Health inspection·October 26, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate patient identifying information was provided to paramedic personnel at the time of emergency transfer and led to a resident being admitted to the hospital emergency room under another resident's information. This failure applied to one (R3) of one resident reviewed for hospital transfer. Residents Affected - Few Findings include: R3 is a [AGE] year-old female admitted to the facility 3/30/21 with diagnoses that included congestive heart failure, hemiplegia and hemiparesis following cerebral infarction, dysphagia, and cognitive communication deficit. R3 was sent to the hospital on 9/8/23 and did not return. R2 is a [AGE] year-old female admitted to the facility 8/3/23 with diagnoses that include encephalopathy, myocardial infarction, alcoholic cirrhosis of the liver with ascites, spinal stenosis, history of breast cancer, nutritional anemias, alcohol dependence with withdrawal. According to nurse progress notes dated 9/8/23, R3 was assessed by the nurse on duty to have difficulty breathing and not responding to verbal cues. On 10/25/23 at 7:40AM, V10 (Registered Nurse) said, R3 was sent out 911 emergently to a local hospital during the night shift early morning. V10 said she was the nurse on duty and responsible for assessment and transfer for R3. At the time of transfer, 911 paramedics arrived and V10 gave report and prepared documents to the paramedics. V10 said these documents included the face sheet of the Resident and the full Physician Order Sheet, including medications and treatments. Once the paramedics left with R3, V10 notified V20 (R3's spouse) regarding the change in condition and disposition. V20 went to the hospital emergency room to attend the bedside, however on arrival, the hospital did not have a record of R3 being admitted . V20 called the facility, spoke with V10 and it was determined that R3 was sent to the hospital with another resident's (R2) identifying paperwork which included name, birth date, social security, insurance information, diagnoses and medication list. V10 said, once she was notified and identified the mistake, the records were faxed to the hospital, however, R3 had already been admitted under R2's information. V10 was informed later by the family that R2 was in the ICU (Intensive Care Unit). During the interview, V10 said, I believed it happened because I printed out information for other residents who were going out on appointment that day, and I must have picked up the wrong information and handed it to the paramedics. On 10/24/23 V2 Director of Nursing said, I am aware R2 was transferred to the hospital with the documents of another resident. I think the nurse in the middle of the night was tired and maybe anxious and somehow got the wrong paperwork. We are all human and we make mistakes. I did an in-service Page 1 of 4 145237 145237 10/26/2023 Generations at Regency 6631 Milwaukee Avenue Niles, IL 60714

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the nurse but not the whole staff. V2 said, I don't think we have a policy regarding this issue, but I think that it would go hand in hand with the rights of the patient- such as making sure we are providing the right care to the right person at the right time and so on. I recognize that this incident could have adversely affected the care R3 received while in the hospital if no one would have caught it. Grievances reviewed included two printed letters submitted on R3's behalf, regarding this incident. In the note dated 9/19/23 V2 Director of Nursing wrote, Received another call from resident's daughter informing writer that medical records obtained from facility related to residents discharge on [DATE] were missing pages. Writer asked which pages were missing and daughter informed writer that all pages were missing since initially the wrong paperwork was given to EMT (Emergency Medical Technician) when resident discharged . 145237 Page 2 of 4 145237 10/26/2023 Generations at Regency 6631 Milwaukee Avenue Niles, IL 60714

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to have effective interventions in place to keep a resident free from fall related injury for a resident with a history of falls. This failure applied to one (R6) of one resident reviewed for accidents and supervision and resulted in R6 experiencing four falls in four months and sustaining a laceration to the head requiring three staples and a subdural hematoma. Findings include: R6 is an [AGE] year-old male who has multiple diagnoses including but not limited to the following: difficulty in walking, altered mental status, need for assistance with personal care, muscle weakness, frontotemporal neurocognitive disorder, unsteadiness on feet, abnormalities of gait and mobility, failure to thrive, and dementia. Per fall report and progress notes for R6 dated 7/8/23, shows resident had an unwitnessed fall while ambulating in his room. R6 was noted to have a laceration to the back of the head and was sent to the hospital where he returned to the facility with three staples. Per fall report, no recommendations were made. Per plan of care, resident did receive a bed alarm that was later discontinued on 8/14/23 and reinstated on 9/8/23. Per fall report and progress notes for R6 dated 8/10/23, shows resident had a witnessed fall while ambulating in room. R6 was seen ambulating with shoes that were bigger than his feet. R6 fell backward in room and hit back of his head. R6's closet was assessed to ensure shoes fit, plan to ensure resident is wearing proper footwear, and roommate's shoes were moved out of reach. Per fall report and progress notes for R6 dated 9/25/23, shows resident had an unwitnessed fall and was found on the floor next to the bed. Interventions were to provide toileting assistance prior to going to bed and a medication review was completed. Per fall report and progress noted for R6 dated 10/1/23, show resident had an unwitnessed fall while ambulating in his room. R6 was found in room behind door, laying on his left side with bed sheet wrapped around lower extremity. R6 was sent to the hospital where he sustained a subdural hematoma and was later admitted to inpatient hospice. On 10/25/23 at 12:16PM, V5 (Licensed Practical Nurse) was interviewed regarding R6. V5 said I took care of R6 many times. R6 had dementia and got very confused later in the day. R6 was noncompliant with care and needed a lot of redirection. R6 would do things like put two legs in one leg pant, put items down his pants, rummage through his closet, etc. V5 said R6 was constantly getting up without asking for assistance. R6 had advanced dementia and could not use the call light. R6 needed one on one supervision but we do not provide this at the facility. V5 said, We would try and have a staff member with him at all times, but that is not something we could sustain. His (R6's) room was not close to the nursing station but was closer to the dining room. I know he had falls but I do not remember specifics. Per R6's fall reports, V5 was the nurse on 8/10/23 and 9/25/23, however V5 could not provide this surveyor with any details on the falls. 145237 Page 3 of 4 145237 10/26/2023 Generations at Regency 6631 Milwaukee Avenue Niles, IL 60714

F 0689 It is to be noted that resident (R6) resided in a room on the other side of the unit, not visible or in close proximity to the nursing station. Level of Harm - Actual harm Residents Affected - Few On 10/23/23 at 12:19PM, V17 (Restorative Director) was interviewed regarding the fall prevention program within the facility. V17 said, (V18 - Assistant Director of Nursing) and me are responsible to complete the fall reports. (V18) lets me know what interventions will be put in place and I add them to the reports and care plans. Some interventions that we utilize in the facility are low beds, floor mats, bolsters that are built into the mattress, anti-slide wheelchair device, anti-roll back brakes, etc. On 10/25/23 at 10:45AM, V2 (Director of Nursing) was interviewed regarding R6. V2 said, I am not familiar with his (R6) falls as I started here in August. I did know (R6) was confused, impulsive, and unaware of his safety. This surveyor requested names of staff members that could provide information regarding R6 and his falls. V2 directed this surveyor to interview V18 (Assistant Director of Nursing). At 11:45AM, this surveyor attempted to interview V18 regarding R6 and his falls. However, V18 said she was not familiar with R6 and could not provide much information about his falls. On 10/24/23, all fall reports for R6 from July 2023-October 2023 were requested from both V1 (Administrator) and V2 (Director of Nursing). Fall reports for 7/8/2023, 9/25/23, and 10/1/2023 were received. The fall list reported falls for R6 on 7/8/2023, 9/25/23, and 10/1/2023. Progress notes dated 8/10/23 showed R6 sustained a fall. Requested fall report for 8/10/23 from V1 and V2 on multiple occasions on 10/25/23. This surveyor was provided a document without R6's name present and brought concern up to V1. Later, this surveyor was given a fall report from 8/10/23. It is to be noted the fall on 8/10/23 was not listed on the fall list and was not initially given to this surveyor with the requested documents. It is also to be noted that this surveyor received fall reports and care plans on 10/26/23, two days after they were requested that did not match the original documents received. It is also to be noted that some of the interventions listed on the original care plan received were not part of the new care plan received on 10/26/23. Facility policy titled Falls Prevention and Management with reviewed dated of 2/2023 states in part but not limited to the following: The purpose of this policy is to support the prevention of falls by implementation of a preventative program that promotes the safety of residents based on care processes that represent the best ways we currently know of preventing falls. Development of the fall risk care plan is based on results of the falls assessment as well as investigation of all circumstances and related resident outcomes. The care plan addresses universal fall precautions and individual fall risk factors as applies to the resident. Staff shall maintain communication with appropriate personnel when situations or residents behavior suggest that the current interventions are not effective. The facility shall re-evaluate as needed to promote safety. 145237 Page 4 of 4