Health inspection·February 20, 2026

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and interviews, the facility failed to ensure interventions were in place to prevent weight loss for 1 out of 3 residents (R3) reviewed for nutritional care. These failures are not in accordance with facility's nutrition policy and affected 1 resident (R3) who sustained multiple significant weight loss.Findings include: R3 [AGE] year-old resident initially admitted on [DATE]. R3's medical diagnosis includes intracerebral hemorrhage, encephalopathy and dysphagia among others. R3 was on enteral feeding upon admission and does not take any food and fluids by mouth. All nutrition will be administered via tube feeding. Weight history records show that R3 sustained multiple significant weight loss from 07/25/2025 initial date of admission to 01/04/2026 three (3) days prior to resident (R3) transfer to hospital on [DATE]. Per R3's weight history, R3's weight upon admission dated 07/25/2025 was 165.0 LBS. On 10/27/2025 R3's weight was 161.8 LBS. On 11/24/2025 R3's weight was 150.0 LBS, a decrease of 11.8 LBS or 7.3% for a period of 28 days. On 12/07/2025 R3's weight was 150.8 LBS. On 12/14/2025 R3's weight was 143.5 LBS, a 7.3 LBS or 4.84% for a period of 7 days or 1 week. On 01/04/2026 R3's weight was 142.5 LBS, a loss of 22.5 LBS or 13.64% for a period of 163 days or 5 months (30 days per month) and 13 days. Per facility's policy on Nutrition Care Significant Weight Loss dated 01/2028: A significant weight loss is 5% in one month, 7 1/2 % in 3 months and 10% in 6 months. Full care plan of R3 was reviewed, significant weight loss was not included or addressed. On 02/19/2026 at 12:55 PM, V3 (State Guardian of R3) stated R3 was transferred to another facility due to hospital doctor recommendation that R3 was not being fed properly in the facility. According to V3, hospital doctor informed him that R3 has poor laboratory results during evaluation that shows R3 was not properly fed. R3 currently is on another facility. Per R3's laboratory results dated [DATE] done in the facility, R3 results on BUN (Blood Urea Nitrogen) 181 mg/dL normal range between 7 to 23 mg/dL. Sodium level 178 mg/dL normal range between 133 to 148 mmol/L. Chloride level 133 mmol/L normal range between 95 to 112 mmol/L. BUN (Blood Urea Nitrogen), Sodium level and Chloride level results are at critical results. Nursing notes of V12 (Registered Nurse) dated 01/07/2026 documents that R3 transferred to hospital due to oral bleeding. V12 received critical laboratory results after R3 was transferred to hospital. V2 (Director of Nursing) on 02/18/2026 stated that R3 has several hospitalizations that may contribute to R3's weight loss. Residents that have weight loss need collaboration from nursing, the dietitian, doctor and family. V2 after reviewing R3's full care plan stated, I mean weight loss should be addressed in the plan of care, but resident has a lot going on. V8 (MDS Coordinator) on 02/18/2026 at 11:34 AM stated that care plan needs to be updated according to the schedule and as needed. Newly identified problems or concerns including pressure sores or significant weight loss need to be care planned. V8 reviewed R3's full care plan stated: No, I don't see a weight loss care plan in there. V7 (Registered Dietitian) on 02/18/2026 at 12:21 PM stated that R3 was NPO or does not take food with mouth since admission in July 2025. All nutrition is given via enteral feeding or tube feeding. V7 stated that R3 did have Residents Affected - Few Page 1 of 2 145688 145688 02/20/2026 Princeton Rehab & Hcc 255 West 69th Street Chicago, IL 60621

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few significant weight loss from October to November and January based on R3's weight history. Per V7 weight loss can be caused by R3's hospitalization. V7's enteral feeding formula does not need to be changed. There needs to be documentation that R3's significant weight loss was being addressed. V7 stated that she does not do care plan. Did not comment about significant weight loss not addressed in R3's plan of care. R3 have three (3) Enteral Nutrition Assessments dated 10/24/2025, 11/28/2025 and 12/22/2025. assessment dated [DATE] documents significant weight loss from 161.8 LBS to 150.0 LBS loss of 11.8%. Per assessment notes current weight of 150.0 LBS. Assessment documents weight stable, although 11.8% loss of weight for a period of one (1) month considered significant weight loss. Recommendation was to continue POC (Plan of Care). Assessment does not offer any other recommendation. R3's does not have plan of care for significant weight loss. assessment dated [DATE] documents significant weight loss from 159.9 LBS to 143.5 LBS loss of 10.26% for a period of three (3) months. R3's weight trending loss of 16.4 LBS or 10.3% period of three (3) months and loss of 21.5 LBS or 13.0% period of five (5) months all are significant weight loss. Recommendation was to start Expedite enteral feeding formula via tube feeding for six (6) weeks. V7 (Registered Dietitian) on 02/18/2026 at 12:21 PM stated that it was not given due to lack of availability. Nutrition Care Significant Weight Loss policy dated 01/2028: Residents with a significant weight loss will be assessed by the Licensed Dietitian. To reduce the risk of resident malnutrition the following procedures are as follows:Residents with significant weight loss will be discussed with members(s) of the interdisciplinary team (IDT).A significant weight loss is 5% in one month, 7 1/2 % in 3 months and 10% in 6 months.The Licensed Dietitian (LD) will evaluate the cause of weight loss and recommend nutrition interventions to prevent further weight loss.Interventions may include supplements, snacks, favorite foods, referral to other members of the health care team for evaluation, diet liberalization, etc.The Licensed Dietitian will document findings and recommendations in the medical record. Recommendations will be discussed with the residents, members of the IDT, and forwarded to the physician via nursing services.Upon change in diet order (physician order) or other interventions the care plan will be updated. 145688 Page 2 of 2