders, and missing oxygen safety signage. Resident #52, who was cognitively impaired and had diagnoses including congestive heart failure and hypertension, was observed receiving oxygen without a sign indicating its use. Additionally, an E-cylinder was found freestanding next to his bed, contrary to the facility's policy requiring cylinders to be secured in appropriate storage racks. The Director of Nursing confirmed these observations, and it was verified that Resident #52's care plan did not include his oxygen use. Resident #264, diagnosed with pneumonia, chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease, was observed receiving continuous oxygen at three liters per minute without any physician's orders for oxygen or monitoring of blood oxygenation saturation. A CPAP machine was present, but no oxygen safety signage was posted. An LPN confirmed the absence of oxygen-related orders and signage, which was against the facility's policy that mandates a physician's order before administering oxygen and the placement of an 'Oxygen in Use' sign.
Failure to Address Pharmacy Recommendations Timely
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed by the physician in a timely manner, affecting three residents. For Resident #15, the pharmacist recommended changing the dosing regimen of trazadone to avoid administering half tablets. Despite multiple recommendations made on 06/12/23 and 07/17/23, the forms remained unsigned, and no changes were made until 10/17/23. This delay was confirmed by the Regional Travel Director of Nursing during an interview. Resident #21 was prescribed Seroquel without a proper diagnosis to support its use. The consultant pharmacist repeatedly recommended discontinuing the medication or adding a supporting diagnosis on 06/12/23, 07/17/23, 08/23/23, and 09/21/23. These recommendations were not signed or addressed, and the resident continued to receive the medication from 04/06/23 to 10/17/23 without a supporting diagnosis. This oversight was verified by the Regional Travel Director of Nursing. For Resident #25, the pharmacist recommended specifying the conditions under which PRN medications acetaminophen and Norco should be used. Recommendations made on 03/25/24 and 04/28/24 were not completed, and there was no evidence that the physician was notified or addressed the recommendations. As of May 2024, no changes were made to the PRN orders to specify parameters for use, contrary to the facility's medication therapy policy.
Failure to Conduct Reference Checks for New Hires
Penalty
Summary
The facility failed to ensure that all staff members received reference checks before being hired, affecting four employees: an LPN, two STNAs, and a Maintenance Director. This deficiency was identified during a record review and interview process. The review of employee files revealed no evidence that the facility made reference checks or attempted to verify information from past or current employers for these staff members. The Human Resources Director confirmed the findings and was unable to provide documented evidence of any reference checks for the affected employees. This oversight had the potential to impact all 63 residents residing in the facility.
Failure to Obtain Proper Authorization for Managing Resident Funds
Penalty
Summary
The facility failed to ensure proper authorization was obtained before managing resident funds, affecting three out of five residents reviewed for funds management. Resident #55 had $50.00 deposited in the facility's resident trust account without a witness signature on the authorization form. Resident #39 had $5.00 deposited in the trust account, but the facility could not provide documented evidence of a signed or witnessed authorization form. Similarly, Resident #61 had previously managed funds in a trust account that was closed, but the facility lacked documented evidence of a signed or witnessed authorization form for managing his personal money. These findings were confirmed during an interview with the Human Resources Director.
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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) |
|---|---|---|---|---|
| Pine Grove Healthcare Center | 0.4 mi | ★★★★★ | 1 | 0 |
| Rae Ann Geneva | 1 mi | ★★★★★ | 9 | 0 |
| Madison Health Care | 3.5 mi | ★★★★★ | 0 | 0 |
| Austinburg Nsg And Rehab Ctr | 4.8 mi | ★★★★★ | 0 | 0 |
| Cardinal Woods Skilled Nursing & Rehab Ctr | 5.4 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 June 2026) and official state health department websites.