Cycle 1
Health 2024-11-08 · Fire 2024-11-08
5 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Geneva, IL
Greenfields Of Geneva
5-star overall rating with 4-star inspections with $14,203 in total fines with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
0n801 Friendship Way, Geneva, IL
(630) 578-6500
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
43
Certified beds
Average residents
42
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifespace Communities
Operator or chain grouping
Approved since
2013-12-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.94
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.16
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.68
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.10
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.05
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.40
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.90
CMS adjusted RN staffing hours
Adjusted total hours
4.59
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,259
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9984
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.19% · Performance 23.64% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.60
Baseline 6.84% · Performance 5.56% · Measure score 7.60 · Achievement 7.60 · Improvement 6.42
Total nurse turnover
6.83
Baseline 91.38% · Performance 42.62% · Measure score 6.83 · Achievement 5.15 · Improvement 6.83
Adjusted total nurse staffing
3.65
Baseline 3.45 hours · Performance 4.12 hours · Measure score 3.65 · Achievement 3.65 · Improvement 2.37
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.41% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 416 · Observed rate 10.34% · Lower 95% interval 9.34% |
| Discharge to community | 66.62% |
50.57%
16.1 pts better
|
Better than the National Rate · Eligible stays 401 · Observed rate 62.84% · Lower 95% interval 60.55% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.11% |
95.27%
1.8 pts better
|
Numerator 235 · Denominator 242 |
| Falls with major injury | 1.24% |
0.77%
0.5 pts worse
|
Numerator 3 · Denominator 242 |
| Discharge self-care score | 65.41% |
53.69%
11.7 pts better
|
Numerator 121 · Denominator 185 |
| Discharge mobility score | 55.68% |
50.94%
4.7 pts better
|
Numerator 103 · Denominator 185 |
| Pressure ulcers or injuries, new or worsened | 1.24% |
2.29%
1.1 pts better
|
Numerator 3 · Denominator 242 · Adjusted rate 1.6% |
| Healthcare-associated infections requiring hospitalization | 5.56% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 252 · Observed rate 3.97% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 75 |
| Staff flu vaccination coverage | 73.77% |
42%
31.8 pts better
|
Numerator 135 · Denominator 183 |
| Discharge function score | 64.32% |
56.45%
7.9 pts better
|
Numerator 119 · Denominator 185 |
| Transfer of health information to provider | 97.1% |
95.95%
1.1 pts better
|
Numerator 67 · Denominator 69 |
| Transfer of health information to patient | 98.68% |
96.28%
2.4 pts better
|
Numerator 149 · Denominator 151 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 38 · Denominator 114 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.0
0.2 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.3
0.9 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.7% |
89.6%
1.1 pts better
|
93.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 90.0% · 4Q avg 90.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.0% |
91.6%
4.6 pts worse
|
95.5%
8.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.3%
2 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 5.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
50.3%
50.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
6.5%
4.2 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
18.5%
3.3 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
22.8%
8.5 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.2% |
15.0%
12.8 pts better
|
14.9%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.3% |
21.3%
5 pts better
|
19.8%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.3% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.2%
3.1 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
68.8%
19 pts better
|
81.7%
6.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 90.2% · Q3 87.3% · Q4 85.3% · 4Q avg 87.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
14.0%
4.9 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.2% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
2.3%
2.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
63.0%
22 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.0% |
26.2%
0.2 pts better
|
23.9%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.0% · Observed 21.4% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
6 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-19
F · Potential for more than minimal harm
2024-11-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-11-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-11-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-11-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-19
F · Potential for more than minimal harm
2023-12-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-15
E · Potential for more than minimal harm
2023-12-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-01-05
C · Minimal harm
2023-12-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-01-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-08
F · Potential for more than minimal harm
2023-01-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-01-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-01-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-08
E · Potential for more than minimal harm
2023-01-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-16
F · Potential for more than minimal harm
2024-11-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-19
E · Potential for more than minimal harm
2024-11-08
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-11-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-19
D · Potential for more than minimal harm
2024-11-08
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-27
G · Actual harm
2023-12-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-04
G · Actual harm
2023-12-14
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-04
F · Potential for more than minimal harm
2023-12-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-01-04
E · Potential for more than minimal harm
2023-12-14
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-14
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-04
D · Potential for more than minimal harm
2023-12-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-01-04
G · Actual harm
2023-07-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-04
F · Potential for more than minimal harm
2023-01-26
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-26
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-06
D · Potential for more than minimal harm
2023-01-26
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-02-27
D · Potential for more than minimal harm
2023-01-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-06
Penalties and ownership
What sits behind the stars
$14,203
2023-12-14
Fine
Fine · fine $14,203
Fine
Ownership
Gorman, Joseph
Corporate Officer · Individual
Harshfield, Nicholas
Corporate Director · Individual
Harshfield, Nicholas
Corporate Officer · Individual
Heyboer, Elijah
W-2 Managing Employee · Individual
Jantzen, Jesse
Corporate Director · Individual
Jantzen, Jesse
Corporate Officer · Individual
Lifespace Communities Inc
Operational/Managerial Control · Organization
Pope, Erin
Corporate Officer · Individual
Robbins, Brian
Corporate Director · Individual
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Bria Of Geneva
Geneva, IL
3-star overall rating with 4-star inspections with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Batavia Rehabilitation and Health Care Center
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2-star overall rating with 3-star inspections with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Michaelsen Health Center
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5-star overall rating with 4-star inspections with $9,110 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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