Health inspection·April 24, 2025

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow contact isolation protocols by failing to place correct signage on resident room door regarding isolation precautions, they failed to ensure that a resident on contact isolation was placed in an appropriate room, and they failed to ensure that a resident's breathing mask was properly contained in accordance with infection control protocols. These failures applied to two (R3 and R4) of six residents reviewed for infection control. Residents Affected - Few Findings include: R4 is [AGE] years old and have resided at the facility since 2019. Face sheet listed the following medical diagnosis among others: Local infection of the skin and subcutaneous tissue, abnormal posture, personal history of malignant neoplasm of the bladder, dependence on renal dialysis, methicillin resistant staphylococcus aureus infection as cause of disease classified elsewhere, methicillin resistant staphylococcus aureus infection unspecified site, pressure induced deep tissue damage of contagious site of back, buttock, and hip etc. 04/22/25 1:15AM, R4 was observed in his room with another resident (R3) sharing the same room. An enhanced barrier precaution signage was noted at the door and some personal protective equipment (PPE) was noted behind the door. R4 was sitting on a motorized wheelchair, awake, alert and oriented and stated that he is doing okay. R4 said that he gets wound care at night, they do it when he lays down and it is okay with him. R4 added that he gets breathing treatment and normally does it himself after breakfast or before, he also takes his two inhalers after the breathing treatment. A breathing machine was noted at the bedside with the breathing mask open to air and not contained. R4 was observed during the survey moving around the facility in his motorized wheelchair and even attended the resident council meeting held by a surveyor. R3 is [AGE] years old, admitted to the facility on [DATE], medical diagnosis includes, but not limited to presence of urogenital implants, unspecified dementia, unsteadiness on feet, type 2 diabetes, retention of urine, presence of aortocoronary bypass graft, etc. Review of facility list for residents on isolation dated February 2025 listed R4 as being on contact isolation for MRSA of wound and C-diff. Isolation was started on 2/24/2025 and the end of isolation was documented as on going. Care plan initiated 3/1/2025 states: R4 is on contact isolation d/t MRSA/ C diff. Goal states: R4 will remain in his room while on contact isolation. Staff will adhere to the contact isolation while providing care to prevent spread of infection. Interventions include Provide education to the resident as able and family on Contact Isolation protocol and rationale, Staff to wear PPE's when providing care per facility protocol. Mask/eye shield as indicated for (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 04/24/2025 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)