Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Genoa Retirement Village during CMS and state inspections, most recent first.
Repeated infection control failures were cited after surveyors observed staff not following PPE, EBP, IV tubing disinfection, and hand hygiene requirements. A CNA entered a room under contact precautions without gown or gloves and later provided care; another CNA provided catheter care without a gown despite EBP signage and orders; an RN reconnected IV tubing to a PICC without disinfecting the tubing end; and an LPN changed a wound dressing without changing gloves or performing hand hygiene between the soiled and clean portions of care.
Infection prevention and control failures were observed during resident care. A CNA entered a room under contact precautions and provided incontinence care without gown or gloves, and another CNA provided catheter care under EBP without a gown. An RN reconnected IV tubing to a PICC line without disinfecting the tubing end after it had been looped into a port, and an LPN changed a heel wound dressing without changing gloves or performing hand hygiene between removing the soiled dressing and applying the clean one.
Inaccurate skin assessment: A resident with CHF, DM2, and CKD had a weekly skin assessment that did not identify a right ankle wound that was later observed as a dark red, scabbed-over area. The resident reported the wound and requested ointment, an LPN was unaware of it, and the DON confirmed the area appeared to have been present before the assessment. A later wound round described the area as dry, stable eschar measuring 1 cm by 1.5 cm with no depth.
Failure to Follow Ordered Heel Wound Care and Offloading: A resident with a stage IV left heel pressure ulcer, osteomyelitis, dementia, and MS did not receive ordered wound care and pressure relief interventions. The wound clinic changed the treatment to daily dressing changes and heel boots for offloading, but the facility did not update the orders or implement the daily care, and staff observed the resident in a wheelchair with the boots left on the couch and feet resting on the chair supports.
Inconsistent HD communication documentation: A resident with ESRD on scheduled HD had a physician order requiring a DCCO form to be completed and sent with the resident. However, the EMR contained only two DCCOs, and the DON confirmed the facility had evidence of HD communications for only four of 10 treatments. RN staff stated forms were scanned into the EMR, while the facility policy required a report from the dialysis provider regarding tolerance, VS, medications, and other care information.
A resident with severe cognitive impairment and multiple comorbidities was not checked for incontinence for over three hours, despite staff stating checks should occur every two hours. The resident was found heavily soiled with urine, with soiling extending through clothing and onto a blanket and shirt. Facility records and staff interviews confirmed the lapse in timely incontinence care.
Repeated Infection Control Failures Across Multiple Residents
Penalty
Summary
The facility failed to have an effective QAPI program to address repeated infection control deficiencies identified during five consecutive comprehensive surveys. Review of the CMS Provider History Profile and CASPER data showed the facility had been cited for infection prevention and control on the four previous comprehensive surveys in February 2018, March 2019, April 2021, and January 2024, and was cited again during the current comprehensive survey with an exit date of 01/27/26. The facility census was 66, and the deficiency had the potential to affect all residents in the facility. For one resident with diagnoses including Parkinson's disease, head injury, pulmonary embolism, CKD, DM2, MRSA, an open scalp wound, depression, heart failure, anxiety, and UTI, the most recent MDS showed a BIMS score of 15 and that the resident was cognitively intact. The resident had an order for contact precautions for an MRSA head wound. Observation showed contact precaution signage at the room door indicating PPE, including gown and gloves, should be donned before entry, but a CNA entered the room without gloves or a gown. The CNA later confirmed she had provided incontinence care and had not donned the appropriate PPE before entering the room and providing care. For another resident with aspiration pneumonia, low back pain, lymphedema, COPD, stage three CKD, white matter disease, history of falls, and cardiomegaly, the MDS showed cognitive impairment, bowel incontinence, an indwelling urinary catheter, and substantial assistance needs with ADLs. The resident had orders and a care plan for enhanced barrier precautions during catheter care, with staff required to wear a gown and gloves during high-contact care. Observation showed EBP signage at the doorway, but a CNA provided urinary catheter care without donning a gown, and the CNA confirmed this during interview. For a resident receiving IV cefepime through a PICC line for infection and inflammatory reaction to a left hip prosthesis and a cutaneous abscess, observation showed an RN administering IV medication by reconnecting IV tubing to the resident's PICC line without disinfecting the end of the IV tubing first. The RN stated the tubing end was looped into a port between medication administrations and verified she did not disinfect the tubing port or end before reconnecting it. Other nurses stated they used a sterile plastic cap between uses and manually disinfected the tubing end before reconnecting it, and one RN stated looped tubing ends should not be used because of infection risk. For a resident with osteomyelitis, dementia, MS, and unhealed pressure ulcers, an LPN was observed changing the dressing on the resident's left heel wound. The resident was seated in a wheelchair with both feet on the footrests. The LPN removed the soiled dressing and then applied the clean ABD pad and gauze while continuing to support the resident's heel with the same gloved hands, without changing gloves or performing hand hygiene between the soiled and clean portions of the wound care. The LPN confirmed this during interview.
Infection Prevention and Control Failures During PPE Use, IV Tubing Handling, and Wound Care
Penalty
Summary
The facility failed to ensure appropriate PPE was used for residents on transmission-based precautions. One resident had an order for contact precautions for an MRSA head wound, and signage at the room door indicated gown and gloves were to be worn before entry. A CNA entered the room without donning gloves or a gown and later confirmed she had provided incontinence care to the resident without the required PPE. The resident’s record showed multiple diagnoses including Parkinson’s disease, diabetes, heart failure, CKD, MRSA, and an open scalp wound, and the most recent MDS indicated a BIMS score of 15. The facility also failed to ensure EBP were followed during catheter care for another resident. That resident had diagnoses including aspiration pneumonia, COPD, stage three CKD, and an indwelling urinary catheter. Her physician orders and care plan directed staff to use EBP, including gown and gloves, during high-contact care activities such as catheter care. During observation, a CNA provided urinary catheter care without donning a gown, and the CNA confirmed she should have worn one. In addition, the facility failed to maintain IV medication administration tubing in a sanitary manner for a resident receiving cefepime via PICC line. During observation, an RN disconnected the IV tubing from a port on the tubing and attached it to the resident’s disinfected PICC line without disinfecting the end of the IV tubing first. The RN stated the tubing end was looped into a port between medication administrations and verified she did not disinfect the tubing port or the end of the tubing before reconnecting it. The resident’s record showed diagnoses including spinal stenosis, peripheral vascular disease, diabetes, heart disease, infection and inflammatory reaction to a left hip prosthesis, and cutaneous abscess. The facility further failed to ensure appropriate hand hygiene during wound dressing changes for a resident with unhealed pressure ulcers. The resident had an order for PRN dressing changes to the left heel wound, with instructions not to remove anything below the steri-strips and to change only the outer dressing components. During observation, an LPN removed the soiled dressing and then continued the wound care without changing gloves or performing hand hygiene before applying the clean dressing materials. The LPN confirmed she did not change gloves or perform hand hygiene between removing the soiled bandage and applying the clean dressing.
Inaccurate Skin Assessment
Penalty
Summary
The facility failed to ensure skin assessments were completed accurately for one resident. The resident was admitted with diagnoses of congestive heart failure, type II diabetes mellitus, and chronic kidney disease, and was oriented to person, place, time, and situation on admission. A physician order directed weekly skin assessments, and the treatment administration history showed no skin findings identified during the skin assessment completed on 01/19/26. On 01/20/26, the resident was observed sitting in a wheelchair with a sock on the left foot and the sock on the right foot pushed down around the arch. During a concurrent interview, the resident stated he had a wound on the outer side of his right ankle and wanted ointment for it. The right ankle was observed to have a dark red area that appeared scabbed over and dry. An LPN confirmed the red area but stated she was not aware of it. The DON observed the area and confirmed it appeared to be scabbed over and likely had been present for more than two days, meaning it was likely present before the weekly skin assessment was completed. The DON later reviewed the record and confirmed the 01/19/26 skin assessment did not identify the area. Another LPN who performed wound rounds stated she assessed the wound on 01/21/26 and described it as dry, stable eschar measuring 1 cm by 1.5 cm with no depth, and stated it would have been present on 01/19/26.
Failure to Follow Ordered Heel Wound Care and Offloading
Penalty
Summary
Pressure ulcer wound treatments and pressure-reducing interventions were not implemented as ordered for a resident admitted with osteomyelitis, dementia, and multiple sclerosis who had an unhealed stage IV pressure ulcer to the left heel. The resident’s quarterly MDS indicated intact cognition, wheelchair use, and dependence for some activities of daily living, and the outside wound clinic had been following the heel wound weekly for Kerecis treatments. During that treatment period, the clinic orders directed the facility to leave the Versatel and everything underneath in place, change only the outer alginate, ABD, and rolled gauze every three days and as needed for drainage, and pad and protect the top of the left foot with foam or an ABD pad. On the wound clinic visit, the left heel ulcer measured 3.6 cm by 0.8 cm by 0.1 cm and a new order was written for daily collagen dressing changes with copper alginate, ABD, and rolled gauze, along with heel boots to offload the heels even while in a chair. The facility did not update the wound care orders to reflect the new daily treatment or the heel boot requirement, and staff confirmed the resident did not receive the daily wound treatments from the wound clinic order period. Observation showed the resident sitting in a wheelchair with socks on both feet and feet resting on the hard plastic foot supports, while the offloading boots were on the couch. Staff also confirmed the boots were not being used and that the wound was not being cleaned or treated per the wound clinic’s daily order.
Inconsistent HD Communication Documentation
Penalty
Summary
The facility failed to ensure consistent communication with the hemodialysis (HD) clinic for one resident receiving offsite HD. The resident was admitted with end stage renal disease with dependence on HD and type II diabetes mellitus, and the admission MDS indicated intact cognition and that the resident received dialysis. A physician order dated 12/28/25 directed the resident to attend HD on Tuesdays, Thursdays, and Saturdays and required staff to complete a Dialysis Center Communication Observation (DCCO) form and send it with the resident. Review of the resident’s EMR showed only two DCCOs, dated 01/10/26 and 01/17/26, while two additional hard-copy DCCOs were available for HD completed on 01/13/26 and 01/20/26. RN #508 stated the facility scanned HD communication forms into the EMR and did not keep hard copies or an HD notebook for the resident, and the DON confirmed the facility only had evidence of HD communications for four of 10 HD treatments. The facility policy titled, Guidelines for Dialysis, stated that a report from the dialysis provider, written or verbal, should be requested to alert the campus regarding tolerance to procedure, vital signs, medications administered, and other information needed for ongoing care.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, Parkinson's disease, dementia, and other significant diagnoses was not provided timely incontinence care. The resident, who was dependent on staff for all activities of daily living and at risk for pressure ulcers, was observed seated in a reclined wheelchair in the common area for over three hours without being checked for incontinence. Staff interviews confirmed that the resident was supposed to be checked every two hours, but it had been approximately 3.5 hours since the last check. Upon being transferred to bed, the resident was found to be heavily soiled with urine, which had soaked through the incontinence brief, clothing, and onto a blanket and shirt. Review of the resident's care plan and facility policies indicated that incontinence care was to be provided as needed, with frequent rounding and individualized interventions to maintain a clean and dry condition. However, the resident's profile did not specify a clear interval for incontinence checks, and staff relied on general instructions rather than specific timing. The failure to provide timely incontinence care resulted in the resident remaining soiled for an extended period, as confirmed by both observation and staff interviews.
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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 Genoa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Otterbein Portage Valley | 6.5 mi | ★★★★★ | 2 | 0 |
| The Gardens Of St. Francis | 9.1 mi | ★★★★★ | 12 | 0 |
| Windsor Lane Healthcare Center | 9.5 mi | ★★★★★ | 6 | 0 |
| Majestic Care Of Perrysburg | 9.6 mi | ★★★★★ | 39 | 0 |
| Ayden Healthcare Of Oregon | 9.7 mi | ★★★★★ | 11 | 0 |
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