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 (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 4 Event ID: 145237 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 145237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Generations at Regency 6631 Milwaukee Avenue Niles, IL 60714 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)