Inspection·January 3, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review the facility failed to transfer a resident in a safe manner. This failure resulted in R1 falling and sustaining lacerations to her right foot 3rd, 4th and 5th toes requiring sutures. Findings include: R1's Physician Order Sheet dated 1/25 show R1 has diagnoses that include chronic kidney disease, spinal stenosis and chronic pain. R1's careplan with initiated date of 9/26/24 show R1 is alert and oriented and able to verbalize her needs. High risk for falls due to impaired balance. R1's careplan under transfers show, - (R1) requires staff assistance with transfer due to decreased physical mobility, She requires staff assistance with transfers using sit to stand lift. She is at times able to transfer from wheelchair/c to bed with staff using gait belt and pivot. She can verbalize if she feel weak to pivot and can use sit to stand lift. The Facility Reported Incident (FRI) sent to the state agency as initial and final dated 12/16/24 show, blood was noted on the floor next to resident's bed by facility staff. It was observed that the resident (R1) had a laceration to her right foot. Resident sent to the emergency room (ER), received three sutures. Resident returned to the facility the same day in good condition. During the investigation, R1 stated the CNA lost her grip which caused her to slide down in the wheelchair. Foot rests were in place at the time. Laceration is clean and healing. Resident remains in good condition, medicated for pain as needed. The facility Incident Report dated 12/16/24 shows, Type-fall. Place-residents room. Activity-transfer. Injury-leg, right toe lacerations to 3 of her toes on the 3rd toe, 4th toe and 5th toe. Lacerations measuring: 1.5 centimeters (cm) x 0.8 cm, 1 cm x 2 cm, 2 cm x 0.6 cm, distal part of the 3rd, 4th, and 5th right toes. On 1/3/24 at 10:45 AM, R1 was in her room, sitting in her wheelchair alert and pleasant. R1 said last month she fell and injured her right foot's 3rd, 4th and 5th toes. R1 said the staff (V7, Certified Nursing Assistant) got her up from bed to put her in her wheelchair. I don't think she realized how heavy I was, she was not able to lift me, she was sort of grabbing me and I ended falling on the floor. Then I saw blood, that was when I was told I needed to go to the hospital, I had sutures in my right toes. (showed this surveyor her right 3rd, 4th and 5th toes that was previously injured). V2 (Director of Nursing) who was with this surveyor said V7 (agency CNA) should have used the mechanical stand lift or ask another staff for assistance to transfer R1 safely. (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: 146199 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 146199 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Three Crowns Park 2323 McDaniel Ave 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)