Inspection·September 28, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents in the facility were free from abuse. This failure affected one of three (R4) residents reviewed for abuse and resulting in R4 acquiring a laceration to the head requiring sutures.Findings include:R4's medical diagnoses include but are not limited to schizophrenia, bipolar disorder, essential hypertension and major depressive disorder.R4's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 15, indicating R4's cognition is intact.R4's progress note dated 08/07/25 documents in part, Resident became agitated, pacing and engaged in a verbal altercation with peer that turned physical. Residents were separated and placed on 1:1. Hospitalization required.R4's progress note dated 08/08/25 documents in part, Resident has had an increase in anxiety and aggressive behavior.R4's progress note dated 08/16/25 documents in part, Writer made aware resident had and altercation as evidenced by pushing his co-peer.R4's care plan dated 09/18/25 documents in part, resident has the potential for/history of physical aggression towards others. History of physical aggression, poor impulse control.R5's medical diagnoses include but are not limited to schizoaffective disorder, violent behavior, bipolar disorder, chronic obstructive pulmonary disease.R5's MDS dated [DATE] has a BIMS score of 3, indicating R5's cognition is severely impaired.R5's progress note dated 08/16/25 documents in part, CNA (Certified Nursing Assistant) informed writer that resident had an altercation, and he was pushed to the floor, hitting the right side of his head. Some bleeding note by the right eyebrow and some swelling noted to the right side of his head.R5's care plan dated 07/01/25 documents in part, R5 is at risk for abuse related to: Has a dx (diagnosis) of severe mental illness and hx (history) of aggression.R5 will remain safe, calm and free from abuse.The Facility's Final Incident Investigation Report sent to the state agency on 08/21/25 documents in part, A follow up interview was conducted with R5 and he stated that while walking down the hallway R4 pushed him causing him to fall to the floor. R5 stated that he believes the incident was an accident. He doesn't feel it was intentional.The Facility's Final Incident Investigation Report sent to the state agency on 08/12/25 documents in part, CNA was interviewed and stated R4 was on his phone singing to himself and walking around the dining room. R7 returned to the dining room and approached R4. Both residents exchanged words. CNA called for help. When she returned to the dining room both residents were on the floor wrestling.On 09/27/25, surveyor attempted to interview R5 regarding the incident between R4 and R5. Surveyor was unsuccessful with interview due to R5's mumbled and distorted speech.On 09/27/25 at 1:00pm V18 (Licensed Practical Nurse/LPN) stated that she witnessed the altercation between R4 and R5 on 08/16/25. V18 stated that R4 and R5 were both walking in the hallway, going in opposite directions. V18 stated that when R4 and R5 were about to pass each other in the hallway, R4 pushed R5 to the floor. V18 stated that when R4 pushed R5 to the floor, R5 slid hit his head on the floor. V18 stated that she then ran to R5 because R5's head was bleeding. V18 stated that R5 was sent to the (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 09/28/2025 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)