Health inspection·September 19, 2025

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. Based on observation, interviews, and record reviews the facility failed to maintain a safe, comfortable home like environment [A] failed to maintain adequate running water for one [R1] resident on the third floor and [B] failed to maintain a dry home like environment due to leaking roof. This failure has the potential affect all sixty residents residing on the third floor.Findings Include:Maintenance Log indicates the following in part:1/23/25 R1's room ceiling. [third floor].3/31/25 R1's room no running water in bathroom. [third floor]5/27/25 Next door to R1's room ceil tile wet and falling [third floor]5/30/25 R1's room no running water in bathroom. [third floor]6/4/25 third floor dining room ceiling leaking water.6/11/25- third floor room, flooding in room.7/26/25- roof leaking in resident room on third floor.7/29/25- roof leaking in resident room on third floor.8/18/25- roof leaking in resident room on third.8/18/25- roof leaking in R1's room [third floor]8/18/25third floor, floor tiles are soaking wet9/8/25- R1's room third floor, bathroom sink water not working.R1 is a sixty-eight-year-old admitted with the following medical diagnosis in part: polyarthritis, peripheral vascular disease, type II diabetes, dementia, essential hypertension, asthma, schizoaffective disorder, osteoarthritis, pulmonary embolism acute pulmonale, and muscle spasm. R1's, minimum data set [MDS] Brief Interview Mental Status score= 15. Indicates R1 is cognitively intact.R1's Census Report indicates:1/23/23 admitted to second floor.8/2/25 R1 was moved to third floor.9/9/25 R1 was moved back to the second floor.On 9/16/25 at 11:58 AM, R1 stated, I requested a room change and was moved to the third floor. During my stay the roof started leaking and I saw water in the light fixture. The bathroom sink was not working. There was no water coming out of the sink. I reported my concerns to the nurse. Nursing told me the roofer fixed the leak, but the bathroom sink was never fixed. I requested to be moved back to the second floor, and I was moved. No one should live with the roof leaking every time it rained. The nurse aides would have to leave out my room to get water to wash me with, that was terrible.During facility tour with V5 [Maintenance Director] on 9/16/25 at 11:45 AM, noted with brownish spots on the ceiling tiles on throughout the building. V5 stated The discolored ceiling tiles on the third floor is from the ceiling leaking. The facility has a metal roof and when it rains hard the water will leak through the roof and travel around. The second and first floor ceiling tiles are stained due to water leaks, air conditioners leaking sometimes, and toilet overflows. On 8/13/25 R1's room on the third floor was leaking water from the ceiling, not in the light fixture. I notified corporate for repairs and repairs were made on 8/18/25. R1's bathroom sink was not running water; I had to replace the whole unit. The unit was replaced on 9/8/25, I am not sure how long it was broken.On 9/18/25 at 2:00 PM V1 [Administrator] stated, The facility roof has some leaks during heavy rain falls and storms. The roofing company came out to make repairs.V4 [Certified Nurse Assistant], V11 [Registered Nurse] and V15 [Housekeeper Supervisor] all said the roof leaks especially when it rains hard at times throughout the summer, but repairs were made recently. Policy:Building Manager Responsibilities dated (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 09/19/2025 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)