Health inspection·August 23, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V1 did not believe the incident happened so V1 did not report/investigate the allegation. V1 stated R1 was alert and oriented and desired to go home, so R1 made up the story to convince R1's family to take him out of an unsafe facility. V1 stated he could not be sure the incident actually occurred. Facility document provided by V1, signed 8/21/24, shows, Initially [R1] told the nurse that he was trying to sit in his chair and slid out, but later, when I spoke to [R1] about 8:00 PM [R1] said he was pushed. That [R2] was in the room and had pushed him into his chair as he was trying to stand. I asked why he hadn't said that initially to the nurse and he stated that he just remembered it. There were no injuries and ]R2] left the room immediately. On 8/21/24 at 3:00 PM, V1 stated he had not yet reported R1's allegation of abuse to IDPH. On 8/21/24, V7 (Agency LPN - Licensed Practical Nurse) stated she was first to respond to R1 on the floor on 8/18/24. V7 stated she asked R1 what happened and R1 reported that R2 shoved him while sitting in his wheelchair in his room and R1 fell out of his wheelchair as a result of the push. V7 stated when V5 came into the room to assess R1, V7 told V5 that R1 reported R2 shoved R1 and then left the room because R1 was not assigned to her that day. Progress note, written by V7 on 8/18/24, shows R1 was observed in a sitting position in front of his wheelchair as R2 was walking out of R1's room. The progress note fails to show R1 reported R2 physically touched R1. On 8/21/24 at 1:45 PM, V5 (LPN - Licensed Practical Nurse) stated at the time of the 8/18/24 incident, he located R1 on the floor in his room and stated R1 did not report that he was shoved or touched by R2 during the incident. V5 stated a nurse coworker responded to R1 first at the time of the incident. Progress note written by V5 (LPN - Licensed Practical Nurse), shows no report that R1 was physically touched by R2. The note shows R2 stated R1's chair rolled back and he slid off the chair while yelling at R2. Physician note, dated 8/19/24, shows, R1 received an X-ray of his left knee due to a fall the day prior. The note shows no acute findings were shown. Progress notes, dated 8/18/24, show the facility performed a fall risk evaluation, skin condition form related to R1's fall, and a pain evaluation assessment related to R1's reports of pain in his left front knee. Facility Abuse Policy and Prevention Program 2022 document, dated 10/2022, shows, Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, to an immediate supervisor who must then immediately report it to the administrator or the compliance officer. In the absence of the administrator, reporting can be made to and individual who has been designated to act in the administrator's absence Supervisors shall immediately inform the administrator or person designated to act in the administrator's absence of all reports of incidents, allegations, allegations or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property. Upon learning of the report, the administrator or designee shall initiate an incident investigation Any allegation of abuse or any incident that results in serious bodily injury will be reported to the Illinois Department of Public Health (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146067 If continuation sheet Page 2 of 3 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 08/23/2024 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)

F 0609 immediately but not more than two hours after the allegation of abuse. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146067 If continuation sheet Page 3 of 3