Health inspection·July 26, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to provide secure wheelchair transportation in facility van/bus for a resident. Residents Affected - Few This applies to 1 resident (R1) reviewed for safe facility van transportation in a sample of 9. The findings include: R1's Face sheet shows diagnoses of morbid sever obesity, abnormalities of gait and mobility, generalized muscle weakness, history of falling, lack of coordination, and peripheral vascular disease. R1's MDS (Minimum Data Set) dated 6/10/24 shows her cognition is intact and she uses a wheelchair. R1's MAR (Medication Administration Record) shows she took PRN (as needed) doses of Tylenol on 7/11/24 at 2224 and again on 7/20/24. On 7/23/24 at 1:50 PM, V7 (Activity Director) said when she was driving the van on 7/11/24, a car drove out in front of her and she braked hard and R1 fell out of her wheelchair. V7 said she parked the van and went back to assess R1, who was sitting on the floor in front of her wheelchair with her left leg extended against the wall of the bus and her right leg extended under the wheelchair of R6, who was sitting right in front of R1. V7 said R1 told her that she was okay but that her feet were hurting. V7 said the other residents on the bus at the time of R1's fall were R6, R7, R8, and R9. On 7/23/24 at 10:48 AM, R1 said she fell out of her wheelchair while being transported in the facility van by V7 (Activity Director) on 7/11/24. R1 said she fell because the seatbelt did not work in the van. R1 said ever since the fall she has had pain in her left foot that she has taken Tylenol for and put ice on to help with the pain. On 7/24/24 at 3:25 PM R1 said she did not have lap belt on when she fell, and she could not recall if she had shoulder belt on. On 7/25/24 at 10:01 AM R1 said it is the facility staff's responsibility to hook everybody in right on the bus and don't cut any corners thinking they're not going to have an accident. On 7/23/24 at 3:10 PM, R7 said on 7/11/24 when he and R1 were on the bus together he recalled hearing V7 (Activity Director) and V13 (Activity Aide) talking and trying to latch R1's seatbelt and having difficulty. R7 said V7 and V13 knew that R1's seatbelt was not latching correctly when they left the facility to go to museum. On 7/25/24 at 12:28 PM, V7 (Activity Director) demonstrated for surveyor on the facility van/bus how she latched R1's seatbelt on 7/11/24 when R1 fell out of her wheelchair. V7 showed surveyor that she fastened the shoulder belt (attached on opposite end to the wall of the van) to the notch on the center of the lap belt by the red button/release, then she attached one side of the lap belt to the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 146067 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 146067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bria of Geneva 1101 East State Street Geneva, IL 60134 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)