Health inspection·January 10, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident (R1) was properly and safely transferred with the use of a gait belt to help prevent or minimize the risk of fall. This failure affected one of three residents (R1) reviewed for falls in the sample of 3. The findings include:R1's face sheet documented an admission date of 12/06/2025 with a past medical history not limited to strain of right quadricep muscle, encounter for orthopedic aftercare, difficulty in walking, osteoarthritis and fall.Review of R1's fall risk assessment dated [DATE] indicated resident is at risk for falls.R1's Minimum Data Set (MDS) dated [DATE] under section GG-functional abilities showed R1 is dependent with toilet transfer. Per the same MDS, dependent means the helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity.R1's care plan created/initiated on 12/12/2025 reads in part: at risk for falls and activities of daily living (ADL) self-care performance deficit related to limited mobility, weakness, fall with tendon tear and repair, arthritis. Resident had a fall during transfer on 12/21/2025.R1's care plan interventions included but were not limited to assist with toileting; intervention for 12/21/25-staff and therapy to use gait belt during transfers to aide in stabling resident (initiated 12/23/2025); requires extensive assistance by one staff for toileting. Update post fall transfer, requires extensive assistance by one staff to move between surfaces with gait belt.R1's physical therapy progress report signed 12/18/2025 at 01:07 PM documented supervision or touching assistance with toilet transfer. No documentation noted that use of gait belt was not required.Care Plan Summary Note with effective Date of 12/19/2025 at 11:03 AM, documented toileting- CGA with one person but did not indicate the meaning of CGA. No documentation noted that use of gait belt was not required.R1's occupational therapy note dated 12/21/2025 at 10:24 AM indicated that the therapist performed toileting task with CGA but did not indicate the meaning of CGA. No documentation noted that use of gait belt was not required.R1's fall incident report dated 12/21/2025 and skilled nursing note dated 12/21/2025 at 11:56 PM (23:56) indicated at approximately 08:45 PM, writer heard the sound of fall and meanwhile [aide] on the duty called for help. Writer observed resident (R1) on the bathroom floor in an upright position with both legs straight and hands were on the floor. Aide was standing in front of the resident and witnessed the fall. When asked what happened, R1 said he was unsure because it happened so fast.On 01/10/2026 at 10:42 AM, observed R1 sitting in wheelchair at table in the unit dining room on second floor. Noted R1 wearing a full length brace to his right leg. R1 said he had a fall a few weeks ago in his bathroom. R1 said a female aide came in his room and helped him stand and pivot in the bathroom then helped him sit on the raised toilet seat with handles to both sides. R1 then said that he does not recall the aide putting a gait belt on him prior to standing up. R1 said after he finished using the toilet, the aide helped him to stand up. R1 added that he then became lightheaded and fell to the floor.On 01/10/2026 at 11:43 AM, Page 1 of 3 146166 146166 01/10/2026 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V3 (Certified Nursing Assistant) said gait belts are usually hanging in the resident's bathroom but if one was not available, he would still transfer the resident without using the gait belt and would be extra careful. V3 then said he works as needed for the last six months and did not recall the last in-service on resident transfers other than upon hire.On 01/10/2026 at 12:32 PM, observed V3 (Certified Nursing Assistant) place a gait belt on R4 then ambulate resident into the bathroom. At 12:36 PM, V3 ambulated R4 back to his recliner chair in his room from the bathroom. Gait belt was in place to R4's waist. At 12:40 PM, R4 said staff do not always use a gait belt when ambulating him and was surprised that V3 used one.On 01/10/2026 at 12:49 PM, R1 said he had urinated on the bathroom floor on day of fall but did not recall whether the aide cleaned the floor prior to assisting him off the toilet.On 01/10/2026 at 02:42 PM, V6 (Certified Nursing Assistant) was observed wearing a gait belt around her waist. V6 indicated she was informed during previous transfer in-services to use a gait belt for transfers then indicated that she would never transfer a resident without using a gait belt for their safety if they did not require the use of a mechanical lift.On 01/10/2026 at 03:11 PM, V4 (Registered Nurse) said on night of R1's fall on 12/21/2025 at approximately 08:45 PM, she was close to R1's room and heard a noise that sounded like someone fell and the aide (V5) yelled out for help. When V4 entered R1's room, she saw him sitting on the bathroom floor, next to the toilet, in an upright position with both legs extended forward. R1 did not have a gait belt on. V4 then said R1 was a one assist transfer with 1 assist, and per physical therapy, R1 only needs minimum assist with transfers. V4 added that a gait belt is now used since the fall, but he did not need one prior to the fall per therapy. V4 then said staff should use a gait belt for transfers if a resident does not require a mechanical lift, but sometimes per resident need or therapy recommendations, they don't need a gait belt. V4 added that if a resident is dependent with transfers, a gait belt should be used.On 01/10/2026 at 04:00 PM, V5 (Certified Nursing Assistant) said on the day of R1's fall on 12/21/2025 at around 08:30-9:00 PM, R1 called to go to the bathroom. R1 was in the bathroom when V5 entered his room. She stood next to R1 during the transfer onto the toilet but indicated that R1 did all the work by himself with the use of the grab bar. V5 said after R1 finished, she was wiping him while he was standing up. R1 was leaning forward then began falling forward. V5 indicated there was some urine on the floor by the toilet, but it was away from R1's feet. V5 added that she did not put a gait belt on R1 prior to the transfer. V5 then said R1 was a one assist at the time of fall and that staff are supposed to use a gait belt with transfers unless the resident is independent per previous transfer in-services. V5 added that she was never told by anyone that R1 did not require the use of a gait belt. On 01/10/2026 at 04:48 PM, V7 (Physical Therapist) said he has never worked with R1 and was not familiar with his plan of care. V7 then indicated that CGA means contact guard assistance which is used with residents who have some independence but are showing that they still require some contact assistance. With CGA, staff are there to help residents and guide them without touching them but can make contact if needed. V7 added with CGA, the resident is not independent yet and does still require the use of a gait belt with transfers. V7 then said a gait belt is used for safety purposes in case a resident falls, and should always be used with transfers unless the resident uses a mechanical lift.On 01/10/2026 at 04:57, V2 (Director of Nursing) said it depends on therapy recommendations whether a gait belt is used for transfers.Review of R1's medical record on 01/10/2026 revealed no therapy documentation that a gait belt is not required to transfer R1 to and from the toilet.Undated Safe Resident Handling/Transfers policy provided by V2 on 01/10/2026 reads in part: it is the policy of this community to ensure its residents are handled and transferred safely to prevent or minimize risks for injury. Our goal is to provide and promote a safe, secure, and comfortable 146166 Page 2 of 3 146166 01/10/2026 Greenfields of Geneva 0n801 Friendship Way Geneva, IL 60134

F 0689 Level of Harm - Minimal harm or potential for actual harm experience for the residents while keeping the team members safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the team members that assist them.Handling aides may include gait belts, transfers boards, and other devices.Resident lifting and transferring will be performed according to the resident's individual plan of care. Residents Affected - Few 146166 Page 3 of 3