Inspection·February 26, 2025

F 0558 the table next to R84. Level of Harm - Minimal harm or potential for actual harm R84's face sheet documents diagnoses that include but are not limited to ataxia, history of falling and chronic systolic heart failure. R84's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R84 is cognitively intact. Residents Affected - Few R84's Care Plan, revision date 8/21/2024, documents, in part, (R84) has an ADL (activities of daily living) Self Care Performance Deficit due to Ataxia, Hx. (history) of falls, weakness, deconditioned, Congestive heart failure and lack of motivation. (R84) uses a wheelchair for ambulation. (R84) is extensive with Adl's at this time, with interventions that document, in part, Assist with ADL (activities of daily living) tasks as need. Provide needed level of assistance and support to complete Activities of Daily Living . On 2/23/25 at 10:07am, while in R84's room, with V24 (Registered Nurse/RN), surveyor asked R84 to locate R84's call light. V24 said, It's under his bed. I was just in here. It must have fell off the bed again. When asked if R84 can reach his call light, V24 replied, Not if it's under the bed. V24 then took R84's call light and secured it to R84's bottom sheet of R84's bed. On 2/24/25 at 12:47pm, V2 (Director of Nursing/DON), said Call lights should be answered in a timely manner, by any staff and within reach of the resident. Call lights are needed so staff can meet the resident's needs. Facility policy titled, CALL LIGHT, USE OF, dated 9/20, documents, in part, . 5. When providing care to residents, position the call light conveniently for the resident's use. Tell the resident where the call light is and show him/her how to use the call light and provide reminders to use the call light as needed. 6. Orient all new residents to the call light at the bedside as well as the call light in the bathroom and in the shower or tub rooms. Have the resident demonstrate the use of the call light to be sure he/she understands your instructions. 7. Be sure call lights are placed within resident reach at all times. Facility presented pamphlet titled, Residents' Rights for People in Long-term Care Facilities, revised date 3/17, documents, in part, . safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 2 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. R133 has a diagnosis of but not limited to Type 2 Diabetes Mellitus, Vascular Dementia, History of Falling, Acute Osteomyelitis, and Malignant Neoplasm of Prostate. R133 has a Brief Interview of Mental Status score of 15. On 2/23/2025 at 10:57am surveyor attempted to turn off R133's sink in the bathroom with no success. Surveyor turned both handles on the sink to turn the water off and the water continued to run from the faucet. Surveyor also observed a missing floor tile from in front of R133's bed. On 2/23/2025 at 10:59am R133 stated he has reported the faucet issue to nursing and maintenance staff and they come and look at it but that never come back to fix it. R133 stated that he gets out of his bed on the other side, by the window, because he does not want to step down on the floor where the floor tile is missing. On 2/25/2025 at 10:31am V30 (Maintenance Coordinator) said, No, faucets should not be running continuously. V30 said that there are guys here today, to assist in replacing floor tiles. On 2/25/2025 at 12:32pm V16 (Building Manager) stated he was just made aware of the sink in R133's bathroom that would not shut off and the missing floor tile and said the water should not be continuously running. 3. R116'S Face sheet shows that R116 has a diagnosis which include but not limited to malignant neoplasm of unspecified part of unspecified bronchus or lung, dizziness and giddiness, cerebral atherosclerosis, other sequelae of cerebral infarction, unspecified severe protein calorie malnutrition, muscle spasm, mixed hyperlipidemia, nicotine dependence cigarettes, and essential primary hypertension. R116's has a Brief Interview for Mental Status (BIMS) dated 12/10/25 with a score of 15 which indicates that R116 is cognitively intact. R159'S Face sheet shows that R159 has a diagnosis which include but not limited to Cauda Equina syndrome, Crohn's disease without complications, anemia, partial loss of teeth due to trauma, undifferentiated schizophrenia, obesity, paraplegia, chronic vascular disorders of intestine and acute pancreatitis without necrosis of infection. R159's has a Brief Interview for Mental Status (BIMS) dated 01/20/25 with a score of 15 which indicates that R116 is cognitively intact. On 02/23/25 at 11:12 am, Surveyors observed R116 and R159's call device plate missing a cover with interior fixtures externally exposed. R116 stated, That has been like that for a long time. They never fixed it. I think that's why I (R116) have to press hard for my call light to work. Surveyor observed R116 and R159's call device functioning without concerns. On 02/25/25 at 11:18 am, Surveyor questioned V16 (Maintenance Director) regarding R116 and R159's call device cover and V16 stated that V16 is aware of R116 and R159 missing call device cover. V16 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 3 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some then explained that V16 has to get approval to purchase more call device covers and has only been allowed to purchase five call device covers at a time. V16 further explained that V16 has approval to order five more call device covers for the facility and that the call device covers are on back order. When V16 was asked regarding the internal fixtures exposed externally from R116 and R159's missing call device cover V16 explained that the exposed fixtures were not wires and cannot harm anyone if touched. V16 stated that the call device cover is for a homelike cosmetic appearance for R116 and R159's room. Based upon observation, interview, and record review the facility failed to ensure that 2 (R116 and R159) residents' call lights main plates were attached, failed to ensure 5 residents' (R112, R133, R136, R179 and R434) bathroom sinks were functioning properly and failed to ensure 1 resident's (R133) room was well-maintained/in good repair. These failures have the potential to affect 7 residents (R112, R116, R133, R136, R159, R179 and R434) reviewed for safe and clean homelike environment, in a total sample of 66 residents. Findings include: 1. On 2/23/25 at 9:38am, while in R179's and R434's bathroom, surveyor observed the bathroom sink clogged with light brownish colored water and numerous hairs floating in the water. On 2/23/25 at 9:41am, with V24 (Registered Nurse/RN), while in R179's and R434's bathroom, V24 said, It looks like someone shaved and clogged it. Housekeeping is up here. I'll see if they have a plunger. R179's Face sheet documents diagnoses that include but are not limited to benign neoplasm of the brain, unspecified psychosis, and schizophrenia. R179's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 9 which indicates that R179's cognition is moderately impaired. R434's Face sheet documents diagnoses that include but are not limited to chronic kidney disease, unspecified psychosis, Type II Diabetes Mellitus, and dementia. R434's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 5 which indicates that R434's cognition is severely impaired. 2. On 2/23/25 at 10:27am, while in R112's and R136's bathroom, surveyor observed the bathroom faucet with continuously running water. Surveyor attempted to shut the water off but was unsuccessful. On 2/23/25 at 10:38am, with V24 (Registered Nurse/RN), while in R112's and R136's bathroom, V24 attempted to shut the water off for the bathroom sink but was unsuccessful. V24 said, I'll call for repair. R112's Face sheet documents diagnoses that include but are not limited to schizoaffective disorder, dementia, and chronic obstructive pulmonary disease. R112's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 00 which indicates that R112's cognition is severely impaired. R136's Face sheet documents diagnoses that include but are not limited to Parkinson's disease, unspecified psychosis, anxiety disorder and major depressive disorder. R136's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 9 which indicates (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 4 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0584 that R136's cognition is moderately impaired. Level of Harm - Minimal harm or potential for actual harm On 2/25/25 at 12:10pm, V7 (Housekeeping Supervisor) said, Maintenance is responsible for sinks. We're (housekeeping) responsible for cleaning up the floor. Residents Affected - Some On 2/25/25 at 12:32pm, V16 (Building Manager) said, There's a log binder on each unit for employees to write repairs in. I check it twice a day. Once in the morning and once towards the end of my shift. I was notified yesterday of the sink issues on the third floor. They are taken care of. Clogged sinks can be a fall issue and the build up of water can cause more damages to the building. Facility policy titled, Housekeeping Department, revised date 1/23, documents, in part, The Facility will follow an effective plan to maintain a clean, safe, and orderly environment . 2. Floors will be maintained as clean and free of slipping and tripping hazards. 3. Reported or discovered environmental hazards will be removed or mitigated promptly. Facility presented pamphlet titled, Residents' Rights for People in Long-term Care Facilities, revised date 3/17, documents, in part, . safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Facility job description titled, BUILDING MANAGER RESPONSIBILITIES, revised date 3/14, documents, in part, . Building Manager will assure that maintenance services are provided to all areas of the building, grounds, and equipment in a prompt and professional manner . The Building Manager is responsible for assuring that the following functions are performed as necessary for the safety and comfort of residents, staff, and visitors: i. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. ii. Maintaining the building in good repair and free from hazards. v. Maintaining the HVAC system, plumbing fixtures, wiring, all equipment, etc., in good working order . ix. Maintaining communication systems (nurse call, paging, telephone) in good working order . xii. Maintaining all areas in a safe condition. Performing Safety Inspections as required. Facility job description titled, Housekeeping Aide, dated 1/2015, documents, in part, . C. Follow and complete cleaning schedules daily as assigned . L. Check all windows, furniture, fixtures, etc. for correct operation and complete maintenance repair slip, turn into supervisor. Facility job description titled, Housekeeping Supervisor, dated 1/2015, documents, in part, . F. Develops and maintains a cleaning schedule to meet the demands of the facility to ensure a clean, sanitary, odor free environment . N. Makes rounds regularly to assure that Housekeeping personnel are performing required duties, and to assure that appropriate Housekeeping Procedures are being followed . R. Ensures that facility equipment is maintained in accordance with manufacturer's guidelines and (Facility) policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 5 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide ADL (Activities of Daily living) care for 5 dependent residents (R30, R34, R70, R91, R95). This failure affected 5 residents out of a sample size of 66 residing in the facility. Residents Affected - Some Findings include: 1. R70 has a diagnosis of but not limited to Schizoaffective Disorder, Depressive Type, Superficial Frostbite of Right Hand, Superficial Frostbite of Left Foot, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side. R70 has a Brief Interview of Mental Status score of 14. R70's care plan focus (Activities of Daily Living) dated 1/15/2025 documents, in part, has an ADL Functional Performance Deficit due to unsteady gait, CVA with left hemiplegia with interventions of Assist with personal hygiene as needed and provide needed level of assistance and support to complete Activities of Daily Living. On 2/23/2025 at 11:48am, surveyor observed R70's fingernails to be extremely long on both hands and R70 stated that he would like his nails to be cut. On 2/24/2025 at 11:24am, V6 (Licensed Practical Nurse) stated nail care is provided twice a week, on shower days, and as needed. 2. R95 has a diagnosis of but not limited to Dysphagia Following Nontraumatic Subarachnoid Hemorrhage, Sequelae Following Nontraumatic Subarachnoid Hemorrhage, Hydrocephalus, Cerebrospinal Fluid Drainage Device, Dementia, Moderate, with Other Behavioral Disturbance and Blindness Left Eye Category 5, Normal Vision Right Eye. R95 has a Brief Interview of Mental Status score of 02. R95's care plan focus (Activities of Daily Living) dated 5/31/2021 documents, in part, R95 has an ADL self-care performance deficit secondary to impaired mobility, deficit in cognition with an intervention of Check nail length and trim and clean on bath days and as necessary and assist with ADL tasks as needed. On 2/23/2025 at 10:27am, surveyor observed R95's fingernails on both hands to be long. On 2/23/2025 at 10:31am, V23 (Certified Nursing Assistant-CNA) stated nail care is provided on shower days (twice a week) and as needed. On 2/25/2025 at 8:56am, V2 (Director of Nursing) stated nail care is provided on shower days and as needed. Policy dated 09/2020 titled Nails (Care of) documents, in part, all residents will have clean, well-trimmed nails. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 6 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0677 Level of Harm - Minimal harm or potential for actual harm CNA Job Description dated 3/2023 documents, in part, provides assistance with activities of daily living to a specific number of residents. 3. On 2/23/25 at 12:05 PM, R30's fingernails appeared long and jagged. A dark substance was visible under R30's fingernails. R30 stated he needs his nails clipped. Residents Affected - Some R30's face sheet dated February 25, 2025, shows R30 was admitted to the facility on [DATE] with multiple diagnoses including Schizophrenia, human immunodeficiency virus, hypertension, hyperlipidemia, chronic viral hepatitis C, rhabdomyolysis and anxiety. R30's MDS (Minimum Data Set) dated February 4, 2025, shows R30 has a score of 11 which means R30 has moderate cognitive impairment, requires supervision or touching assistance with most ADLs and is incontinent of bowel and bladder. R30's care plan dated November 15,2024 shows R30 requires assistance with personal hygiene and ADLs including brushing teeth, washing/drying face and hands, combing hair, cutting nails, shaving etc. due to decreased motivation, incontinence and impaired cognition. Intervention/Tasks: staff will assist [R30] with needed level of assistance and support to complete ADLs through next review. 4. On 2/23/25 at 12:11 PM, R34 was sitting in chair in R34's room. R34's fingernails were long, and a dark brown substance was visible under R34's nails. R34 stated he wants his nails cut. R34's face sheet dated February 25, 2025, shows R34 was admitted to the facility on [DATE] with multiple diagnoses including Dementia, hypertension, hyperlipidemia, schizoaffective disorder bipolar type, impulse disorders, and depression. R34's MDS (Minimum Data Set) dated December 6, 2024, shows R34 has a score of six which means severe cognitive impairment, requires supervision or touching assistance with most ADLs and is incontinent of bowel and bladder. R34's care plan dated May 15,2024 shows R34 requires assistance with personal hygiene and ADLs including brushing teeth, washing/drying face and hands, combing hair, cutting nails, shaving etc. due to Dementia and Alzheimer's disease. Intervention/Task: staff will assist [R34] with personal hygiene and ADLs through next review. 5. On 2/23/25 at 11:44 AM, R91's fingernails appeared long and jagged. A dark substance was observed under R91's fingernails. R91 stated he needs his nails clipped. R91's face sheet dated February 24, 2025, shows R91was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, major depressive disorder, psychosis, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and anxiety. R91's MDS (Minimum Data Set) dated February 12, 2025, shows R91 has a score of 11 which means R91 has moderate cognitive impairment, requires supervision or touching assistance with most ADLs. R91's care plan dated December 6,2024 shows R91 requires assistance with personal hygiene and ADLs including brushing teeth, washing/drying face and hands, combing hair, cutting nails, shaving etc. due to bipolar disorder. Intervention/Task: staff will assist [R91] with personal hygiene and ADLs through next review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 7 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to assure that emergency medical equipment stored to be used in emergency basic life support was checked daily. This deficient practice has the potential to affect all sixty one residents that reside on the 3rd floor of the facility. Findings include: Facility census, dated [DATE], documents 61 residents residing on the third floor. On [DATE] surveyor observed document titled, Emergency Cart Daily Review, month February 2025, with missing a daily crash cart check for [DATE]. On [DATE] at 11:58am, V25 (Licensed Practical Nurse/LPN) said, Yes, the emergency cart should be checked daily. We (staff) want to make sure everything is working in case of an emergency. If the crash cart is not checked, and something is missing or not working, something bad can happen to the resident that could have been prevented. On [DATE] at 12:47pm, V2 (Director of Nursing/DON), said Crash carts are checked daily and signed off that they were checked to ensure its locked, there's O2 (oxygen), backboard, and the suction machine is working and ready to go. Facility policy titled, Emergency Carts, dated 9/2020, documents, in part, . Emergency carts will be accessible for facility staff to readily provide supplies for emergency situations . 3. Emergency carts will be checked daily to assure that the lock tab is not broken. If the lock tab is broken, supplies must be checked against the supply checklist, missing or expired supplies replaced. Check that oxygen tank is filled, suction machine is set-up ready and CPR board is present. Facility presented pamphlet titled, Residents' Rights for People in Long-term Care Facilities, revised date 3/17, documents, in part, . safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Facility job description titled, Staff Nurse (Registered Nurse/License Practical Nurse), dated 1/2015, documents, in part, . Responsible to provide direct nursing care to the customer, and to supervise the day-today nursing activities performed by the nursing assistants. Such supervision must be in accordance with current Federal, State, and local standards, guidelines and regulations, facility policies. The objective is to ensure the highest degree of quality care is maintained at all times . C. Assume all Nursing procedures and protocols are followed in accordance with established policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 8 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview,observation and record review the facility failed to ensure that resident was scheduled for his follow up appointment for hearing for one (R91) of one resident reviewed for hearing and vision in a sample of 60 residents. Residents Affected - Few Findings include: R91's face sheet dated February 24, 2025, shows R91was admitted to the facility on [DATE] with multiple diagnoses including bipolar disorder, major depressive disorder, psychosis, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and anxiety. R91's MDS (Minimum Data Set) dated February 12, 2025, shows R91 has a score of 11 which means R91 has moderate cognitive impairment, requires supervision or touching assistance with most ADLs. R91's diagnosis includes Bipolar disorder,Major Depressive Disorder,Psychosis,Chronic Obstructive Pulmonary Disease,Anxiety,Benign Prostate hyperplasia. R91's Minimum Data Set, dated [DATE] Brief Interview for Mental Status score is 11 which means that R91's cognition is moderately intact. On 2/23/25 at 11:44 am R91 was observed to be hard of hearing , during interview R91 stated yell loud in my ear on the right side so I can hear the question. R91 stated he does not have a hearing aid right now because he is waiting on his next appointment. R91's After Visit summary from hospital dated 12/4/2024 showed that R91 was scheduled to have a follow up appointment with Ear Nose and Throat (ENT) clinic on 12/18/2024. On 2/24/25 at 1:33pm V2 ( Director of Nursing/ DON) stated prior to residents going out on appointments I expect my nurses to do an assessment of the residents , take their vital signs, complete Activities of Daily Living care, document in electronic health record prior to resident going out on appointment and when they return. If the resident has a follow up appointment the nurse should put in appointment as an order in Electronic health record, scheduler receives appointment information from the nurses,then the scheduler calls for transportation and informs the nurse of transportation time and if resident will need to have an escort. On 2/25/25 at 9:00am V2 ( DON) presented a sheet that states Appointment/Transportation and Escort with R91's name on sheet and appointment date of 2/27/2025 for follow up appointment with ENT clinic at the hospital.V2 stated that follow up appointment on 12/18/24 was never scheduled so that is why the appointment has now been scheduled for 2/27/2025. On 2/25/25 at 10:08am V25 ( Licensed Practical Nurse) stated I was the nurse on 12/4/24 when (R91) went out to appointment and returned on 12/4/24 with new order for ear drops and a follow up appointment for 12/18/24. V25 stated she is expected to document in progress notes that the resident has returned from the appointment,document any new orders for medications and if the resident has a follow up appointment this should be placed in electronic medical record as an order. V25 stated that she could not remember about R91's follow up appointment. V25 stated that the director of nursing expects V25 to write an order in electronic medical record if a resident has an appointment and then (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 9 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0685 Level of Harm - Minimal harm or potential for actual harm inform the scheduler after the order is placed in electronic medical record so transportation can be made. V25 stated I missed making the appointment. Policy dated 9/2020 titled Appointments documents : Physician orders are received for appointments. Assistance will be given to residents in need of arranging and scheduling appointments. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 10 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 observation, interview, and record review, the facility failed to ensure the janitor closet was locked at all times where residents with a diagnosis of dementia reside. This failure has the potential to affect all the 25 residents on the 2nd floor [NAME] Wing of the facility. Findings include: On 02/25/2025 at 3:12pm, V1 (Administrator) stated the resident's rooms on the second floor [NAME] wing are from rooms 201 to 212. The (02/22/2025) Midnight Census Report documented that there were 25 residents on the second floor's [NAME] Wing. On 02/23/2025 at 11:00 AM, the janitor closet on the second floor's [NAME] Wing was not locked. This observation was pointed out to V7 (Housekeeping Supervisor). V7 checked the closet, removed a piece of paper from the strike plate hole where the latch bolt lies when closing the door, and stated somebody put a piece of paper or something to stop the door from locking. This surveyor requested V7 to keep the door open and to tell this surveyor what's inside the Janitor's closet. V7 stated we have the electric circuit breaker and chemical solution dispenser inside the janitor closet. This door should not be left unlocked. The janitor closet should be locked at all times because we have a circuit breaker, and chemicals are stored inside. On 02/23/2025 at 12:50pm, facing the 2nd floor elevator, V6 (Licensed Practice Nurse) stated you cannot use the elevator without an elevator key. V6 used the elevator key to access the elevator. On 02/24/25 at 11:07 AM, V16 (Building Manager) stated the janitor closet should be locked at all times to prevent anybody from shutting off the power. The chemicals inside the janitor closet, I am pretty sure, are harmful. On 02/24/2025 at 11:15am, with V16 (Building Manager). This surveyor instructed to open the second floor [NAME] Wing janitor closet and inquired what potentially could happen if the janitor closet was left unlocked. V16 opened the janitor closet and stated well we have the breaker panel on the right side of the Janitor closet and chemicals on the left side. Resident may potentially shut off the breaker and there will be no electric power on the nurse's station and on the rooms on this wing. On 02/24/2025 at 11:20am, V16 used the elevator key to access the 2nd floor elevator. On 02/26/2025 at 9:42am, V2 (Director of Nursing) stated the 2nd floor is a skilled floor. This surveyor inquired why a key is needed to use the elevator on the second floor. V2 stated because some of the skilled residents on the second floor have a dementia diagnosis. The (02/25/2025) Inservice/meeting Attendance record documented, in part The HSKP (housekeeping) staff will make sure that the janitor's closet(s) are closed and properly locked on a daily basis. The (3/14) Secured Hazardous Area Door Check documented, in part A. Policy. All doors to hazardous areas will be kept locked to ensure the safety of residents and staff. B. Procedure. 5. Housekeeping (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 11 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 are responsible for locked areas under their control. Level of Harm - Minimal harm or potential for actual harm The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. Your facility must be safe. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 12 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews the facility failed to ensure that the oxygen tubing was labeled with dates when changed, failed to ensure the oxygen tubing was contained when not in use, failed to contain a Bipap (Bilevel positive airway pressure) mask when not in use, and failed to obtain an order for oxygen per nasal cannula. These failures affected one resident (R43) reviewed in a sample of 66. Residents Affected - Few Findings include: R43 has a diagnosis of peripheral vascular disease, hypertension, diabetes, COPD (Chronic Obstructive Pulmonary Disease), dependence on supplemental oxygen, cerebral infarction, and flaccid hemiplegia. R43's (1/30/25) Brief Interview for Mental Status (BIMS) score is 15. R43 is cognitively intact. On 2/23/25 at 11:37 am, surveyor observed R43's Bipap mask laying on top of the personal refrigerator uncontained and the nasal cannular laying on the oxygen machine uncontained and not dated. R43 stated that he does use both (nasal cannula and Bipap mask) and has asked staff if his mask should be covered. On 2/25/25 at 12:07 pm observed R43's nasal cannular tubing laying on the oxygen machine not contained or dated. On 2/25/25 at 12:10 pm, V2 DON (Director of Nursing) stated, Oxygen tubing and mask should be in a bag when not in use. The oxygen tubing and mask is dated after it is changed. The policy doesn't say it should be dated. Surveyor inquired to V2 if the tubing and mask is not dated, how does the staff know it was changed? V2 stated, They should just know it was changed. Surveyor inquired to V2 how often is the mask and oxygen tubing changed? V2 stated, I have to look at the policy. R43's Active Orders as of 2/24/25 documents in part, Respiratory Bipap: apply at bedtime and PRN (As Needed). There is no order for the nasal cannula. On 2/25/25 at 3:00 pm, Surveyor had V4 ADON (Assistant Director of Nursing) to look at R43's active orders to see if there was an order for oxygen per nasal cannula. V4 stated, I do not see an order for oxygen per nasal cannula. Surveyor inquired to V4 if the resident is getting oxygen with a nasal cannula should there be an order? V4 stated, There should be an order for oxygen and if it is discontinued it should not be in the room. R43's care plan documents in part, Focus: R43 is noted with potential for respiratory difficulty secondary to COPD. R43 requires the use of a Bipap secondary to DX (Diagnosis) COPD. Facility's policy titled, Equipment Change Schedule and dated 9/2020, documents in part, Procedure: 1. Oxygen: a. oxygen tubing, nasal cannula and masks are changed every month and PRN (As Needed).7. BIPAP/CPAP (Continuous Positive Airway Pressure) tubing will be changed every 3 months and prn (as needed). Facility's job description titled, Staff Nurse (Registered Nurse/ License Practical Nurse) documents in part, Essential Functions: C. Assume all Nursing procedures and protocols are followed in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 13 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0695 accordance with established policies. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 14 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to ensure the daily nursing staffing information was accurate. These failures affected all 185 residents residing in the facility. Residents Affected - Many Findings include: On 2/23/2025 at 8:53am upon entrance to the facility surveyor observed facility's Nurse Staffing posted on the wall with the date of 2/21/2025. On 2/23/2025 at 8:57am V21 (Receptionist) stated that she must update the form before she puts it back up on the wall. Nurse Staffing form documents a date of 2/21/2025. On 2/25/2025 at 2:47pm V39 (Lead Receptionist) stated the receptionist is responsible for updating the information and posting the Nurse Staffing every day. On 2/26/2025 at 12:09pm via email V1(Administrator) stated when surveyor asked for a policy/procedure for completing the nurse staffing V1 replied, For completing the nursing staffing we follow state regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 15 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to label opened multi dose vials. This failure has the potential to affect 2 residents (R43 and R109) reviewed for medications in the sample of 66 residents. Findings include: On 2/24/25 at 10:44am, with V13 (Registered Nurse/RN), during observation of medication storage, R43's vial of Fluticasone Propionate Nasal spray and vial of Azelastine HCl Nasal Solution 0.1 % was observed opened and not labeled with an open date. Also observed was R109's vial of Prednisolone Acetate Ophthalmic Suspension 1 % eye drops opened and not labeled with an open date. These observations were pointed out to V13 and V13 affirmed that the Fluticasone Propionate Nasal spray, Azelastine HCl Nasal Solution, and Prednisolone Acetate eye drops were opened and did not have an opened date labeled. V13 affirmed that the Fluticasone Propionate Nasal spray, Azelastine HCl Nasal Solution, and Prednisolone Acetate eye should have an opened date labeled on the medications. When asked the purpose of labeling multi dose medications with an open date, V13 replied, Some medications expire earlier once they (multi dose medications) are opened. On 2/24/25 at 12:47pm, V2 (Director of Nursing/DON), said Multi dose medications are used for the same patient and should be labeled with an opened date because it shortens the life of the med (medication). We (facility) follow the pharmacy's recommendations. R43's Face Sheet documents diagnoses that include but are not limited to chronic frontal sinusitis, Type 2 Diabetes Mellitus, and hypertension. R43's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R43 is cognitively intact. R43's physician order, dated February 2025, documents, in part, Azelastine HCl Nasal Solution 0.1 % (Azelastine HCl) 1 spray in both nostrils two times a day for chronic Rhinitis. R43's physician order, dated February 2025, documents, in part, Fluticasone Propionate Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal) 1 spray in both nostrils every 24 hours as needed for Allergy symptoms. R109's Face Sheet documents diagnoses that include but are not limited to Type 2 Diabetes Mellitus and hypertension. R109's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview of Mental Status (BIMS) score of 15 which indicates that R109 is cognitively intact. R109's physician order, dated February 2025, documents, in part, Prednisolone Acetate Ophthalmic Suspension 1 %. Instill 1 drop in left eye three times a day for post-op eye surgery for 1 week and instill 1 drop in left eye two times a day for post op surgery for 1 week. The manufacturing package insert of vial of Fluticasone Propionate Nasal spray, title Fluticasone Nasal Spray Prescribing Information, documents, in part, After 120 metered sprays, the amount of fluticasone propionate delivered per actuation may not be consistent and the unit should be discarded. Facility policy titled, Mult-Dose Vials, Use of, dated 1/2022, documents, in part, The opened and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 16 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some beyond-use (expiration) dated will be noted and initialed at the time the vial cap is removed. In general, MDVs (multi dose vials) may be used for 28 days after the initial opening of the vial . Facility presented pamphlet titled, Residents' Rights for People in Long-term Care Facilities, revised date 3/17, documents, in part, . safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Facility job description titled, Staff Nurse (Registered Nurse/License Practical Nurse), dated 1/2015, documents, in part, . Responsible to provide direct nursing care to the customer, and to supervise the day-today nursing activities performed by the nursing assistants. Such supervision must be in accordance with current Federal, State, and local standards, guidelines and regulations, facility policies. The objective is to ensure the highest degree of quality care is maintained at all times . C. Assume all Nursing procedures and protocols are followed in accordance with established policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 17 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the container of the multi blood glucose test strips was labeled with an open date. These failures have the potential to affect 10 residents (R23, R36, R41, R43, R59, R68, R72, R88, R109, and R435) on team 2 who receive blood glucose monitoring tests on the first floor, reviewed for medication storage in storage in the sample of 66 residents Residents Affected - Some Findings include: On 2/24/25 at 10:44am, with V13 (Registered Nurse/RN), during observation of medication the first floor, team 2 medication cart, an opened container of the multi blood glucose test strips with no open date labeled was observed. The label on the container of multi blood glucose test strips states open date with a blank place to write the open date on the container. This observation was pointed out to V13. V13 then open the container of multi blood glucose strips with no open date and stated, Yeah, this isn't a full container. They must have forgot to label this one because the other one in my cart is labeled with an open date (V13 showed this surveyor another container of blood glucose strips that was labeled with an open date). It (container of the multi blood glucose test strips) should be labeled with an open date. You can get a wrong reading if the strips are outdated. Surveyor requested a list of residents that V13 (Registered Nurse/RN) was assigned to on 2/24/25 that receive blood glucose monitoring. Facility presented document titled, Diagnosis Report, dated 2/25/25, that documents, in part, Type 2 Diabetes Mellitus Without Complications. This document lists 10 residents (R23, R36, R41, R43, R59, R68, R72, R88, R109, and R435). On 2/24/25 at 12:47pm, V2 (Director of Nursing/DON), said I'll (V2) have to check the policy on dating the glucose strips container once opened. Facility policy titled, (Name of Company) BLOOD GLUCOSE MONITOR QUALITY CONTROL TESTING, dated 8/2024, documents, in part, . 2. Check expiration dates for solution and test strips. Date solution bottles and test strips container when opening new. Control solutions and test strips should be discarded ninety (90) days after opening. Facility presented pamphlet titled, Residents' Rights for People in Long-term Care Facilities, revised date 3/17, documents, in part, . safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Facility job description titled, Staff Nurse (Registered Nurse/License Practical Nurse), dated 1/2015, documents, in part, . Responsible to provide direct nursing care to the customer, and to supervise the day-today nursing activities performed by the nursing assistants. Such supervision must be in accordance with current Federal, State, and local standards, guidelines and regulations, facility policies. The objective is to ensure the highest degree of quality care is maintained at all times . C. Assume all Nursing procedures and protocols are followed in accordance with established policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 18 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to monitor personal refrigerator temperature logs for one resident. This failure affected one resident (R43) out of 66 residents in the total sample. Residents Affected - Few Findings include: R43 has a diagnosis which includes but not limited to peripheral vascular disease, hypertension, diabetes, COPD (Chronic Obstructive Pulmonary Disease), dependence on supplemental oxygen, cerebral infarction, and flaccid hemiplegia. R43's Brief Interview for Mental Status (BIMS) dated 1/30/25 documents that R43 BIMS score is 15. R43 is cognitively intact. On 2/20/25 at 11:37 am, Surveyor observed R43's personal room refrigerator temperature log sheet for February 2025 with missing dates for checking the temperature. From February 1st to February 23rd there was only two days checked (2/5/25 and 2/6/25) on the temperature log. Food items were noted in the refrigerator with a foul odor in the refrigerator. R43 stated that the staff do not check the refrigerator. On 2/25/25 at 12:15 pm, V2 DON (Director of Nursing) stated, I have to check and see who supposed to check the resident's personal refrigerators. On 2/25/25 at 12:30 pm, V36 Housekeeper stated that housekeeping does not check the personal refrigerators in the resident's room. The CNAs (Certified Nursing Assistant) are supposed to check the resident's personal refrigerator. On 2/25/25 at 12:35 pm, V7 housekeeping supervisor stated that the housekeeping department do not check the resident's personal refrigerators. The nursing department checks the resident's refrigerators. On 2/25/25 at 12:40 pm, V35 CNA stated that the resident's personal refrigerators should be checked daily. On 2/25 25 at 12:45 pm, V37 MDS (Minimal Data Set) Coordinator state, I checked R43's refrigerator today. It should be checked daily to make sure it's at the right temperature. Facility's (7/18) policy titled Resident Refrigerator documents in part, Purpose: To reduce the risk of food borne illness. 4. Facility staff assigned to monitor resident refrigerators will monitor temperature. Temperatures will be recorded on the Refrigerator Temperature Log . Facility's job description titled Certified Nursing Assistant documents in part, Essential Functions: A. Ensure that all nursing procedures and protocols are followed in accordance with established policies . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 19 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure the call lights, in the third floor shower room, were functioning properly. This deficient practice has the potential to affect all sixty one residents that reside on the 3rd floor of the facility. Residents Affected - Some Findings include: Facility census, dated 2/23/25, documents 61 residents residing on the third floor. On 2/23/25 at 10:22am, with V25 (Licensed Practical Nurse/LPN), during observation of the third floor shower room, 3 call lights were noted to be inoperable/non-functional. V25 attempted to turn each of the 3 call lights on but was unsuccessful. V25 sated, Let me get V24 (Registered Nurse/RN). He (V24) knows more about these (call lights). On 2/23/25 at 10:28am, with V24 (Registered Nurse/RN), during observation of the third floor shower room, 3 call lights were noted to be inoperable/non-functional. V24 attempted to turn each of the 3 call lights on but was unsuccessful. V24 said, Ididn't know these (call lights) weren't working. I'll call right now to get them fixed. When asked the purpose of assuring the call lights are functioning properly, V24 replied, So the resident can get help from (staff) if they need it. On 2/25/25 at 12:32pm, V16 (Building Manager) said, I was just told yesterday that those call lights on the third floor weren't working. Some I can fix, and some require an outside person to fix. I sent an e-mail out yesterday to (Electric Company) to come fix the call lights. Facility presented document titled, (Facility Name) Maintenance and Housekeeping Request Log, that documents, in part, 2/23/25 3rd floor Bathroom call lights out no cord. On 2/24/25 at 12:47pm, V2 (Director of Nursing/DON), said Call lights should be answered in a timely manner, by any staff and within reach of the resident. Call lights are needed so staff can meet the resident's needs. Facility policy titled, CALL LIGHT, USE OF, dated 9/20, documents, in part, . 5. When providing care to residents, position the call light conveniently for the resident's use. Tell the resident where the call light is and show him/her how to use the call light and provide reminders to use the call light as needed. 6. Orient all new residents to the call light at the bedside as well as the call light in the bathroom and in the shower or tub rooms. Have the resident demonstrate the use of the call light to be sure he/she understands your instructions. 7. Be sure call lights are placed within resident reach at all times. Facility presented pamphlet titled, Residents' Rights for People in Long-term Care Facilities, revised date 3/17, documents, in part, . safety and good care. Your facility must provide services to keep your physical and mental health, and sense of satisfaction. Facility job description titled, BUILDING MANAGER RESPONSIBILITIES, revised date 3/14, documents, in part, . Building Manager will assure that maintenance services are provided to all areas of the building, grounds, and equipment in a prompt and professional manner . The Building Manager is responsible for assuring that the following functions are performed as necessary for the safety and comfort of residents, staff, and visitors: i. Maintaining the building in compliance with current federal, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 20 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0919 Level of Harm - Minimal harm or potential for actual harm state, and local laws, regulations, and guidelines. ii. Maintaining the building in good repair and free from hazards. v. Maintaining the HVAC system, plumbing fixtures, wiring, all equipment, etc., in good working order . ix. Maintaining communication systems (nurse call, paging, telephone) in good working order . xii. Maintaining all areas in a safe condition. Performing Safety Inspections as required. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 21 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to maintain effective pest control on the third floor. This failure has the potential to affect three (R4, R7, and R30) of three residents observed in a census of 61 residents on the third-floor unit. Residents Affected - Some Findings Include: On 02/23/25 at 11:30 AM, V27, observed a brown creature crawling across the floor and Housekeeper verified that it is a live roach crawling across the floor where R4, R7, and R30 reside. On 2/23/25 at 11:33 am V27(Housekeeper) walked to R4, R7 and R30's room and verified with surveyor multiple dead roaches on glue traps and mouse traps under a wall heater. V27, (housekeeper) stated that she reports any findings of pests or rodents to maintenance and maintenance will take care of it. V27 stated that this is not the first time that she has seen roaches and that she does report any sightings of pests when she sees pests. 02/23/25 at 12:16 PM, surveyor noticed a resident jump up from his chair and step on an insect crawling on the dining room floor during lunch time. On 02/23/25 at 12:22 PM, V38, Business Office Manager (BOM), verified that it was a small roach on the dining room floor. V38 stated that it was his first time seeing a roach in the dining room and someone must have brought it in the facility. V38 stated staff is to report any findings of pests or rodents to maintenance. On 2/24/25 at 10:48 am during the resident council meeting, all residents (R22, R28, R59, R87, R88, R106, R117, R118, R148, and R155) in attendance stated they had concerns about the rodents in the facility. R88 (Resident Council President), R59, and R22 stated the residents have had concerns about rodents for a while, but it is getting better. On 2/24/25 at 1:13 pm, V1 (Administrator) stated that the facility has a Pest Control Agreement with a Pest Control Vendor and pest control services are provided twice a week. V1 stated that they had contact another pest control company for better services, but that company does not service the facility's area. V1 stated she is in the process of finding another Pest Control Company to address the facility's pest and rodent issue. Facility's document named Pest Control Service Agreement prepared by a Pest Management Services Vendor dated 8/24/2024 documents regular scheduled Pest Control Service frequency is 2 services a week. These services targets pests such as Pavement ants, House mice, Norway rats, American cockroaches, German cockroaches, and Oriental cockroaches. Facility provided a screen shot of text messages between one individual claiming to be a representative of a pest control company and another individual conversating regarding pest control services are not provided in an undisclosed service area. Facility document named Resident Council Minutes dated 12/19/2025 documents Maintenance: Residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 22 of 23 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 145688 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621 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 0925 has concerns with rodents. Level of Harm - Minimal harm or potential for actual harm Facility document named Resident Council Minutes dated 1/17/2025 documents Maintenance: Residents had some concerns about rodents. Residents Affected - Some Facility document named Maintenance and Housekeeping Request Log documents the following: 11/4/2024 roaches/bugs located in pantry and action taken by Pest Control Vendor on 11/4/24. 11/8/2024 roaches located in room [ROOM NUMBER] and action taken by Pest Control Vendor on 11/13/24. 11/12/24 a mouse was located in room [ROOM NUMBER] and action taken by Pest Control Pest Vendor Company 11/12/24. Facility document named Maintenance and Housekeeping Request Log documents a roach was in the counselor's office and action taken by Pest Control Vendor on 2/18/25. Facility policy undated and named Pest Control documents All employees will maintain the Pest Control Program by communicating and documenting pest sightings, maintaining a clean environment, and eliminating conditions conducive to pest harborage. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 23 of 23