Inspection·October 13, 2024

F 0689 R1's MDS (minimum data set), dated 7/16/24, notes R1 with functional limitation in range of motion in both upper extremities. R1's cognitive status for daily decision making is severely impaired. Level of Harm - Actual harm Residents Affected - Few R1's ADL care plan, initiated 8/6/2019, notes R1 is at risk for ADL decline related to generalized weakness and deconditioning. Interventions include transfers - R1 is dependent on staff for all transfers, use mechanical lift device for all transfers. Wheelchair - R1 requires substantial/maximum assistance for locomotion. R1 may require two person assist in periods of lethargy, weakness. On 10/12/24 at 12:40 PM, V3 CNA (certified nurse aide) stated prior to R1's fall, R1 was able to self-propel in wheelchair. V3 denied witnessing R1 lean forward in wheelchair or attempt to stand unassisted by staff. On 10/12/24 at 12:45 PM, V4 CNA stated prior to R1's fall, R1 was able to self-propel in wheelchair. V4 denied witnessing R1 lean forward in wheelchair or attempt to stand unassisted by staff. V4 stated prior to fall R1 was able to take a few steps with staff assistance. On 10/13/24 at 4:15 PM, V5 LPN (licensed practical nurse) stated on 8/17/24, V5 was in the resident room next door to R1's room. V5 stated when V5 exited room V5 observed R1 on the floor. V5 stated V6 CNA informed her R1 leaned forward and fell out of wheelchair. V5 stated R1 was able to stand while sitting in wheelchair but would sit right back down. V5 stated R1 was able to self-propel in wheelchair prior to the fall. On 10/14/24 at 12:13 PM, V9 CNA stated she was working on 8/17/24 evening shift when R1 fell. V9 stated prior to the event she was sitting at nurses' station charting on computer. V9 stated R1 is a two person transfer and she instructed V6 to let her know when she was ready to have her assist with transferring R1 to bed. V9 stated V6 CNA stated, okay R1 lets go. V9 stated she did not hear V6 call out to R1 after this. V9 stated no other words were spoken prior to the fall. V9 stated she then heard a boom and looked up to find R1 lying on the floor on side in a fetal position; R1's legs are semi contracted. R1's medical record, dated 8/17/24 at 7:08pm, V5 LPN (licensed practical nurse) noted after eating dinner, R1 was being taken to bed by V6 CNA in wheelchair upon which R1 leaned forward in wheelchair and fell forward, face down to the floor. Upon assessment R1 received moderate sized abrasion to middle of forehead with moderate blood present. R1 remains alert, and verbal during occurrence. Neurological check initiated: no deficits noted. No indication of pain or discomfort. No vomiting or loss of consciousness observed. Pupils equal and reactive to light. Level of consciousness and range of motion to all four extremities at baseline. R1's vital signs stable. EMS (emergency medical services) 911 called and arrived within 5 minutes of occurrence. R1 transported to the hospital for further evaluation. On 8/18, the emergency room nurse said R1 had CT (computerized tomography) scan of the head, cervical spine, facial bones, and all are negative. R1 received seven sutures to laceration on forehead. On 8/22 at 11:00am, V7 LPN noted V7 was notified by therapy upon R1 assessment, R1 grimacing and pointing fingers to the left knee. Upon assessment V7 noted R1's left knee swollen, light redness, warm to touch, skin intact. On pain scale, R1's pain is 6 out of 10. Acetaminophen administered. V8 NP (nurse practitioner) informed with order to send R1 back to the hospital to repeat CT scan, radiology due to R1's recent fall. (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 10/13/2024 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 0689 On 8/22, V8 NP noted laceration of mid forehead with seven sutures, discoloration of right and left eyes, and discoloration of chin. Left knee redness and swelling, limited range of motion. Level of Harm - Actual harm Residents Affected - Few 8/22 at 3:56pm, R1 returned to facility with diagnosis of non-displaced transverse fracture of left patellabrace (knee immobilizer) applied in the emergency room with order to follow up with orthopedic surgeon. This facility's investigation into R1's fall notes R1 is cognitively impaired, with memory and recall problems. R1 communicates primarily in Polish. Per V6 CNA, R1 looked tired, V6 went to R1, unlocked brakes on wheelchair and was preparing to wheel R1 to room when R1 suddenly leaned forward resulting in R1 falling from wheelchair. V6 is no longer employed at this facility and was unable to be interviewed during this survey. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145237 If continuation sheet Page 3 of 3