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
Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to
implement care plan interventions, and failed to provide ADL (Activities of Daily Living) care to one of three
dependent residents (R3) reviewed for quality of life.
Residents Affected - Few
Findings include:
R3's diagnoses include osteoarthritis of right knee, muscle wasting/atrophy of bilateral thighs, and
dementia.
R3's (4/14/25) BIMS determined a score of 9 (moderate impairment).
R3's (4/14/25) functional assessment affirms supervision or touching assistance is required for eating and
substantial/maximal assistance is required for dressing.
R3's (4/26/23) care plan states resident has an ADL self-care performance deficit due to impaired cognition
and limited mobility, intervention: assist with ADL tasks as needed.
On 5/12/25 at 1:27pm, R3 was seated at a table in the dining room and the table was completely cleared
however dried red sauce was observed on the front of R3's shirt & pants. A large ravioli was also noted on
R3's thighs. Surveyor inquired what time lunch was served today R3 stated 12 or 12:30.
On 5/12/25 at 1:30pm, V5 (CNA/Certified Nursing Assistant) affirmed that she was currently assigned to
monitor the dining room and stated, It's one CNA assigned at a time. Surveyor inquired about R3's
appearance, V5 responded I'm not her CNA, her CNA is (V6's name). Surveyor inquired why R3 remained
seated at the table and not attended to, V5 replied The residents, they sit in the dining room and failed to
provide R3 any assistance. Surveyor inquired when lunch was served today V5 stated Like 12:00 (1.5 hours
ago).
On 5/12/25 at 1:34pm, V7 (CNA) stated All of the CNAs have a set time in the dining room, every 30
minutes so we (staff) have time to complete whatever we are assigned to. We got fall risk in there (dining
room), we gotta watch em (residents). Surveyor inquired what staff should do if residents (in the dining
room) need attended to, V7 responded Usually a CNA not doing anything or anybody for that matter can
help with that. If I'm assigned to the resident, there's someone in the dining room that can relay to me that
the resident needs something so we can get the patient taken care of. Surveyor inquired if R3 requires
assistance, V7 replied She's a feeder, she needs maximal assistance. Restorative (staff) usually sets her
up, and someone tries to assist her. Surveyor inquired who's assigned to R3 today, V7 stated (V6's name).
At 1:37pm (10 minutes after surveyors' initial observation), surveyor inquired about concerns with R3's
appearance, V7 subsequently entered the dining room and
(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 2
Event ID:
145688
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
05/15/2025
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
Residents Affected - Few
stated She (R3) needs to be repositioned; she's sliding down the chair. She also needs to be changed; her
clothes need to be changed. Surveyor inquired what was on R3's clothing, V7 responded Food, its stains
from the ravioli, some of it is wet some of it is dry. Surveyor inquired what was on R3's lap, V7 replied
Ravioli.
On 5/12/25 at 1:41pm, V8 (Minimum Data Set Coordinator) presented the (5/12/25) assignment sheet and
affirmed that V6/CNA (assigned to R3) was also assigned to the dining room from 12:30 to 1:00.
The (09/2020) facility feeding policy states place a napkin under the resident's chin or put on clothing
protection if desired by the resident.
The (3/10/22) dressing/grooming policy states dressing/grooming refers to activities provided to improve or
maintain the resident's self-performance in dressing and undressing and performing other personal hygiene
tasks. These activities are individualized to the resident's needs, planned, monitored, evaluated, and
documented in the resident's medical record. Determine if the resident has specific tasks and areas
requiring dressing/grooming assistance.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145688
If continuation sheet
Page 2 of 2
