Health inspection·November 4, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to investigate thoroughly and report an altercation of potential abuse. This applies to two residents: (R1 and R2) of six residents reviewed for potential abuse. Residents Affected - Few Findings Include: R1 is a [AGE] year old male originally admitted on [DATE] with medical diagnosis that includes but not limited to: Parkinson's disease without dyskinesia, anxiety disorder, obsessive compulsive disorder and spinal stenosis. R1 is ambulatory and independent on all activities of daily living. Minimum Data Set (MDS) reads, BIMS (Brief Interview for Mental Status), dated: [DATE] score of 15/15 indicating intact cognition. R2 is a [AGE] year old male originally admitted on [DATE] with medical diagnosis that includes and but not limited to: epilepsy, Alzheimer's disease, and anxiety disorder R2 is wheelchair dependent and is a total care for all activities of daily living. Minimum data set- reads, BIMS (Brief Interview for Mental Status) score of 5/15 indicating a severe cognitive impairment. On 11-2-2024 at 11:10 am V9 (Housekeeping/ Maintenance Aide) said, On 10-10-2024 after dinner probably about 6:00 pm, I was cleaning the floor in the third-floor dining room. R1 was the only person in the dining room. He was sitting at a table by himself using a computer. R2 came into the dining room. R2 was propelling himself in a wheelchair using both hands. R2 approached R1's table. They (R1 and R2) became very loud, screaming at each other. I did not know what had happened. I became so nervous and scared that I ran out of the dining room. I left them alone. I went to look for any nursing staff to come and assist to de-escalate the situation. I know it was my fault for leaving them alone because they could have hurt each other. I do not know how long it took me to find a female nurse at the end of the hallway. I reported to the nurse that R1 and R3 were arguing, and I did not know what to do. V10 (Licensed Practical Nurse) and I went into the dining room, and we saw that a heavy dining room table was flipped over. R1 and R2 appeared to be ok. I do not know who turned over the table. It happened when I was looking for the nurse. V10 came into the room and separated the residents. R1 left the room very upset and said, I am calling the police. The police came at about 6:40 pm. No manager talked or asked me what had happened or requested for me to write any statement. On 11-2-2024 at 10:25 am V1 (Director of Nursing) said, I was told by V14 (Administrator) that R1 and R2 had a verbal altercation. I did not investigate. I did not interview anyone about it. I do not have any file with any reportable or internal investigation for that incident. V14 is the abuse coordinator and is responsible for investigating any alleged abuse incidents. On 11-2-2024 at 12:45 pm V14 (Administrator) said, on 10-10-2024 R1 had a verbal altercation with (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 4 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 11/04/2024 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)