Inspection·February 15, 2024

F 0622 being very difficult to open and only opened several inches. Level of Harm - Minimal harm or potential for actual harm On 2/13/24 at 2:35 PM, V3 (LPN) stated, I was the nurse the day we discharged the resident, so yes I remember him. The first couple of days he (R2) was moved up to my floor, he was doing much better than he did on his previous floor. But then he didn't like it at all, and he wanted to go somewhere, and he said he felt like he was in prison. Surveyor asked the type of floor R2 was placed on, V3 stated, It's a locked dementia floor. Surveyor asked if R2 was given time to get acclimated to his new surroundings, V3 stated, Maybe he was, I don't know. Surveyor asked if she received any dementia training, V3 stated, Yes but it was quite a while ago. Surveyor asked about R2's alleged aggressive behavior, V3 stated, He was agitated sometimes and sometimes he would refuse his medications. Surveyor asked if R2 ever tried to hit her or demonstrate any physical violence towards her or anyone, V3 stated, He never hit me or anyone I know of, but he did try to swing at me because he didn't like his roommate. Surveyor asked what would trigger this type of response and how she intervened, V3 stated, I don't know why he did this, and I don't remember what I did. Surveyor asked if she saw R2 trying to jump out the window, V3 stated, I never saw this happen, but he blocked the door and when I tried to come in, I saw the window was cracked open. The resident must have opened the window. Surveyor asked if R2 could get out the window. V3 stated, No, it can't be opened wide enough. Surveyor asked about V3's allegation that the resident tried to put his fingers in an electrical outlet. V3 stated, I never said this or saw this, but other staff said he put his fingers in the electrical outlet. Surveyor asked if anyone reported to maintenance so they could put plastic guards on the outlets, V3 stated, No we didn't think of that. Surveyor asked if she ever felt endangered by R2, V3 stated, No sir, not at all. Residents Affected - Few On 2/13/24 at 2:50 PM, V5 (LPN) stated, (R2) used to be a resident on the 4th floor and he escaped from there, so he was transferred to the 5th floor. During time on the 5th floor, (R2) didn't escape from the 5th floor, so it probably was a better floor for him. Surveyor asked if V5 could recall any time R2 became physically or verbally aggressive towards him or any other residents, V5 stated, There were times there he would say some words like Leave me alone, get out of my face. Surveyor asked if V5 ever felt endangered by R2, V5 stated, No, never. Surveyor asked about any type of physical violence R2 may have exhibited. V5 stated, One time on the day we were going to discharge him, (R2) tried to grab one of the ambulance people who came here, and he fought with them. Surveyor clarified that V5 saw R2 grabbing and fighting with the ambulance people, V5 stated, Yes I did. Ambulance dispatch report dated 12/11/23 disputes V5's statement about R2's behavior and reads in part, Basic Life Support unit responding to an [AGE] year-old male for a non-emergent transfer from nursing home to hospital for a psychiatric evaluation. Crew donned PPE (Personal Protective Equipment) and found the patient in standing position alert and oriented times 3. Crew assessed patient on scene and obtained vital signs within normal limits. The patient was seated onto the stretcher with no assistance all by himself. The patient was safely loaded into the ambulance and was monitored enroute to the destination hospital. Enroute to the destination, the patient's health acuity did not change. At all times appropriate. On 2/13/24 at 3:00 PM, V8 (CNA Coordinator) stated, I knew (R2) when he was on both units. (R2) was very stubborn, he wanted his way, and it was hard redirecting him. (R2) became aggressive and he to tried to injure himself. Surveyor asked V8 to elaborate on this self-injurious behavior. V8 stated, He (R2) tries to punch himself on his body. Surveyor asked if V8 observed this behavior and how she intervened when this happened. V8 stated, I don't remember, but I know he tried hitting himself. Surveyor asked if R2 hit himself in the face or other body part. V8 stated, I think on his arm, I don't remember. He also pushed the bed to the door. I tried to open the door, but he would not let us (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145237 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 145237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 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)

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few in. When we got in, I saw the window was open, and the screen was moved up. He (R2) admitted to opening the window. He didn't exactly say he was trying to get out of the window because you can't open it but 5 inches. (R2) is at times aggressive. He tried to push me, but he did not touch me. He didn't do anything to me. Surveyor clarified whether the resident made physical contact with V8 or threatened V8 in any way. V8 stated, No he didn't but he did push the nurse (V3) and she was pregnant at the time. Surveyor asked when V8 saw this happen, V8 stated, When we were trying to discharge the resident, he pushed V3 and she's pregnant. Review of MDS (Minimum Data Set) dated 8/28/23 and 11/27/23 of Section E for behaviors showed R2 with no indicators of psychosis, no behavioral symptoms that were present or with frequency. No physical behavioral symptoms directed toward others, no verbal behavioral symptoms direct toward others and no rejection of care that was present including wandering behavior. On 2/14/24 at 2:05 PM, V7 (CNA) stated, Most of the time (R2) was not confused and he knew what he was doing. I was on duty that day he was sent out. He barricaded himself around noon time. I was in the dining room at the time. Surveyor asked why V7 came to talk to the surveyor. V7 stated, The DON asked me to talk to you because I know (R2). I was not part of the staff trying to get him out of the room. Surveyor asked if V7 saw R2 hit the nurse or any other staff or residents. V7 stated, I never saw (R2) hit anyone. Surveyor asked if presented any danger to herself, V7 stated, No. On 2/14/24 at 3:15 PM, V1 (Administrator) and V2 (Director of Nursing) both affirmed R2 never physically nor verbally threatened or endangered the lives of any residents or staff in the facility. V1 indicated she was told that her staff were no longer able to manage R2's behavior. V1affirmed never witnessing any of R2's behaviors that endangered staff or residents as listed in the form used to discharge R2. Surveyor asked V1 if the hospital social worker was told R2 could not return, V1 indicated no recollection of what was said. However, on 2/13/24 at 10:30 AM, V10 (hospital discharge planner) indicated that she needed to seek alternative placement for R2 because the facility refused to accept the resident back to the facility. Per surveyor's record review there was no physician's entry in R2's notes regarding how the facility was unable to meet R2's behavioral needs. There were no interventions noted in the care plan from the facility to modify R2's behavior to safely remain at the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145237 If continuation sheet Page 3 of 3