Health inspection·July 3, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement fall care plan interventions and update the fall care plan to prevent further falls as per its fall policy. This applies to 4 of 8 residents (R3, R4, R7, R8) reviewed for fall. Findings include: 1. R3 is a [AGE] year-old female admitted on [DATE] having severe cognitive impairment as per MDS dated [DATE]. Record review for fall risk assessment dated [DATE] documents that R3 is at high risk for falls. A record review of the last six months' fall log documents falls happened on [DATE] and [DATE] with no major injuries. On [DATE] at 10:05 AM, R3 was observed on a low bed with the call light hanging from the bed. On [DATE] at 10:05 AM, V11 (Registered Nurse - RN) stated, The call light should be within her reach, and I will give her back. On [DATE] at 3:00 PM, R3 was on her bed with a call light on the floor. On [DATE] at 3:00 PM, V13 (Licensed Practical Nurse - LPN) stated, Sometimes certified nursing assistants (CNAs), after changing resident, forgot to give her call light back to the resident. It should be available to residents. 2. R4 is an [AGE] year-old male admitted on [DATE] with moderate cognitive impairment. Record review on admission clinical evaluation with Braden Scale dated [DATE] document R4 is at high risk for falls. A record review of the last six month's fall log documents a series of falls that happened on [DATE], [DATE], and [DATE] without having any major injuries. On [DATE] at 9:30 AM, R4 was in his room with only one-floor padding on his right side. R4 stated that he had a fall last week when he slipped from his wheelchair. On [DATE] at 3:10 PM, observed R4's call light behind the headboard and trapped under the bed wheel. On [DATE] at 3:10 PM, V14 (Certified Nursing Assistant - CNA) stated, The call light is trapped under the wheel. It should be available to the resident, and I will give it to him. On [DATE] at 10:40 AM, V3 (Assistant Director of Nursing - ADON) stated, R4 should have the floor padding on both sides, and I will make sure my staff put it on both sides. (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: 145803 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 145803 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Evanston,the 820 Foster Street Evanston, IL 60201 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)