Health inspection·July 9, 2025

F 0605 Obtain informed consent prior to initiation of medication or increase in dosages. Level of Harm - Minimal harm or potential for actual harm 3. Residents Affected - Some R7's admission record showed admit date on 11/29/23 with diagnoses not limited to Epilepsy, Schizophrenia, Unspecified dementia, Unspecified psychosis, Bipolar disorder, History of falling. MDS dated [DATE] showed R7 was cognitively intact. MDS showed R7 took antipsychotic medication. R7's July POS and MAR showed order not limited to: Quetiapine Fumarate Oral Tablet 50 MG Give 1 tablet by mouth in the evening for Schizophrenia with Order date on 2/19/24. Risperidone Tablet 1 MG Give 1 tablet by mouth every 12 hours related to psychotic disorder with order date on 12/5/23. Lithium Carbonate ER Oral Tablet Extended Release 450 MG Give 1 tablet by mouth one time a day related to schizophrenia with order date on 12/5/23. MAR showed Quetiapine, Risperidone and Lithium Carbonate were given. R7's EHR reviewed and found consent for Risperidone and Lithium Carbonate. No consent for Quetiapine was found. Facility was not able to provide consent for Quetiapine. Care plan dated 2/21/2025, showed in part: R7 is receiving antipsychotic medications Quetiapine and Risperidone, and mood stabilizing medication, Lithium and Lamotrigine, to manage behaviors related to a diagnosis of schizophrenia. Care plan interventions included but not limited to: Obtain informed consent prior to initiation of medication or increase in dosages. 4. R10's admission record showed admit date on 2/05/2025 with diagnoses not limited to Type 2 diabetes mellitus, Epilepsy, Major depressive disorder, Encounter for attention to gastrostomy, Essential (primary) hypertension, Primary insomnia, Alcohol dependence with unspecified alcohol-induced disorder, Altered mental status. MDS dated [DATE] showed R10's cognition was moderately impaired. MDS showed R10 took antidepressant medication. R10's July POS and MAR showed order not limited to: Sertraline HCl Oral Tablet 25 MG Give 1 tablet via G-Tube in the morning for Depression with order date on 2/13/25 and it showed medication was given. R10's EHR reviewed, no consent for Sertraline found. Facility was not able to provide consent for Sertraline. Care Plan dated 2/21/25 showed in part: R10 is receiving antidepressant medication, Sertraline, to manage depressive symptoms (low mood) related to diagnosis of Major Depressive Disorder. Care plan interventions included but not limited to: Obtain informed consent prior to initiation of medication or increase in dosages. 5. R11'S admission record showed admit date on 8/20/2021, with diagnoses not limited to Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Epilepsy, Essential (primary) hypertension, Type 2 diabetes mellitus, Schizophrenia, Undifferentiated schizophrenia, Altered mental status. MDS dated [DATE], showed R11's cognition was moderately impaired. MDS showed R11 took (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 2 of 4 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 07/09/2025 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 0605 antipsychotic medication. Level of Harm - Minimal harm or potential for actual harm R11's JULY POS and MAR showed order not limited to: Olanzapine Oral Tablet 7.5 MG Give 1 tablet by mouth at bedtime related to undifferentiated schizophrenia with order date on 5/2/25 and it showed medication was given. Residents Affected - Some R11's EHR reviewed, no consent for Olanzapine found. Facility was not able to provide consent for Olanzapine. Care plan dated 9/19/2024, showed in part: R11 Receiving Olanzapine psychotropic medication. Noted to have diagnosis of undifferentiated schizophrenia. Noted with behavior or mood issues of noncompliance, hallucinations and verbal aggression. Care plan interventions included but not limited to: Obtain informed consent prior to initiation of medication or increase in dosages. On 7/8/25, at 11:35AM, observed R1 resting in bed, on moderate high back rest. Alert and oriented x 3, and verbally responsive. R1 stated she has been residing in the facility for over 3 years. R1 said she is on antibiotic treatment for UTI (Urinary Tract Infection). She said she was sent out to hospital on 7/6/25. The other day she was hearing voices or crazy stuff. R1 said the psychiatrist came on to see her and prescribed medication for her. R1 said she and her family did not give the consent for the medication. R1 stated she took the medication without their consent, and she started hearing voices in her head like crazy sounds. R1 said the medication is given at night; it was a small white round pill. She said after coming back from the hospital, the other day, nurse gave her the same white round pill at nighttime, and she did not take it. On 7/8/25, at 11:53 AM, V5 (RN / REGISTERED NURSE) stated he has been working in the facility for 9 years. He stated psychotropic medication need consent before administering the medication, it should not be given if there is no consent from the resident or representative. V5 said he is working with R1 and Olanzapine medication is on hold due to no consent. Surveyor checked R1's Olanzapine order with V5 in the medication cart, medicine is small white round pill. On 7/8/25, at 1:22 PM, V2 (DIRECTOR OF NURSING / DON) stated has been working in the facility for over 5 years. She stated she oversees psychotropic medication use. V2 said psychotropic medications are antidepressant, antianxiety, sedatives / hypnotics and antipsychotic medicines. V2 stated If there is an order for psychotropic medication, staff is expected to educate the resident and family / representative regarding the use and side effects of the medication. V2 said staff is expected to obtain consent of psychotropic medication and should not be given with no consent. V2 said staff will complete the consent form and upload it in the resident's health record. V2 stated the care plan is needed for use of psychotropic medication use. Surveyor reviewed R1's EHR with V2. V2 stated R1 is on psychotropic medication Olanzapine. V2 was unable to find care plan and consent for psychotropic medication use in R1's EHR. V2 stated it is important to obtain consent for psychotropic medication use before giving the medication to educate or inform the resident / family / representative regarding the side effects, and purpose of the medication. V2 stated the care plan should be individualized and personalized according to resident's needs. She said psychotropic medication use should have a care plan so staff would know the plan of care of the resident. On 7/8/25, at 1:38 PM, V8 (RN Care plan coordinator) stated she has been working in the facility for 15 years. The nurse should get consent before starting psychotropic medication and it should not be given if there is no consent obtained from resident if cognitively intact, family or representative. V8 said psychotropic medication use should be care planned. SS / Social Service should be doing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 3 of 4 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 07/09/2025 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 0605 care plan for psychotropic medication use. Level of Harm - Minimal harm or potential for actual harm On 7/8/25, at 2:46 PM, V21 (SOCIAL SERVICE DIRECTOR / SSD) stated he has been working over 6 years in the facility. He is doing resident's care plan for psychosocial wellbeing, behavior, cognition and psychotropic medications. He said the care plan is to inform the staff regarding the plan of care of the resident that would include goals and interventions and would direct staff on how to care for the resident. Residents Affected - Some Facility was not able to provide psychotropic medication consent for R1, R6, R7, R10 AND R11 despite several requests. Facility's use of psychotropic medications policy dated 9/2020, showed in part: To establish a standardized system to inform residents and / or their responsible parties and about psychotropic medications and their side effects. Plan of care including treatment goals, evaluation of any precipitating factors in the resident's environment, and any non-drug approaches to providing care. For each psychotropic medication ordered either a verbal or a written consent from the resident or the resident's responsible party will be obtained prior to initiation of the medication. Information regarding possible side effects will be discussed with the resident's responsible party. Facility's comprehensive care plan policy dated 11/2017, documented in part: an individualized, person-centered comprehensive care plan, including measurable objectives with timetables to meet resident's physical, psychosocial and functional needs, is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145688 If continuation sheet Page 4 of 4