Greenfields of Geneva

In the surveyor’s words

From the most serious findings on record at Greenfields of Geneva, in the surveyor’s own words.

• Actual harm, isolatedF686Dec 14, 2023

  Based on observation, interview, and record review the facility failed to identify an area of pressure prior to it becoming unstageable in a resident (R27) at high risk for pressure injury. This failure resulted in R27 needing to be hospitalized with osteomyelitis (bone infection) which required antibiotics. This applies to one of three residents reviewed for pressure in the sample of 12. The findings include: The facility face sheet for R27 shows diagnoses to include adult failure to thrive, pressure ulcer of the sacral region and osteomyelitis of the sacral region and was admitted into the facility on [DATE] after a hip fracture. […]

• Actual harm, isolatedF689Dec 14, 2023

  Based on observation, interview, and record review the facility failed to ensure a resident was assessed for safety prior to the use of a motorized wheelchair for 1 of 2 residents (R6) reviewed for safety in the sample of 12. This failure resulted in R6 being sent to the emergency room and receiving 30 stitches to the right lower leg. The findings include: R6's face sheet printed on 12/14/23 showed diagnoses including but not limited to dementia, cognitive communication deficit, altered mental status, anxiety, osteomyelitis (bone infection), absence of right toe, foot pain, and history of falls. R6's facility assessment dated [DATE] showed moderate cognitive impairment. […]

• Actual harm, isolatedF689Jul 25, 2023

  Based on observations, interviews, and record reviews the facility failed to supervise a resident to prevent a resident's fall. This failure resulted in R1 sustaining a displaced fracture of the left distal femoral shaft requiring surgery. This applies to 1 of 4 residents (R1) reviewed for falls. Findings include: R1's electronic health record showed that on July 3rd, 2023, R1 was left on the commode in her bathroom, and she fell to the floor while trying to self-transfer to her wheelchair. R1's 7/3/23 hospital X-ray report showed that R1 has sustained a fracture to her left femur. R1's 7/3/23 - 7/7/23 (after visit summary) hospital records showed that R1 had a 4-day hospital stay. R1's 7/4/23 Operative Report showed R1 had an open reduction internal fixation of the left distal femur. […]

• No harm, potential for more than minimal, widespreadF812Nov 8, 2024

  Based on observation, interview, and record review, the facility failed to properly label, date, seal, store items, remove expired items, and wear hair restraint while serving food from facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 42 residents. On [DATE] at 3:20 PM, V2 (DON/Director of Nursing) said there is only 1 NPO (Nothing by Mouth) resident; all other residents eat from the facility kitchen. […]

• No harm, potential for more than minimal, widespreadF812Dec 14, 2023

  Based on observation, interview, and record review, the facility failed to ensure food was kept off the floor, failed to maintain food storage areas in a clean and orderly manner, failed to ensure ice cream freezer temperature was monitored, failed to maintain cleanliness of ice cream freezer, and failed to discard expired food items. These failures have the potential to affect all residents in the facility. The findings include: The facility's resident roster dated [DATE] showed 42 residents currently residing in the building. On [DATE] at 9:58AM, The facility's refrigerator had multiple pans of food and boxes of food stacked on top of each other. There were boxes filling all racks of the refrigerator, some boxes filled with plastic bags that were packed tightly into each box. […]