Inspection·June 5, 2025

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 Based on interviews and record review, the facility failed to follow physician orders for a resident (R2) who required a physical and occupational therapy evaluation. This failure affected 1 resident out of 3 residents reviewed for therapy services. Residents Affected - Few Findings include: R2 has a history of diverticulosis, syncope, congestive heart failure, chronic kidney disease, and alcohol abuse. R2's Brief Interview of Mental Status (BIMS) dated 4/15/25 score is 8, which indicates R2 has moderate cognitive impairment. R2's mobility function requires mobility devices walker and wheelchair. Functional status for toileting hygiene, shower/bath, lower body dressing, putting on /taking off footwear requires partial/moderate assistance. R2's Physician orders dated 4/9/25 documents in part, may evaluate and treat PT/OT (Physical Therapy/Occupation Therapy). On 6/4/25 at 10:18 am, V3 DON (Director of Nursing) stated that Doctors orders should be followed. Therapy department is notified by the floor nurse for an evaluation order. The therapy supervisor is in the morning meetings and made aware of the therapy orders. The stand down meetings in the evening we follow up to make sure that therapy is done. On 6/4/25 at 10:40 am V14 Occupational Therapist stated We (Therapy Department) get the information from the nurses or facility staff who needs to be seen or evaluated for therapy. The communication is verbal or in the morning meeting. I would not know to evaluate him (R2) if I am not told. V14 looked at R2's orders and stated, He (R2) should have been seen by the therapy department. V14 looked at her computer and then stated, I do not see where therapy evaluated him. He was not seen for therapy. On 6/4/25 at 2:40 pm, V17 Physical Therapy Assistant stated, If there were an ancillary order for an evaluation for therapy, the nurses would notify the department. The nurses did not notify the therapy department for the order to evaluate. I (V17) would have done an evaluation with insurance approval if I was aware of the order. He (R2) was not evaluated from the order of 4/9/25. On 6/4/25 requested from V3 DON facility policy for following doctor's orders. Received a policy titled Physician Orders for Medication . On 6/5/25 at 10:30 am, V3 sent an email stating the policy for medications in the one the facility have for following doctor's orders. (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 06/05/2025 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)