Health inspection·July 25, 2023

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few 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. On 7/21/23 at 10:00am V10 (Certified Nurse's Assistant) said that on 7/3/23 he found R1 on the floor of her bathroom. V10 said that R1 should never be left alone on the toilet because she will try to self-transfer to her wheelchair and fall. On 7/21/23 at 9:43am V9 (Certified Nurse's Assistant) said that on 7/3/23, R1 needed to be toileted, and she placed her on the commode chair in her bathroom and then left her there unattended to go assist another resident. V9 said that she did not want to leave R1 alone because she felt that she was a fall risk, but V8 (Nurse) told her she would be okay to be left alone. On 7/20/23 at 3:01pm V8 (Nurse) said that on 7/3/23 R1 fell off the commode in her bathroom. V8 said R1 told her she fell while trying to self-transfer back to her wheelchair. On 7/21/23 at 11:21am V11 (Director of Nursing) said on 7/3/23 R1 was unsupervised and fell while on the toilet and it caused a fracture to her left femur. V11 said that her expectations would be that R1 be supervised while in the bathroom. On 7/21/23 at 1:09pm V12 (R1's Primary Care Physician) said on 7/3/23 R1 fell while on the toilet and it caused a fracture to her left femur. V12 said that his expectations would be that R1 would be supervised while in the bathroom. On 7/21/23 at 3:36pm V13 (Administrator) said on 7/3/23 R1 was unsupervised and fell while on the toilet and it caused a fracture to her left femur. V13 said that his expectations would be that R1 be supervised while in the bathroom. R1's 7/10/23 MDS (Minimum Data Set) Sect. G showed that R1 is an extensive assist with toileting Page 1 of 2 146166 146166 07/25/2023 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0689 Level of Harm - Actual harm Residents Affected - Few and transfers and section C shows that R1 cognition is severely impaired. R1's progress notes showed that in the last 12 months R1 has been found on the bathroom floor after falling while attempting to self-transfer 8 times, 7/3/23, 5/20/23, 1/12/23, 12/26/22, 12/31/22, 11/10/22, 11/6/23, and 9/20/22. A review of the progress notes showed that R1 was alone when she fell. R1's 7/9/23 care plan showed that R1 is a high risk for falls related to gait/imbalance problem and right-side paralysis with interventions including encourage use of safety devices, anticipate needs, and call light within reach. R1's 7/9/23 care plan showed that R1 has impaired cognitive function, judgement and decision making with interventions including supervision with all decision making. 146166 Page 2 of 2