Geneva Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Geneva Center for Rehabilitation and Nursing, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 3, 2024

  Based on observation, record review, facility policy review and interview the facility failed to provide comprehensive, individualized and necessary pressure ulcer assessment and care for Resident #56. This affected one resident (#56) of two residents reviewed for pressure related wound care. The facility census was 63. Actual harm occurred on 03/26/24 when the facility failed to adequately assess and implement pressure ulcer wound care for Resident #56, a new admission who had impaired cognition and bowel incontinence. On 03/28/24 the resident was transferred to the emergency room where hospital staff identified an extensive coccyx/sacral pressure ulcer with surrounding cellulitis and additional concern for osteomyelitis. […]

• No harm, potential for more than minimal, widespreadF804Apr 16, 2026

  Based on observation and interviews, the facility failed to serve hot and palatable foods. This affected four residents (Residents #2, #6, #8 and #61) and had the potential to affect all 68 residents residing in the facility. The facility census was 68.Findings include: Interview with Resident #2 on 04/13/26 at 10:41 A.M. revealed the facility's food was The worst food I ever ate in the world. It's cooked until it's leather and dry. Interview with Resident #8 on 04/13/26 at 11:06 A.M. revealed the facility's food was scrambled eggs terrible, tasteless, and not real hot.Interview with Resident #61 on 04/13/26 at 11:11 A.M. revealed the facility's food was not hot, tasteless sometimes, and the meat is hard.Interview with Resident #6 on 04/13/26 at 12:49 P.M. […]

• No harm, potential for more than minimal, widespreadF730Jun 3, 2024

  Based on record review and interview, the facility failed to ensure state-tested nursing aides (STNAs) received annual performance evaluations. This affected two STNAs (#604 and #614) of three reviewed for completed employee files. This had the potential to affect all 63 residents residing in the facility. Findings include: Record review of the employee files for STNA #604 revealed she was hired 12/21/22. Record review of the employee file for STNA #614 revealed she was hired 12/22/22. No documented evidence could be found in either employee file indicating they received annual performance evaluations. Interview with Human Resources Director #663 on 05/29/24 at 4:05 P.M. confirmed the above findings. She said the facility did not perform annual evaluations for their employees.

• No harm, potential for more than minimal, widespreadF812Jun 3, 2024

  Based on observation and staff interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and the dish machine was monitored to ensure all service ware, cutlery, and utensils were sanitized effectively. This had the potential to affect 63 residents residing in the facility. The facility identified no residents received nothing by mouth. Findings include: An initial kitchen tour was conducted on 05/28/24 between 8:59 A.M. and 9:22 A.M. with Dietary Manager (DM) #655. Observation of the low temperature dish machine revealed the following: Dietary Worker/Cook #661 did not know what the temperature of dish machine should be or how to test the chemical level. […]

• No harm, potential for more than minimal, widespreadF880Jun 3, 2024

  Based on observation, interview, record review, facility policy review, and review of the memorandum from the Department of Health and Human Services, the facility failed to initiate and use enhanced barrier precautions (EBP) when appropriate for Residents #56, #262, #264, and #313. This affected four residents (#56, #262, #264 and #313) of seven residents reviewed for infection prevention and control and had the potential to affect all 63 residents residing in the facility. Findings include: 1. Observation and interview on 05/28/24 at 9:08 A.M. with Resident #262 revealed a PICC (peripherally inserted central catheter) in the right arm. There was no EBP posted and no personal protective equipment (PPE) available at the room entrance. […]