Inspection Reports for
GreenFields of Geneva
0N801 Friendship Way, Geneva, IL 60134, United States, IL, 60134
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
129% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
55% occupied
Based on a November 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 10, 2026
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure safe transfer of a resident (R1) using a gait belt to prevent falls.
Complaint Details
The complaint investigation found that the resident (R1) fell during transfer due to staff not using a gait belt as required. The fall was substantiated with evidence from staff interviews, resident statements, and medical records.
Findings
The facility failed to ensure that resident R1 was properly transferred with a gait belt, resulting in a fall on 12/21/2025. Staff interviews and record reviews confirmed inconsistent use of gait belts during transfers despite policy and therapy recommendations.
Deficiencies (1)
F 0689: The facility failed to ensure that a resident was safely transferred using a gait belt, resulting in a fall. Staff did not consistently use gait belts during transfers despite resident dependency and therapy recommendations.
Report Facts
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Registered Nurse | Witnessed fall and provided statements about gait belt use |
| V5 | Certified Nursing Assistant | Involved in transfer of resident at time of fall and admitted not using gait belt |
| V7 | Physical Therapist | Provided clarification on transfer assistance and gait belt use |
| V2 | Director of Nursing | Provided policy and statements on gait belt use |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 9, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state regulations for the facility.
Findings
The facility failed to ensure that a comprehensive physician assessment was completed annually for one resident. Additionally, service plans for three residents did not address required elements such as activities of daily living and medication administration, and were not signed by residents or their representatives.
Deficiencies (2)
Failed to ensure a comprehensive physician assessment was completed at least annually for a resident (R5).
Service plans did not address level of service including activities of daily living and medication administration, and were not signed by residents or representatives for residents R1, R4, and R6.
Report Facts
Residents reviewed for physician assessment: 6
Residents involved in service plan deficiencies: 3
Admission date: Mar 29, 2024
Admission date: May 2, 2024
Admission date: Apr 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding physician assessment and service plan deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 9, 2024
Visit Reason
This document is a Plan of Correction submitted by Greenfields of Geneva in response to deficiencies identified during an annual survey conducted on 12/9/2024.
Findings
The Plan of Correction outlines corrective actions taken to address deficiencies related to physician certification and service plans, including audits, policy revisions, education, and quality assurance monitoring to prevent recurrence and ensure compliance.
Deficiencies (2)
Deficiency related to physician certification for resident R5.
Deficiency related to service plans for residents R1, R4, and R6.
Report Facts
Completion Date: Dec 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janet Woodard | Physician | Signed physician certification for resident R5 on 12/11/24. |
| Laura A. Shermer | User | User listed on medication review report dated 12/10/2024. |
Inspection Report
Routine
Census: 42
Deficiencies: 4
Date: Nov 8, 2024
Visit Reason
Routine inspection of Greenfields of Geneva nursing home to assess compliance with medication storage, medication administration, food safety, and antibiotic stewardship regulations.
Findings
The facility failed to safely store medications at bedside without proper orders or assessments, failed to administer medications as ordered resulting in a 6.67% medication error rate, and failed to maintain proper food labeling, storage, and hygiene practices in the kitchen. Additionally, the facility did not discontinue antibiotics appropriately for a resident who did not meet criteria to continue treatment.
Deficiencies (4)
F 0554: The facility failed to safely store medications for residents without orders or assessments allowing bedside storage or self-administration. This applied to 4 of 4 residents reviewed for medication storage.
F 0759: The facility failed to administer medications as ordered, resulting in 2 errors out of 30 opportunities (6.67% error rate) during medication pass observation for 1 of 5 residents observed.
F 0812: The facility failed to properly label, date, seal, store items, remove expired items, and wear hair restraints while serving food from the facility kitchen, affecting all residents receiving oral nutrition.
F 0881: The facility failed to discontinue antibiotics for a resident who did not meet criteria to continue antibiotic therapy, affecting 1 of 3 residents reviewed for antibiotic stewardship.
Report Facts
Medication error rate: 6.67
Total census: 42
Expired food items: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements regarding medication storage and administration policies |
| V6 | Registered Nurse | Observed medication pass and provided statements on medication administration and documentation |
| V7 | Registered Nurse | Provided statements on medication storage and administration policies |
| V8 | Infection Preventionist/Registered Nurse | Provided information on antibiotic stewardship and resident antibiotic use |
| V3 | Interim Dietary Manager | Provided information and observations during kitchen inspection |
| V4 | Executive Chef | Provided information and observations during kitchen inspection |
| V5 | Server | Observed serving meals without proper hair restraint |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Dec 14, 2023
Visit Reason
The inspection was conducted based on complaints and concerns regarding pressure ulcer care, resident safety with motorized wheelchair use, infection control during peri care, oxygen administration, medication management, medication error rates, medication storage, meal/snack provision, and food storage conditions.
Complaint Details
The visit was complaint-related, triggered by concerns about pressure ulcer care, resident safety with motorized wheelchair use, infection control during peri care, oxygen administration, medication management, medication error rates, medication storage, meal/snack provision, and food storage conditions. Specific substantiation status is not stated.
Findings
The facility was found deficient in multiple areas including failure to prevent pressure ulcers leading to hospitalization, inadequate safety assessment for motorized wheelchair use resulting in injury, improper peri care causing cross contamination risk, lack of physician orders for oxygen administration, inaccurate narcotic medication documentation, medication administration delays, improper medication storage, failure to provide evening snacks, and poor food storage and sanitation practices.
Deficiencies (9)
F 0686: The facility failed to identify and treat a pressure injury before it became unstageable, resulting in hospitalization for osteomyelitis in resident R27.
F 0689: The facility failed to assess resident R6 for safety prior to use of a motorized wheelchair, resulting in injury requiring 30 stitches.
F 0690: The facility failed to perform peri care properly for resident R100, using contaminated gloves and risking cross contamination.
F 0695: The facility failed to obtain a physician order and care plan for oxygen administration for resident R96.
F 0755: The facility failed to document and maintain accurate narcotic medication counts for residents R6 and R95.
F 0759: The facility failed to administer medications at ordered times, resulting in a 12% medication error rate for resident R145.
F 0761: The facility failed to store insulin medications per manufacturer directions and facility policy for residents R11 and R37.
F 0809: The facility failed to provide evening snacks to 5 residents who requested them and were not on restricted diets.
F 0812: The facility failed to maintain proper food storage conditions including food on the floor, expired items, unclean ice cream freezer, and lack of temperature monitoring.
Report Facts
Medication error rate: 12
Sutures: 30
Pressure injury size: 4
Pressure injury size: 8
Narcotic count discrepancy: 2
Residents without evening snacks: 5
Facility census: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements regarding pressure injury reporting, peri care glove use, oxygen administration orders, medication administration, medication storage, and snack provision. |
| V3 | Wound Care Nurse | Reported on resident R27's pressure injury and expectations for early detection. |
| V7 | Registered Nurse | Administered medications and commented on wound care and narcotic documentation. |
| V8 | Registered Nurse | Administered narcotics, performed narcotic counts, and managed oxygen administration. |
| V15 | Occupational Therapist | Provided assessment on resident R6's motorized wheelchair use and safety. |
| V16 | Physical Therapist | Provided assessment on resident R6's ability to safely operate motorized wheelchair. |
| V17 | Resident's Daughter | Provided information about motorized wheelchair use by resident R6. |
| V2 | Director of Nurses/Infection Control Preventionist | Provided infection control statements regarding glove use during peri care. |
| V5 | Chef | Provided information about food storage and ice cream freezer conditions. |
| V6 | Interim Dietary Manager | Acknowledged food storage issues and cleaning deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 25, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall incident at the nursing home.
Complaint Details
The investigation was triggered by a complaint related to a resident fall on 7/3/2023. The fall was substantiated as the resident was left unsupervised on the commode and fell while trying to self-transfer, resulting in a fracture.
Findings
The facility failed to supervise a resident (R1) who fell while attempting to self-transfer from the commode to her wheelchair, resulting in a displaced fracture of the left distal femoral shaft requiring surgery. The resident had a history of multiple falls while unsupervised in the bathroom over the past year.
Deficiencies (1)
F 0689: The facility failed to ensure adequate supervision to prevent a resident's fall, resulting in actual harm to the resident who sustained a fractured left femur requiring surgery.
Report Facts
Resident falls: 8
Hospital stay duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V10 | Certified Nurse's Assistant | Reported finding resident R1 on the bathroom floor after fall |
| V9 | Certified Nurse's Assistant | Left resident R1 unattended on commode to assist another resident |
| V8 | Nurse | Authorized leaving resident R1 unattended on commode |
| V11 | Director of Nursing | Stated expectations for supervision of resident R1 in bathroom |
| V12 | Primary Care Physician | Stated expectations for supervision of resident R1 in bathroom |
| V13 | Administrator | Stated expectations for supervision of resident R1 in bathroom |
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 5
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards in multiple areas including resident care, safety, and food handling.
Findings
The facility was found deficient in providing timely incontinence care, pressure ulcer prevention and treatment, range of motion exercises, safe resident transfers, and proper food handling practices including hair net use and food storage.
Deficiencies (5)
F 0677: The facility failed to provide timely incontinence care to a resident, resulting in a saturated brief left unchanged for 6 hours, risking skin breakdown and urinary tract infections.
F 0686: The facility failed to provide pressure ulcer prevention and timely treatment for a resident with a full thickness wound, including lack of documentation of dressing changes.
F 0688: The facility failed to provide range of motion exercises to a resident with muscle wasting disease, delaying initiation of passive ROM therapy until the day before the survey.
F 0689: The facility failed to use a gait belt when transferring a high fall risk resident requiring one, increasing risk of injury during transfers.
F 0812: The facility failed to ensure dietary staff wore hair nets, properly thawed frozen foods, and covered bulk food containers, risking foodborne illness.
Report Facts
Residents: 40
Residents reviewed: 13
Residents reviewed for pressure ulcers: 4
Residents reviewed for safety and supervision: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements regarding incontinence care policy, wound care documentation, and transfer safety |
| V4 | Executive Chef | Observed and commented on improper thawing of frozen meat and hair net use in kitchen |
| V3 | Director of Dining | Provided expectations for food thawing, hair net use, and food storage |
| V5 | Wound Care Nurse | Provided information on wound care treatment and documentation |
| V7 | Certified Nursing Assistant | Observed transferring resident without gait belt and admitted fault |
| V8 | Registered Nurse | Provided statements on wound care and gait belt use |
| V9 | Restorative Nurse | Discussed ROM therapy responsibilities and resident's lack of ROM program |
| V10 | Certified Nursing Assistant | Provided statements about ROM exercises during dressing |
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